CMS SOM App. U, Tag R130

(1) The governing body, administration, and staff are responsible for ensuring that

the quality assessment and performance improvement program addresses identified

priorities in the RNHCI and are responsible for the development, implementation,

maintenance, and performance improvement of assessment actions.

Interpretive Guidelines: §403.732(b)(1)

The governing body is responsible for the organization including its QAPI program. The

governing body, administration and staff are responsible for ensuring that issues and

concerns are identified to be included in the QAPI program and that initiatives are taken

to improve quality and performance.

The development, implementation, maintenance and actions taken by the RNHCI to

improve performance are generally based on quality indications or performance

measures associated with improved outcomes for the patient and organization as a

whole. Quality and safety indicators used in the program should differ in terms of the

weight and type of evidence for their effectiveness in measuring quality. Indicators

should also differ in terms of how the data is collected, and how frequently the data

should be collected. CMS is not defining how the RNHCI organizes its QAPI program

and the development of improvement activities, however the organization should consider

use of measures or indicators.

Survey Procedures:

• How does the RNHCI ensure that responsibilities for quality assessment are

identified, performed and monitored with the goal of continuous performance

improvement?