US · guidance
CMS SOM App. U, Tag R194
(3) The RNHCI must evaluate the performance of staff and implement measures for
improvement.
Interpretive Guidelines: §403.740(b)(3)
For effective service and safety of the patients, it is critical that all staff use the skills and
techniques necessary to do their jobs correctly. As part of the organization’s performance
evaluation, the RNHCI must also have a process for assessing improvement. For
instance, in the event an evaluation of a staff member results in potential for
improvement, does the organization track the methods for improvement? Are there
reassessments and evaluation to determine if implemented measures for improvement
were effective?
Survey Procedures:
• How has the facility addressed areas of weakness identified in its evaluation of its
staff and incorporated actions to improve staff and the facility's overall
performance?
• How does coordination of care among staff and/or contract personnel providing
services to the facility occur on an ongoing basis?
History
Rev. 239; Issued: 04-24-26; Effective: 04-24-26; Implementation: 04-24-26
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
6003044be384f2f227f0aa67272ad2371e10e212b614c8f0cef0dd22de7128b8
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