CMS SOM App. W, Tag C-0336

The CAH has an effective quality assurance program to evaluate the quality and

appropriateness of the diagnosis and treatment furnished in the CAH and of the

treatment outcomes. The program requires that--

Interpretive Guidelines §485.641(b)

There is nothing in this requirement to preclude a CAH from obtaining QA through

arrangement. Whether the CAH has a freestanding QA program or QA by arrangement,

all of the requirements for QA must be met. If a CAH chooses to have a freestanding QA

program, the QA program should be facility wide, including all departments and all

services provided under contact. For services provided to the CAH under contract, there

should be established channels of communication between the contractor and CAH staff.

“An effective quality assurance program” means a QA program that includes:

• Ongoing monitoring and data collection;

• Problem prevention, identification and data analysis;

• Identification of corrective actions;

• Implementation of corrective actions;

• Evaluation of corrective actions; and

• Measures to improve quality on a continuous basis.

Survey Procedures §485.641(b)

Review a copy of the CAH QA plan and other documentation regarding QA activities,

(e.g., meeting notes from QA committees, reports produced by the QA director and/or

QA committees, if designated, and follow-up communication relative to corrective

actions) to become familiar with the scope, methodology and organization of the CAH

QA program.