[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR403.732]



[Page 55-56]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 403_SPECIAL PROGRAMS AND PROJECTS--Table of Contents

 

   Subpart G_Religious Nonmedical Health Care Institutions_Benefits, 

                Conditions of Participation, and Payment

 

Sec. 403.732  Condition of participation: Quality assessment and 

performance improvement.



    The RNHCI must develop, implement, and maintain a quality assessment 

and performance improvement program.

    (a) Standard: Program scope. (1) The quality assessment and 

performance improvement program must include, but is not limited to, 

measures to evaluate:

    (i) Access to care.

    (ii) Patient satisfaction.

    (iii) Staff performance.

    (iv) Complaints and grievances.

    (v) Discharge planning activities.

    (vi) Safety issues, including physical environment.

    (2) In each of the areas listed in paragraph (a)(1) of this section, 

and any other areas the RNHCI includes, the RNHCI must do the following:

    (i) Define quality assessment and performance improvement measures.



[[Page 56]]



    (ii) Describe and outline quality assessment and performance 

improvement activities appropriate for the services furnished by or in 

the RNHCI.

    (iii) Measure, analyze, and track performance that reflect care and 

RNHCI processes.

    (iv) Inform all patients, in writing, of the scope and 

responsibilities of the quality assessment and performance improvement 

program.

    (3) The RNHCI must set priorities for performance improvement, 

considering the prevalence of and severity of identified problems.

    (4) The RNHCI must act to make performance improvements and must 

track performance to assure that improvements are sustained.

    (b) Standard: Program responsibilities. (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.

    (2) The RNHCI must include all programs, departments, functions, and 

contracted services when developing, implementing, maintaining, and 

evaluating the program of quality assessment and performance 

improvement.