Dynamic List Information
Dynamic List Data
Title
Patient Safety Work Products (PSWP), Survey Process, and Quality Assessment and Performance Improvement (QAPI) Survey Documents
Memo #
QSO-23-24-Hospital
Posting Date
2023-09-29
Fiscal Year
2023
Title
Memorandum Summary
Survey activities to assess for compliance with the regulations for QAPI programs require surveyors to review the facility’s documentation to demonstrate the ongoing and sustainable actions taken to provide for patient safety and prevent adverse events.
PSWP do not include the information to be disclosed to comply with CMS’ Condition of Participation (CoP) or Condition for Coverage (CfC) requirements.
Facilities may choose to identify certain documents as PSWP that cannot be disclosed and used in the assessment of compliance but are still required to provide alternate documentation to demonstrate compliance with the CoPs.
Survey activities to assess for compliance with the regulations for QAPI programs require surveyors to review the facility’s documentation to demonstrate the ongoing and sustainable actions taken to provide for patient safety and prevent adverse events.
PSWP do not include the information to be disclosed to comply with CMS’ Condition of Participation (CoP) or Condition for Coverage (CfC) requirements.
Facilities may choose to identify certain documents as PSWP that cannot be disclosed and used in the assessment of compliance but are still required to provide alternate documentation to demonstrate compliance with the CoPs.