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US · guidance

CMS SOM App. FC, Tag M0292

§485.917(d)(1) The number and scope of distinct performance improvement projects

activein force · 2026-07-22 – presentas-observed

conducted annually, based on the needs of CMHC’s population and internal

organizational needs, must reflect the scope, complexity, and past performance of the

CMHC’s services and operations.

Interpretive Guidelines §485.917(d)(1)

The CMHC identifies a performance issue from sources such as adverse events tracking

documents, reports from staff and/or clients, complaints from clients or families, and

feedback from affiliated programs or organizations.

There is no requirement for CMHCs to conduct a specific number of performance

improvement projects. The CMHC should select the number and topics of projects based

on the results of their internal quality monitoring and other quality information outcomes,

such as the results of State surveys.

When determining the number and scope of performance improvement programs to be

conducted in a year, the CMHC should consider its past performance of services and

operations. Performance improvement projects must be documented in written form and

include the elements outlined in this standard.

History

Rev. 196, Issued: 01-10-20, Effective: 01-10-20, Implementation: 01-10-20

Provenance

Source
cms.gov
Retrieved
2026-07-22
Edition
som-2026-07-22
Content hash
eda9e5e1fe9c1903a7f66625e0a6183f01201a8a4c9e1774dcce6c8872297e7f
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