US · guidance
CMS SOM App. H, Tag V625
§ 494.110 Condition: Quality assessment and performance improvement
Interpretive Guidance § 494.110:
This Condition looks at facility aggregate data and requires facility-based assessment and
improvement of care, while the plan of care Condition expects patient-based improvement of
care.
Page 244 of 420
Compliance with this Condition is determined by review of clinical outcomes data and the
records of the quality assessment performance improvement activities of the facility, and by
interviews of responsible staff including the medical director.
Noncompliance at the Condition level may be warranted if a pattern of deficient practices which
could impact patient health and safety is identified. Examples include, but are not limited to:
• Absence of an effective QAPI program;
• Failure to recognize and prioritize major problems that threaten the health and safety of
patients; or,
• Failure to take action to address identified problems.
History
Rev.
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
89e2485c37b8d5e852183965d0853ecacb23994af38d45204cf1fc58dcfceb74
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