US · guidance
CMS SOM App. M, Tag L570
§418.58(c)(3) The hospice must take actions aimed at performance improvement
and, after implementing those actions, the hospice must measure its success and
track performance to ensure that improvements are sustained.
Interpretive Guidelines §418.58(c)(3)
Hospices must consider how often certain quality issues arise and the severity of potential
harm when prioritizing opportunities for improvement. When adverse event monitoring
reveals a problem area, the hospice must implement changes designed to decrease
occurrence of the adverse event. The hospice must assure that the new process is
implemented hospice-wide and that it is effective in reducing the adverse event. For
performance improvement in all areas of operations, the hospice must monitor the level
of improvement over time to be sure that it is sustained.
History
Rev. 210; Issued:02-03-23; Effective:02-03-23; Implementation:02-03-23
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
1f3a5bd865783a68fa45b6add09fb65eb6fc48b71994a11a09c6a86e35cc8d84
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