Hospice QAPI under 42 CFR 418.58: requirements and evidence
Short answer
A hospice must run a hospice-wide QAPI program, the quality program CMS requires. It measures palliative (comfort care) outcomes, tracks adverse patient events using its own definitions and completes improvement projects. The governing body evaluates it every year and names who runs it. CMS tags L559 through L576 cover each standard.
- Rule
- 42 CFR 418.58, condition of participation
- CMS tags
- L559 to L576, State Operations Manual Appendix M
- Governing body
- Approves data frequency, designates who runs QAPI, evaluates the program annually
- Projects
- No set number, documented in writing
- Adverse events
- The hospice may define its own, then must follow it
- Survey interval
- No more than 36.9 months between completed surveys (CMS FY2027)
Applies to: Medicare-certified hospices surveyed by a state agency · Deemed hospices accredited by a CMS-approved accrediting organization
What does 42 CFR 418.58 require?
An effective, ongoing QAPI program that covers all hospice services, even those given under contract or arrangement. Indicators tie to palliative outcomes. It is a condition of participation, a rule a hospice must meet to bill Medicare. The hospice must show CMS proof that it runs.
| Standard | What it asks for |
|---|---|
| (a) Program scope | Be able to show measurable gains in palliative outcomes and hospice services. Measure, analyze and track quality indicators, including adverse patient events. |
| (b) Program data | Use quality indicator and patient care data to design the program, check that it works and is safe, and set priorities. The governing body approves how often and how much data is collected. |
| (c) Program activities | Focus on high-risk, high-volume or problem-prone areas. Track adverse patient events, analyze causes, act, share what was learned across the hospice, then measure and sustain results. |
| (d) Improvement projects | Develop, carry out and evaluate projects that fit the hospice's scope and past performance. Record each project's purpose and measurable progress. |
| (e) Executive responsibilities | The governing body makes sure the program is defined, maintained and evaluated every year. It makes sure improvement actions are checked for effect. It names one or more people to run the program. |
Who does what in hospice QAPI?
- Governing body: approves how often and how much data is collected. It names the people who run the program and makes sure it is evaluated every year.
- Named QAPI people: run the program day to day and report results to the governing body.
- All disciplines and contracted services: are part of the program, not outside it.
CMS says the governing body may take hands-on control or appoint people to run the program. It keeps final responsibility either way.
What do surveyors look for?
See State Operations Manual Appendix M, tags L559 to L576 (Rev. 210, February 3, 2023). CMS expects a written plan. It also expects objective data showing gains in care outcomes, processes of care, patient and family satisfaction, operations or other indicators. It describes a blame-free approach that fixes systems, not single problems. The plan should cover:
- Program objectives and all patient care disciplines
- How the program is run and coordinated
- Ways to monitor and evaluate quality of care
- Priorities for resolving problems
- Monitoring to confirm that actions worked
- Reports to the governing body
- A written review of the hospice's own QAPI program
What should a hospice show?
- The written plan and minutes approving data frequency and detail
- The hospice's definition of adverse event and the log built on it
- Data from every service, not only patient assessments
- Dated analyses showing change over time, with actions and results
- Written project records: what, why and measurable progress
- Names of the people who run QAPI
- Proof of the yearly evaluation and results sent to the governing body
How should a hospice track adverse events?
CMS lets the hospice choose. It may write its own definition of an adverse event or use one from an accreditor or industry group. It must then follow it when tracking, analyzing and acting. In general, an adverse event is any action or inaction by the hospice that harmed a patient. Hospices are not bound to that wording.
Data must reach beyond patient assessments. CMS lists physician, nursing, social work and counseling services, clinical records, infection control, pharmaceutical services, durable medical equipment, patient rights, administrative services, contract services, volunteers, hospice aides and adverse events. Sources include clinical records, incident reports, complaints, satisfaction surveys, direct observation and interviews.
When monitoring shows a problem, the hospice must change the process hospice-wide. It must show the change reduced the event. IncidentKit turns the hospice's definition into incident types, severity levels and routing. Corrective actions record the change and the check that it worked.
Where do hospices fall short?
Gaps measured against CMS guidance:
- Using only patient assessment data
- Defining adverse events, then not tracking to that definition
- Fixes applied to one team or site, not hospice-wide
- No objective data showing improvement over time
- Project notes missing the written elements the standard lists
- A governing body that does not evaluate the program yearly or name who runs it
How often is a hospice surveyed?
CMS's fiscal year 2027 priorities set a maximum of 36.9 months between completed recertification surveys for any hospice. A hospice may choose a CMS-approved accreditor instead of a state survey. CMS requires accreditors to survey at least every 36 months. ACHC says it has held hospice deeming authority (CMS approval to survey in place of the state) since 2009. It also says its deemed surveys are unannounced. See ACHC.
How IncidentKit supports this requirement
| What the rule asks for | Where it lives in IncidentKit |
|---|---|
| 418.58(a)(2), (c)(2): track adverse patient events | Intake by text, QR code, email or web form. Your own definition becomes incident types, severity levels and routing. |
| 418.58(c)(2): analyze causes | Investigations record contributing factors and five whys. Lauren drafts. A person signs. Human-authored RCA templates are rolling out. |
| 418.58(c)(3): change the process hospice-wide, measure success and sustain it | Corrective actions with owner, due date, evidence and an effectiveness check. Analytics show whether the cluster went away. |
| 418.58(b)(1): data beyond patient assessments | Incident data from any service sits in one record set. Infection, satisfaction and clinical data stay in their own systems. |
| 418.58(e)(1)-(2): annual evaluation and results to the governing body | A compliance packet gives the governing body a QAPI summary. The audit trail logs every change. |
| 418.58(e)(3): designated individuals run the program | Roles control who reviews, investigates and signs. Naming the QAPI lead is the governing body's call. |
Product parts involved: Incident reporting, Routing and escalation, Investigations and RCA, Corrective actions (CAPA), Analytics, Compliance packets, Multi-site and roles. Capabilities marked “rolling out” are being released in stages; see the changelog.
Frequently asked questions
Does a hospice have to complete a set number of performance improvement projects?
No. CMS guidance sets no number. The hospice picks the number and topics from its monitoring and survey results. Each project must be written up, with why it began and measurable progress.
Can a hospice write its own definition of an adverse event?
Yes. A hospice may write its own definition or adopt one from an accreditor or industry group. It must then apply it consistently.
Who is responsible for running hospice QAPI?
The governing body. It must name one or more people to run the program, or take hands-on control. It keeps final responsibility either way.
How often must a hospice evaluate its QAPI program?
Every year. The governing body must ensure the program is evaluated annually under 42 CFR 418.58(e)(1). CMS also expects a documented review of the hospice's own QAPI program.
Sources
- 42 CFR 418.58, Quality assessment and performance improvement (eCFR)
- CMS Transmittal 210: State Operations Manual Appendix M, Hospice (February 3, 2023)
- CMS Fiscal Year 2027 Mission and Priorities Document
- ACHC: Hospice accreditation
- Federal Register: CMS approval of the Joint Commission's hospital accreditation program, 2025 (36-month survey rule)
Reviewed against the sources above on Oct 5, 2026. Rules change: confirm current requirements with the issuing body or your counsel before relying on any summary.
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