F865: QAPI program and plan
Short answer
F865 requires every nursing home to run an effective, comprehensive, data-driven QAPI program and keep the records to prove it. The home presents its QAPI plan at each annual recertification survey and shows proof of use on request. Leaders are accountable. Good faith attempts to find and fix problems cannot be used for sanctions.
- Tag title
- QAPI Program/Plan, Disclosure/Good Faith Attempt
- Regulation
- 42 CFR 483.75(a), (b), (f), (h) and (i)
- Guidance relied on
- Appendix PP Rev. 232 (issued 07-23-25, in use since 04-28-25); F865 section Rev. 211 (02-03-23)
- Plan presented
- Each annual recertification survey, and on request at other surveys
- Survey timing
- QAPI review comes last. Surveyors may not use it to find new deficiencies or widen scope or severity
- Not protected
- Incident and accident reports, wound logs and infection control logs
- Refusal to produce evidence
- Cited at F865; plan of correction required; remedies up to termination of the provider agreement
Applies to: Medicare-certified skilled nursing facilities · Medicaid-certified nursing facilities · Facilities that are part of a multiunit chain
What F865 covers
F865 enforces the program-level parts of 42 CFR 483.75, paragraphs (a), (b), (f), (h) and (i). These cover the program, its design, governing body accountability, limits on disclosing committee records and good faith protection. The program must be ongoing, comprehensive, data-driven and focused on outcomes of care and quality of life. It must cover all systems of care.
CMS moved the old F866 requirements into F867. Committee membership and meetings are at F868. The home must also keep records and proof of its program, including adverse event systems and corrective action records.
Governing body or executive leadership must keep the program going through staff changes. It must give the program staff time, equipment and training, and check that corrective actions work.
What surveyors check
Surveyors use the Facility Task Pathway for QAPI and QAA Review. They do it after investigating every other area, so their findings stand on their own.
| Surveyors ask for | Have ready |
|---|---|
| The QAPI plan | A written plan based on the facility assessment: how problems are tracked, analyzed and corrected |
| Proof the program runs | Regular data, analysis, and corrective actions with results |
| Adverse event and problem tracking | Reports, logs and analysis showing identification, investigation and prevention |
| Governing body involvement | Reports to the governing body or its designee, priorities set, resources assigned |
| Proof of a good faith attempt | A dated record of data, analysis, cause, action and monitoring for the issue the survey team found |
What QAPI records are protected
Committee minutes and internal papers are generally protected. That ends when they hold the proof needed to decide whether the home meets the QAPI rules. Then the home must let surveyors review and copy them. Incident and accident reports, wound logs and infection control logs are not protected, and surveyors may request them at any point.
If QAPI material is patient safety work product held with a patient safety organization (PSO), surveyors must not ask to see it. They ask to see the PSO agreement. CMS warns of a trap. If all QAPI proof sits in the protected system, the home may be unable to show compliance without a separate non-confidential record.
How to show a good faith attempt
If the committee already found the issue and made a good faith attempt to correct it, the home is not cited for QAPI. Other tags may still apply. Surveyors ask when the home should have known, what it did, and whether enough time has passed to judge the result.
- Collect dataFrom incidents, complaints, MDS and audits, on high-risk, high-volume or problem-prone issues.
- AnalyzeFind where results fall short of what is expected.
- Study the causeFind underlying causes and contributing factors.
- ActStart a corrective action with an owner and a date.
- MonitorCheck whether the fix holds. Revise it if not.
What raises F865 severity
The F865 guidance has no severity examples. If the home refuses to produce proof of QAPI compliance, surveyors cite F865 and require a plan of correction. Remedies can run up to termination of the provider agreement. QAPI sections are not on the substandard quality of care list in 42 CFR 488.301.
Harm links to other tags. At scope and severity level E or higher, or with substandard quality of care, the QAPI reviewer asks if monitoring should have caught it. Issues likely to cause serious harm, impairment or death must be answered immediately. F867 shows QAPI findings at immediate jeopardy.
Cadence and clocks
| Item | Timing |
|---|---|
| Present the QAPI plan | Each annual recertification survey; on request at any other survey |
| QAPI documentation and evidence of implementation | On request of the State Survey Agency, a federal surveyor or CMS |
| QAA committee meeting | At least quarterly and as needed. See F868 |
| Performance improvement project | At least annually on a high-risk or problem-prone area. See F867 |
Gaps that lead to citations
- The plan is generic, not tailored to this home.
- Nothing links the plan to the facility assessment.
- No record shows governing body review of QAPI results or priorities.
- Minutes list topics with no data, decisions, owners or dates.
- All QAPI proof sits in a protected PSO system, with no separate record.
- A good faith attempt is claimed, but no dated actions exist.
How IncidentKit supports F865
IncidentKit keeps the non-confidential record surveyors can ask for: incidents, investigations, corrective actions and an audit trail of who did what and when. Compliance packets assemble QAPI summaries and analytics support setting priorities from data. It does not write your QAPI plan or replace your governing body's review. See the QAPI guide.
How IncidentKit supports this requirement
| What the rule asks for | Where it lives in IncidentKit |
|---|---|
| Documentation and evidence of an ongoing QAPI program | Incidents, investigations and corrective actions form a record with an audit trail, and compliance packets assemble QAPI summaries. |
| Systems that identify, report, investigate, analyze and prevent adverse events | Intake, routing, investigations and analytics cover the identify-to-analyze steps. |
| Corrective actions evaluated for effectiveness | Corrective actions carry an owner, due date, evidence and effectiveness check. Nothing closes until verified. |
| Evidence of a good faith attempt | Dated records of data, analysis, cause, action and monitoring, from the audit trail and analytics. |
| QAPI plan and governing body oversight | IncidentKit does not write your plan or replace governing body review. Attach both to the compliance packet. |
Product parts involved: Incident reporting, Investigations and RCA, Corrective actions (CAPA), Analytics, Compliance packets, Audit trail, Multi-site and roles. Capabilities marked “rolling out” are being released in stages; see the changelog.
Frequently asked questions
What does a surveyor review under F865?
Whether the home keeps proof of an ongoing QAPI program, can present its plan, and has governing body oversight. They check at the end of the survey.
Are incident reports protected from surveyors?
No. CMS says incident and accident reports, wound logs and infection control logs are not protected, and surveyors may request them at any time.
Can a nursing home put all QAPI records in a patient safety organization?
Yes, but CMS warns that keeping every QAPI record there may leave the home unable to show compliance. A second, non-confidential system is allowed.
What counts as a good faith attempt?
Proof that the QAA committee found the issue and acted: data, analysis, causes, corrective action and monitoring. A claim alone is not enough.
What happens if a home will not provide QAPI proof?
It is cited at F865 and needs a plan of correction. Remedies can go up to termination of the provider agreement under 42 CFR 489.53.
Sources
- eCFR, 42 CFR 483.75 (quality assurance and performance improvement), current through 2026-10-01
- CMS State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities (Rev. 232, issued 07-23-25; revised guidance used on surveys since 04-28-25): F865 section (Rev. 211, issued 02-03-23, effective 10-21-22, implementation 10-24-22)
- LeadingAge, List of Revised F-tags in New RoPs Guidance 2022 (tag titles as listed for CMS's June 2022 revisions)
- CMS memo QSO-25-14-NH (revised 2025-03-10): Revised Long-Term Care Surveyor Guidance, effective April 28, 2025
- CMS State Operations Manual, Chapter 7, Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities (Rev. 244, issued 06-26-26): scope and severity matrix, immediate jeopardy, substandard quality of care
- eCFR, 42 CFR 488.301 (definitions: immediate jeopardy, substandard quality of care), current through 2026-10-01
- CMS, Revision History for LTC Survey Process Documents and Files (updated 08-13-2026): confirms the official Appendix PP version posted 05/21/25
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.
Map this requirement to your records.
IncidentKit connects each rule to the incident, investigation and corrective action that satisfy it.