C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER G—STANDARDS AND CERTIFICATION › PART 483—REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES › Subpart B—Requirements for Long Term Care Facilities

42 C.F.R. § 483.75

Quality assurance and performance improvement

Read at: eCFRecfr.gov CornellLII GovInfogovinfo.gov CasesGoogle Scholar

(a) Quality assurance and performance improvement (QAPI) program. Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must—

(1) Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities;

(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation;

(3) Present its QAPI plan to a State Survey Agency or Federal surveyor at each annual recertification survey and upon request during any other survey and to CMS upon request; and

(4) Present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements to a State Survey Agency, Federal surveyor or CMS upon request.

(b) Program design and scope. A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must:

(1) Address all systems of care and management practices;

(2) Include clinical care, quality of life, and resident choice;

(3) Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a SNF or NF.

(4) Reflect the complexities, unique care, and services that the facility provides.

(c) Program feedback, data systems and monitoring. A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at § 483.71 and including how such information will be used to develop and monitor performance indicators.

(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

(d) Program systematic analysis and systemic action. (1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

(2) The facility will develop and implement policies addressing:

(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;

(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems ; and

(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

(e) Program activities. (1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

(3) As a part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at § 483.71. Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

(f) Governance and leadership. The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that—

(1) An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities.

(2) The QAPI program is sustained during transitions in leadership and staffing;

(3) The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed;

(4) The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to resident based on performance indicator data, and resident and staff input, and other information.

(5) Corrective actions address gaps in systems, and are evaluated for effectiveness; and

(6) Clear expectations are set around safety, quality, rights, choice, and respect.

(g) Quality assessment and assurance. (1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:

(i) The director of nursing services;

(ii) The Medical Director or his or her designee;

(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and

(iv) The infection preventionist.

(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary; and

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; and

(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.

(h) Disclosure of information. A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section.

(i) Sanctions. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

[81 FR 68867, Oct. 4, 2016, as amended at 82 FR 32259, July 13, 2017; 89 FR 41000, May 10, 2024]
Notes of Decisions
Cited in 49 cases (7 in the last 5 years), 1997–2025 · leading case: United States ex rel. Johnson v. Golden Gate Nat'l Senior Care, L.L.C., 223 F. Supp. 3d 882 (D. Minnesota 2016).
Sort: Relevance Newest Treatment
United States ex rel. Johnson v. Golden Gate Nat'l Senior Care, L.L.C., 223 F. Supp. 3d 882 (D. Minnesota 2016). · cites it 12× “During the time period at issue, 42 C.F.R. § 483.75 (b) required SNFs to “operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals…”
United States v. Anderson, 605 F.3d 404 (6th Cir. 2010). · cites it 4× “A facility’s ongoing participation in Medicaid is conditioned on its compliance with various federal, state, and local regulations, 42 C.F.R. § 483.75 (b), including the requirement that a long-term healthcare facility “designate a physician to serve as medical director,” 42 C.”
Bedell v. Williams, 386 S.W.3d 493 (Ark. 2012). · cites it 3× “17WiIliams argues, as she did below, that 42 C.F.R. § 483.75 (d) creates the duty required.”
United States Ex Rel. Absher v. Momence Meadows Nursing Ctr., Inc., 764 F.3d 699 (7th Cir. 2014). · cites it 2× “” See 42 C.F.R. § 483.75 (d); A-913. Thus, he was legally responsible “for establishing and implementing policies regarding the management and operation of the facility.”
Wirth v. Sun Healthcare Grp., Inc., 2017 NMCA 007 (N.M. Ct. App. 2016). · cites it 3× “{10} The federal regulation, 42 C.F.R. § 483.75 (h) (2014), is part ofa complex scheme of conditions that nursing homes must meet to participate in medicare and medicaid programs.”
Mariner Health Care v. Est. of Edwards, 964 So. 2d 1138 (Miss. 2007). · cites it 2× “42 C.F.R. § 483.75 ( l )(1)(i)(ii); Miss.”
Sunshine Haven Nursing Operations, LLC v. United States Dep't of Health & Human Servs., Centers for Medicare & Medicaid Servs., 742 F.3d 1239 (10th Cir. 2014). · cites it 3× “” 42 C.F.R. § 483.75 (o )(4). The DAB upheld the ALJ’s conclusion that Sunshine failed to show the additional deficiencies cited under § 483.”
Beverly Health & Rehab. Servs., Inc. v. Thompson, 223 F. Supp. 2d 73 (D.D.C. 2002). · cites it 3× “5 - 42 CFR 483.75) [the regulations].” (Pis.’ Mem.”
Moore v. Warr Acres Nursing Ctr., LLC., 2016 OK 28 (Okla. 2016). · cites it 2× “5 The exhibit list includes: Oklahoma Department of Health Regulation §310: 675-7-17-1 governing infection control in nursing homes; 42 Code of Federal Regulation §483.65, governing facilities which provide medicare & medicaid services; 42 CFR §483.”
Watkins v. Arkansas Elder Outreach of Little Rock, Inc., 420 S.W.3d 477 (Ark. Ct. App. 2012). · cites it 2× “Watkins in order to owe her a duty, and that certain federal and state statutes and regulations imposed a duty of care upon him.”
Crestview Parke Care Ctr. v. Tommy Thompson United States Dep't of Health & Human Servs., 373 F.3d 743 (6th Cir. 2004). · cites it 2× “Fifth, the ODH found that Crest-view failed to provide the annual twelve hours of in-service training that were “sufficient to ensure the continuing competence of nurse aides,” 42 C.F.R. § 483.75 (e)(8)®, for fourteen of the twenty-nine nurse aides employed at Crestview.”
St. Benedict's Health Ctr. v. North Dakota Dep't of Human Servs., 2004 ND 63 (N.D. 2004). · cites it 7× “Benedict’s employed some “certified nurse assistants” and also employed between twenty-two and twenty-five “nursing department helpers” who had not been certified as “nurse aides” under 42 C.F.R. § 483.75 (e) and who performed “non-hands-on jobs that a [certified nurse…”
Show all 49 citing cases →
— 42 C.F.R. § 483.75(b) — 1 case
Centennial Healthcare Mgmt. Corp. v. Dep't of Consum. & Indus. Servs., 657 N.W.2d 746 (Mich. Ct. App. 2003).
— 42 C.F.R. § 483.75(d) — 1 case
Scott v. Cent. Arkansas Nursing Centers, Inc., 278 S.W.3d 587 (Ark. Ct. App. 2008).
— 42 C.F.R. § 483.75(h)(1) — 1 case
Wirth v. Sun Healthcare Grp., Inc., 2017 NMCA 007 (N.M. Ct. App. 2016). “{10} The federal regulation, 42 C.F.R. § 483.75 (h) (2014), is part ofa complex scheme of conditions that nursing homes must meet to participate in medicare and medicaid programs.”
— 42 C.F.R. § 483.75(k) — 1 case
JSC Lake Highlands Operations, LP D/B/A Villages of Lake Highlands, Metrostat Diagnostic Servs., Inc., Richard M. Williams, M.D. & Richard M. Williams, M.D., P.L.L.C. v. Karen Miller, Individually & as Rep. of the Est. of Betty Ruth Hathcock & Betty Crockett, Individually, 539 S.W.3d 359 (Tex. App. 2016).
— 42 C.F.R. § 483.75(o)(3) — 1 case
Nordman v. The Evangelical Lutheran Good Samaritan Soc'y, Inc. (W.D. Ky. 2021).
— 42 C.F.R. § 483.75(r) — 1 case
Hyland Assisted Living & Memory Care LLC v. Dhhs (Mich. Ct. App. 2019).
— 42 C.F.R. § 483.75(r)(3) — 1 case
Hyland Assisted Living & Memory Care LLC v. Dhhs (Mich. Ct. App. 2019).
— 42 C.F.R. § 483.75(s) — 1 case
Hyland Assisted Living & Memory Care LLC v. Dhhs (Mich. Ct. App. 2019).
Annotations are extracted automatically from the opinions in the Syfert caselaw corpus and ranked by authority, recency, and treatment. Dots show Syfertize treatment of the citing case itself.