Nursing homes and other healthcare facilities must develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. The program must address all systems of care and management practices, include clinical care, quality of life, and resident choice, utilize the best available evidence to define and measure indicators of quality and facility goals, and reflect the complexities, unique care, and services that the facility provides. The governing body and/or executive leadership is responsible for ensuring the ongoing QAPI program is defined, implemented, and maintained, and that the QAPI program is adequately resourced. The facility must present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of the regulation, and 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. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions. This letter will impact nursing homes/healthcare facilities by requiring them to develop and maintain a QAPI program that focuses on indicators of the outcomes of care and quality of life. The governing body and/or executive leadership must ensure the QAPI program is adequately resourced, and the facility must present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of the regulation, and 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.

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