What CMS Surveyors Look For in Your QAPI Program

The Quality Assurance and Performance Improvement (QAPI) program is one of the most scrutinized areas during a CMS home health survey. Under the Medicare Conditions of Participation (§484.65), agencies are required to maintain a QAPI program that is data-driven, patient-focused, and demonstrates continuous improvement. Surveyors will carefully evaluate whether your QAPI program goes beyond “checking the box” and truly drives quality outcomes. This article explains what surveyors look for in your QAPI program and how to keep your agency compliant and survey-ready.

Understanding the QAPI Condition of Participation (§484.65)

CMS requires every home health agency to:

1. Develop, implement, evaluate, and maintain an effective QAPI program.

2. Ensure the program is ongoing, comprehensive, and data-driven.

3. Focus on indicators of improved outcomes, patient safety, and quality of care.

4. Conduct Performance Improvement Projects (PIPs) annually.

5. Maintain documentation of QAPI activities for surveyors.

What CMS Surveyors Look For in Your QAPI Program

1. Evidence of Data-Driven Monitoring

Surveyors want to see that your QAPI program is guided by measurable data.

• Do you collect data on infection rates, falls, medication errors, and hospital readmissions?

• Are you using OASIS and CASPER reports for outcome analysis?

• Is the data consistently reviewed and trended over time?

Red Flag: Agencies that cannot show surveyors how data influences decision-making will be cited under §484.65(b) (Program Scope).

2. Active Performance Improvement Projects (PIPs)

QAPI is more than data collection—it requires action.

• Do you have at least one active PIP per year addressing a high-risk, high-volume, or problem-prone area?

• Can staff explain the purpose and progress of the PIP?

• Are the interventions documented and outcomes measured?

Survey Focus: CMS expects agencies to demonstrate not only that PIPs are in place but that they resulted in measurable improvement.

3. Governing Body Oversight

Surveyors will confirm that your agency’s governing body is involved in the QAPI process.

• Are QAPI findings reported to leadership?

• Does the governing body approve PIPs and resources for quality improvement?

• Is there documentation of governing body involvement (e.g., meeting minutes)?

Survey Trigger: Deficiencies under §484.65(d) if there is no evidence of leadership accountability.

4. Staff Engagement in QAPI

Surveyors often interview staff to ensure QAPI isn’t just a paper program.

• Do field clinicians know what the QAPI program is and how they contribute?

• Can staff describe any recent PIPs or improvement goals?

• Are education and feedback loops documented?

Survey Focus: CMS requires evidence that QAPI is agency-wide and not limited to administrators.

5. Documentation of Ongoing Improvement Activities

Your QAPI binder or electronic system must show clear evidence of ongoing work:

• Data collection schedules and monitoring tools.

• QAPI committee meeting minutes.

• PIP action plans, interventions, and outcomes.

• Policies and procedures that align with §484.65.

Red Flag: “Stale” QAPI documentation (e.g., outdated data, last meeting 6 months ago) is a common survey deficiency.

Common Deficiencies Surveyors Cite in QAPI Programs

• No evidence of active PIPs.

• Data collected but not analyzed or acted upon.

• Lack of governing body involvement.

• Documentation limited to “meeting minutes” without measurable outcomes.

• Staff unable to describe QAPI goals or activities.

Best Practices to Stay Survey-Ready

• Keep QAPI Ongoing: Schedule monthly or quarterly reviews, not just annual reports.

• Tie QAPI to Patient Outcomes: Always connect data and PIPs back to how they improve patient care.

• Train Staff: Include QAPI education in orientation and ongoing in-services.

• Show Progress: Even if a PIP isn’t fully resolved, surveyors want to see documented effort and measurable steps.

• Audit Documentation: Ensure your QAPI binder or electronic records are organized, up-to-date, and easily accessible.

Conclusion: Building a QAPI Program That Passes Surveyor Scrutiny

CMS surveyors expect a living, breathing QAPI program—not just a binder on a shelf. By focusing on data-driven outcomes, active PIPs, governing body oversight, staff involvement, and detailed documentation, your agency will stay compliant with §484.65 and strengthen the quality of care delivered to patients.

At SummitRidge, we help home health agencies design and maintain QAPI programs that not only meet CMS requirements but also deliver measurable quality improvements. Our consulting team provides custom QAPI templates, PIP frameworks, and compliance documentation to keep your agency survey-ready at all times.