Use this as a working plan at the start of a year, after a leadership transition, or when regulations change. It is organized around federal and South Carolina requirements that surveyors actually use. Which items apply depends on your license type.
Days 1-30: Assess
| Action | Applies to | Reference |
|---|---|---|
| Compare policies against current regulations | All; the regulation depends on license type | CRCFs: R.60-84 (amended May 23, 2025). Nursing homes: R.60-17 and 42 CFR Part 483. Adult day: R.60-75. |
| Confirm the facility assessment is current | Nursing homes | 42 CFR 483.70(e) |
| Review the last 12 months of incident reports for patterns, and run a documentation audit on a sample of records | All | Audit approach in HHS-OIG's General Compliance Program Guidance |
| Check your QAPI program against the five CMS QAPI elements: design and scope; governance and leadership; feedback, data systems and monitoring; performance improvement projects; systematic analysis and systemic action | Nursing homes | CMS QAPI Five Elements |
Days 31-60: Close gaps
| Action | Applies to | Reference |
|---|---|---|
| Update outdated policies with a version and review date | All | |
| Fix the specific gaps your audit found with targeted retraining, then verify the change in practice | All | |
| Make sure the QAPI plan includes at least one performance improvement project each year focused on a high-risk or problem-prone area | Nursing homes | 42 CFR 483.75(e) |
Days 61-90: Verify and sustain
| Action | Applies to | Reference |
|---|---|---|
| Run a mock survey walkthrough using your licensing regulation or CMS survey guidance as the checklist | All | Your licensing regulation or CMS survey guidance |
| Confirm emergency preparedness items are current: plan, policies and communication plan reviewed and updated at least annually; training at least annually; exercises at least twice a year | Nursing homes | 42 CFR 483.73 |
| Hold QAA committee meetings at least quarterly, and use that rhythm as your audit-and-close-gaps cycle even if you are not federally certified | Nursing homes (the rhythm helps any provider) | 42 CFR 483.75(g)(2) |
Treat this as a repeating cycle, not a one-time project.
Sources: 42 CFR 483.70, 483.73, 483.75; CMS QAPI Five Elements; SC DPH regulations R.60-17, R.60-75, R.60-84; HHS-OIG GCPG.
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