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Administration / QAPI42 CFR §483.75(d)
F0867 — QAPI/QAA Data Collection/Monitoring
F0867 requires the facility's QAPI program to use data to monitor performance in areas including adverse events, and to develop corrective actions when data indicates a problem. This tag focuses specifically on whether the facility is actually collecting and acting on data, not just the program's existence.
Common Deficiency Examples
- Adverse event data collected but not analyzed for trends or acted upon
- QAPI data collection not covering all federally required focus areas
- Identified negative trend in data without a corresponding corrective action plan
- Data collection frequency inconsistent with the facility's own QAPI plan
What Your Plan of Correction Needs
F0867 PoCs should demonstrate a closed loop from data to action:
Gap identifiedwhich data area wasn't being collected, analyzed, or acted on
Immediate actionany retrospective analysis of the missed data period
Systemic fixdefined data collection tool, frequency, and review responsibility
Monitoring planQAPI committee review cadence with documented action items and follow-through
Frequently Asked Questions
What data is a facility required to track under QAPI?+
Requirements include adverse events and other facility-identified risk areas — the exact required scope should be confirmed against current CMS QAPI guidance rather than assumed to be a fixed universal list.
Related tags in Administration / QAPI
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