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Administration / QAPI42 CFR §483.75(g)

F0868QAPI/QAA Program Activities

F0868 requires the facility to have a QAA (Quality Assessment and Assurance) committee that meets at least quarterly, includes required members (director of nursing, a physician, and other designated staff), and develops/implements corrective action plans for identified quality deficiencies.

Common Deficiency Examples

  • QAA committee not meeting the required minimum frequency
  • Required committee membership not present or not documented
  • Corrective action plans developed but not tracked to completion
  • Committee meeting minutes lacking substantive quality discussion

What Your Plan of Correction Needs

F0868 PoCs should show the committee functioning as required, with documentation to prove it:

Gap identifiedmeeting frequency, membership, or follow-through issue
Immediate actionany catch-up meeting or membership correction
Systemic fixcalendar-locked meeting schedule and defined membership roster
Monitoring planmeeting minutes and action-item tracking reviewed at each meeting
See the four required elements of every Plan of Correction →

Frequently Asked Questions

How is F0868 different from F0865 and F0867?+

F0865 covers overall QAPI improvement activities; F0867 covers data collection/monitoring specifically; F0868 covers the QAA committee's structure and required activities. They're closely related and frequently cited together.

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