CMS-Mandatory Compliance Programs Every Nursing Home Needs
Beyond individual care standards, 42 CFR Part 483 requires nursing homes to run several facility-wide programs — not just policies on paper, but ongoing, documented activity CMS expects to see evidence of at survey.
Quick answer
42 CFR Part 483, Subpart B requires nursing homes to maintain several facility-wide compliance programs: QAPI (§483.75), Infection Prevention and Control (§483.80), Compliance and Ethics (§483.85), Emergency Preparedness (§483.73), Abuse/Neglect/Exploitation Prevention (§483.12), a Facility Assessment (§483.71), and facility-wide Training (§483.95). Each requires ongoing, documented activity — not a policy that exists only on paper.
The programs, and what CMS expects from each
Quality Assurance and Performance Improvement (QAPI)
42 CFR §483.75An ongoing, data-driven program covering the full range of care and services the facility provides, run through a QAA committee that reviews data and directs corrective action.
Infection Prevention and Control Program
42 CFR §483.80Written standards for surveillance, hand hygiene, isolation precautions, and outbreak response, overseen by a designated, trained Infection Preventionist who participates in the facility’s QAPI process.
Compliance and Ethics Program
42 CFR §483.85Required of every facility under the Affordable Care Act; must include written standards and procedures, a way to communicate them to staff, and — for organizations operating five or more facilities — annual staff training.
Emergency Preparedness Program
42 CFR §483.73A risk-based emergency plan, policies and procedures, a communication plan, and a training and testing program, reviewed and updated at least annually.
Abuse, Neglect, and Exploitation Prevention
42 CFR §483.12Written policies and procedures for screening staff, training, preventing and identifying abuse, and reporting and investigating any allegation.
Facility Assessment
42 CFR §483.71A written assessment of the facility’s resident population and the resources needed to care for it, reviewed and updated at least annually and whenever there is a significant change.
Training Requirements
42 CFR §483.95A facility-wide training program covering communication, resident rights, abuse/neglect/exploitation, QAPI, infection control, compliance and ethics, and behavioral health, among other required topics.
Why these get audited as programs, not checkboxes
Surveyors don't just ask whether a policy exists — they ask for evidence the program is actually running: QAPI committee minutes, infection control surveillance logs, compliance training attendance, emergency plan testing records. A program that exists only as a binder on a shelf, without a documented trail of ongoing activity, is functionally the same as not having one at all from a survey standpoint.
PoC360's Programmes Monitor
PoC360 tracks your CMS-mandatory compliance programmes in one dashboard with RAG status — green, amber, or red — so gaps in QAPI, infection control, abuse prevention, and the rest surface before a surveyor finds them, with an evidence log built in.
See the Programmes Monitor →Frequently Asked Questions
How many CMS-mandatory compliance programs must a nursing home maintain?+
Seven, under 42 CFR Part 483, Subpart B: QAPI (§483.75), Infection Prevention and Control (§483.80), Compliance and Ethics (§483.85), Emergency Preparedness (§483.73), Abuse/Neglect/Exploitation Prevention (§483.12), a Facility Assessment (§483.71), and facility-wide Training (§483.95).
What does the Compliance and Ethics Program require?+
Required of every facility under the Affordable Care Act, it must include written standards and procedures and a way to communicate them to staff. Organizations operating five or more facilities must also provide annual staff training on the program.
How often must the Emergency Preparedness Program and Facility Assessment be updated?+
The Emergency Preparedness Program must be reviewed and updated at least annually. The Facility Assessment must be reviewed and updated at least annually and whenever there is a significant change to the resident population or the resources needed to care for it.
What evidence does CMS expect beyond a written policy for each program?+
Documented, ongoing activity — QAPI committee minutes, infection control surveillance logs, compliance training attendance records, and emergency plan testing records. A program that exists only as a binder on a shelf, without that evidence trail, is treated the same as not having one at survey.