# F868: the QAA committee

> F868 requires a quality assessment and assurance committee. Members are the director of nursing, the medical director or a designee, the infection preventionist and at least three other staff. One of those three is the administrator, owner, board member or another leader. It meets at least quarterly and reports to the governing body.

Source: https://incidentkit.ai/compliance/f-tags/f868 · Updated Oct 5, 2026

## Key facts

- **Tag title:** QAA Committee
- **Regulation:** 42 CFR 483.75(g)(1) and (g)(2)(i); 483.80(c) for the infection preventionist's role
- **Guidance relied on:** Appendix PP Rev. 232 (issued 07-23-25, in use since 04-28-25); F868 section Rev. 225 (08-08-24)
- **Minimum members:** DON, medical director or designee, infection preventionist, and three others including a leader
- **Meeting clock:** At least quarterly, and as needed
- **Reporting line:** Reports its activities to the governing body, or whoever acts as one
- **Severity note:** The tag has no severity examples. QAPI sections are not on the substandard quality of care list

- **Citation:** F868 · 42 CFR 483.75(g)(1), (g)(2)(i) and 483.80(c)
- **Authority:** CMS
- **Applies to:** Medicare-certified skilled nursing facilities, Medicaid-certified nursing facilities

## What F868 covers

F868 covers the committee itself. It sets who is on it, how often it meets and whom it reports to. [F867](https://incidentkit.ai/compliance/f-tags/f867) covers what the committee does with data. [F865](https://incidentkit.ai/compliance/f-tags/f865) covers the program and plan.

The committee must include the director of nursing, the medical director or a designee, the infection preventionist and at least three other staff members. One of the three must be the administrator, owner, board member or another leader. That leader needs knowledge of facility systems and authority to change them. Departments such as maintenance, housekeeping and laundry should be able to take part when their data is discussed.

Section 483.80(c) requires the infection preventionist, or at least one of them, to be a member. The infection preventionist reports on the infection prevention and control program regularly. CMS reads that as the same frequency as committee meetings.

## Roster rules surveyors check

*What CMS expects and what to keep*

| Member | What CMS expects | Proof to keep |
| --- | --- | --- |
| Director of nursing | Required member | Attendance on every meeting record |
| Medical director or designee | The designee cannot be another required member such as the DON. It may be a nurse practitioner, clinical nurse specialist or physician assistant who knows the home's policies. The medical director stays responsible for the role | Attendance, plus proof the medical director received and acknowledged the meeting content |
| Infection preventionist | Should attend each meeting and report on the IPCP, outbreaks, healthcare-associated infections and antibiotic stewardship. If absent, another staff member reports, but the IP's duty stays | The IP's report in the minutes |
| Three others, including a leader | At least one is the administrator, owner, board member or other leader with authority to change systems | Names and roles on the roster |

## What surveyors check

Surveyors use the QAPI and QAA Review pathway at the end of the survey. CMS's F868 guidance does not list specific documents. Surveyors also interview staff and leaders about how the committee works.

*What to have ready*

| Surveyors look for | Have ready |
| --- | --- |
| The roster with roles | Every required seat filled, with the medical director's designee, if any, named and qualified |
| Meeting dates over the past year | At least four, with extra meetings when issues needed them |
| Attendance and minutes | Who attended, what data was reviewed, what was decided, owners and dates |
| Report to the governing body | A dated report, or for a small home with no governing body, proof the administrator is a member and briefed |
| Medical director involvement | Proof of meaningful participation, such as reporting on trends from the medication regimen review |

## What raises F868 severity

The F868 guidance gives no severity examples. QAPI sections are not on the substandard quality of care list in 42 CFR 488.301. A missing seat or a skipped quarter is usually a process finding. The risk is indirect. A committee that did not meet, or lacked the right people, may miss problems that harm residents. F867 examples show this can reach immediate jeopardy.

## Meeting and reporting clocks

| Duty | Timing |
| --- | --- |
| Committee meets | At least quarterly, and as needed to do its QAPI work |
| Data review | Often enough that the committee knows whether improvement is needed or happening. Not every data set at every meeting |
| Report to the governing body | Activities and QAPI implementation. The regulation sets no fixed interval |
| Infection preventionist reports | Same frequency as the committee meets |

## Gaps that lead to citations

- One of the four named roles is missing, or the infection preventionist rarely attends.
- The medical director's designee is the DON, who is already a required member.
- The medical director gets no minutes and nothing records acknowledgement.
- A quarter's meeting is skipped with no catch-up meeting.
- Minutes list topics but not data, decisions, owners or dates.
- Nothing shows the governing body received the committee's report.

## How to show a committee that works

Show the loop, not only the meeting. Data comes in, the committee reviews it, assigns corrective actions with owners and dates, and checks results later. Each meeting's minutes should point back to the last and forward to the next.

## How IncidentKit supports F868

IncidentKit does not schedule your committee or keep your official minutes. Attendance and minutes stay in your records. [Compliance packets](https://incidentkit.ai/product/compliance-packets) include a QAPI summary for each meeting. [Analytics](https://incidentkit.ai/product/analytics) show where incidents cluster. Open [corrective actions](https://incidentkit.ai/product/corrective-actions) show what is owed and to whom. Roles and sites are managed under [multi-site and roles](https://incidentkit.ai/product/multi-site-and-roles). See the [QAPI meeting use case](https://incidentkit.ai/use-cases/qapi-committee-meetings) and the [agenda and minutes template](https://incidentkit.ai/templates/qapi-meeting-agenda-and-minutes).

## What the rule asks for, and how IncidentKit supports it

| Requirement | IncidentKit |
| --- | --- |
| Committee with the required members | Roles and sites are managed in the platform, so the right people see the same data. The roster stays in your records. |
| Meet at least quarterly and review data | Compliance packets include a QAPI summary for each meeting. Analytics show clusters by location, shift, equipment and cause. |
| Develop and implement plans of action to correct quality deficiencies | Corrective actions carry an owner, due date, evidence and an effectiveness check, so open items go into each agenda. |
| Infection preventionist reports on the IPCP | Routing and escalation sends infection-related incidents to the infection preventionist, who can bring them to the meeting. |
| Attendance, minutes and governing body report | Not run by IncidentKit. Attach your minutes and sign-in to the compliance packet. |

## Frequently asked questions

### Who must be on a nursing home QAA committee?

The director of nursing, the medical director or a designee, the infection preventionist and at least three other staff. One of the three must be the administrator, owner, board member or another leader.

### How often must the QAA committee meet?

At least quarterly, and as often as needed to coordinate and evaluate QAPI activities. Data must be reviewed often enough to know whether improvement is needed or happening.

### Can the medical director send a designee?

Yes. The designee cannot be another required member, such as the DON, and must know the home's policies. The medical director stays responsible and must receive and acknowledge the meeting content.

### What does the infection preventionist do on the committee?

The IP must be a member and report regularly on the infection program, including outbreaks, healthcare-associated infections and antibiotic stewardship. If absent, another staff member can report, but the IP stays responsible.

### Does the committee have to report to a governing body?

Yes. The committee reports its activities, including QAPI implementation, to the governing body or whoever acts as one. In a small home with no separate governing body, an administrator who is a required member is already briefed.

## Sources

- [eCFR, 42 CFR 483.75 ((g) quality assessment and assurance), current through 2026-10-01](https://www.ecfr.gov/current/title-42/section-483.75)
- [eCFR, 42 CFR 483.80 ((c) infection preventionist participation on the QAA committee), current through 2026-10-01](https://www.ecfr.gov/current/title-42/section-483.80)
- [CMS State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities (Rev. 232, issued 07-23-25; revised guidance used on surveys since 04-28-25): F868 section (Rev. 225, issued 08-08-24, effective 08-08-24, implementation 08-08-24)](https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf)
- [LeadingAge, List of Revised F-tags in New RoPs Guidance 2022 (tag titles as listed for CMS's June 2022 revisions)](https://leadingage.org/sites/default/files/List%20of%20Revised%20F-Tags.pdf)
- [CMS memo QSO-25-14-NH (revised 2025-03-10): Revised Long-Term Care Surveyor Guidance, effective April 28, 2025](https://www.cms.gov/files/document/qso-25-14-nh-revised-2025-03-10.pdf)
- [eCFR, 42 CFR 488.301 (definitions: immediate jeopardy, substandard quality of care), current through 2026-10-01](https://www.ecfr.gov/current/title-42/section-488.301)
- [CMS, Revision History for LTC Survey Process Documents and Files (updated 08-13-2026): confirms the official Appendix PP version posted 05/21/25](https://www.cms.gov/files/document/revision-history-ltc-survey-process-documents-files-updated-08-13-2026.pdf)

## Related

- [F865 QAPI program and plan: what surveyors ask for](https://incidentkit.ai/compliance/f-tags/f865)
- [F867 QAPI improvement activities: adverse event tracking](https://incidentkit.ai/compliance/f-tags/f867)
- [F880 infection prevention and control: survey guide](https://incidentkit.ai/compliance/f-tags/f880)
- [QAPI Committee Meetings: Agenda, Data and Minutes](https://incidentkit.ai/use-cases/qapi-committee-meetings)
- [QAPI Meeting Agenda and Minutes Template (Printable)](https://incidentkit.ai/templates/qapi-meeting-agenda-and-minutes)
- [QAA committee: definition and meaning](https://incidentkit.ai/glossary/qaa-committee)
- [QAPI program guide for ASCs, nursing homes and hospitals](https://incidentkit.ai/guides/qapi-program-guide)