# One record you can stand behind when the surveyor asks

> Every report, deadline and action in one place, with numbers for your board.

Source: https://incidentkit.ai/solutions/facility-administrators · Updated Oct 5, 2026

**Who:** Staff report and department heads investigate. You sign state reports, answer to the governing body and own survey readiness.

## The problems

- **You find out last:** Nursing home allegations must reach you at once, and within 2 hours for abuse or serious bodily injury. A phone tree cannot promise that.
- **Survey readiness is a scramble:** A nursing home must show its QAPI plan and proof it works at each annual recertification survey. Binders mean a scramble when the team arrives.
- **The plan of correction deadline is short:** CMS says a plan of correction is due 10 calendar days after the CMS-2567. It covers affected residents, others at risk, system changes and monitoring.
- **The governing body asks for numbers:** The governing body answers for QAPI (42 CFR 483.70(d) in nursing homes, 42 CFR 416.41 in surgery centers). It wants trends and proof fixes worked.

## Incident types in the pack

- Abuse, neglect and exploitation allegations, reportable in 2 or 24 hours
- Falls with injury and injuries of unknown source
- Resident and patient complaints and grievances
- Events that need a call to the family or responsible party
- State filings for reportable events
- Medication errors
- Staff injuries and workers' compensation claims
- Infection outbreaks and public health notices
- Survey findings, CMS-2567s and plans of correction in progress
- Quarterly QAA committee agendas and minutes
- Carrier notices and renewal questions on incident history
- Overdue corrective actions, by department and owner

## Regulators and standards

- **Administration, 42 CFR 483.70(d):** The governing body appoints the administrator. The administrator manages the facility and answers to it. The governing body answers for the QAPI program.
- **Abuse and neglect reporting, 42 CFR 483.12(c):** Report alleged violations at once to the administrator and State Survey Agency. Allow 2 hours for abuse or serious bodily injury, otherwise 24. Results are due in 5 working days.
- **QAPI, 42 CFR 483.75 (F865, F868):** Present the QAPI plan at each annual recertification survey. Show the program is running. The QAA committee includes the administrator, owner, a board member or another leader.
- **Plans of correction, 42 CFR 488.402(d):** Deficiencies need a plan of correction, except isolated ones with potential for minimal harm and no actual harm. CMS says it is due within 10 calendar days of the CMS-2567.
- **Surgery centers, 42 CFR 416.41 and 416.43:** The governing body has full legal responsibility for the ASC's policies and for its QAPI program. That program must track adverse patient events and document improvement projects.
- **State licensing and reportable events:** States add their own reportable-event rules and timelines. Check yours. See [state reporting overview](https://incidentkit.ai/compliance/reporting-deadlines/state-reporting-overview).

## How it works

1. **You hear first, by rule** Allegations and serious events route to you the moment they are reported, with the 2-hour, 24-hour and 5-working-day windows noted on the record. Lauren drafts the report as the nurse describes what happened.
2. **You see every open clock and action** One view shows open incidents, reporting windows, overdue actions by department and owner, and plans of correction in progress.
3. **You sign what is complete** You review the draft, edit it and sign. Fields Lauren drafted stay marked 'Lauren · draft' until a person approves them, and every change goes into the audit trail with who, when and what.
4. **You are ready before the survey** QAPI summaries and survey packets build from the record. When a CMS-2567 arrives, the investigation, the evidence and the effectiveness checks are already in one place.

## Scenario: A survey exit and the 10-day plan of correction

A nursing home survey cites one falls deficiency, and the administrator has 10 calendar days from receiving the CMS-2567 to return a plan.

- **Survey day 4, 15:00, Exit conference cites F689 deficiency.** The administrator opens the records for the residents named in the deficiency tied to F689.
- **Survey day 4, 16:00, Resident records show the full trail.** Each record shows the incident, investigation, interventions, and the evidence and checks for each action.
- **Day 5, Deadline set, plan sections assigned.** The CMS-2567 arrives. The administrator sets the 10-calendar-day deadline. Plan sections go to the director of nursing and unit managers.
- **Day 6, Plan of correction takes shape.** The plan covers affected residents and how others at risk are found. It states what systems change and how the facility will monitor.
- **Day 8, Corrective actions created, audit scheduled.** New corrective actions get owners, dates and evidence requirements. A monitoring audit is scheduled. Results go to the QAA committee.
- **Day 9, Signed plan carries an evidence index.** The administrator reviews the draft plan, edits it and signs. The evidence index attaches to the signed plan.
- **Day 40, Effectiveness checks reach the QAA agenda.** The effectiveness checks come due, and the administrator reports results to the governing body.

## What is in the pack

**Forms:** Incident report for your setting: nursing home, surgery center and others; Abuse and neglect form with reporting windows and 5-working-day result; Complaint and grievance record; Corrective action plan: owner, due date, evidence, check

**Routing:** Allegations and serious events go to you at once; Department-head routing by event type; Alerts to the corporate office by severity; Overdue actions remind the owner, then you

**Exports:** QAPI summary for the QAA committee and governing body; Survey packet; Plan of correction evidence index; Timestamped reportable-event record for your state filing

**Roles:** Administrator: receives, reviews and signs; Director of nursing and department heads: investigate, own actions; Corporate office: reads across facilities; Reporters: any staff member, by text, QR, email or web

## Outcomes

- **Hear first:** Routing rules put allegations and serious events in front of you as they are reported, not after the phone tree.
- **Survey evidence in one place:** Incidents, investigations, actions and checks sit together, so QAPI evidence is a view, not a binder. See [always survey-ready](https://incidentkit.ai/use-cases/always-survey-ready).
- **A plan of correction built on fact:** When a CMS-2567 arrives, the record shows what was done, by whom and whether it was checked. A credible plan needs that.
- **Numbers for the governing body:** Trends by shift, location and cause, plus open and verified actions, go to the governing body as a signed summary.

## Frequently asked questions

### Who has to be told within two hours of an abuse allegation?

The administrator and other officials, including the State Survey Agency, must be told immediately. Allow 2 hours if abuse is involved or serious bodily injury results (42 CFR 483.12(c)(1)), otherwise 24 hours. This covers alleged abuse, neglect, exploitation or mistreatment, including injuries of unknown source. See [abuse reporting deadlines](https://incidentkit.ai/use-cases/abuse-reporting-deadlines).

### What does a surveyor ask to see for QAPI?

Your QAPI plan at each annual recertification survey. On request, also proof that the program is running. That includes systems to find, report, investigate and prevent adverse events, plus corrective actions you evaluated. See the [QAPI requirements for nursing homes](https://incidentkit.ai/compliance/cms-qapi/skilled-nursing-facilities).

### How long do we have to submit a plan of correction?

Within 10 calendar days of the date you receive the statement of deficiencies, form CMS-2567, CMS says. See [plan of correction](https://incidentkit.ai/compliance/survey-readiness/plan-of-correction).

### Does IncidentKit file state reports for me?

No. IncidentKit holds the record and shows the reporting windows. State filing channels differ. The final submission is the administrator's job. Check your state's rules.

### What if I run a surgery center, assisted living community, hospice or home-health agency?

Each setting has its own pack, forms and regulations. See [surgery centers](https://incidentkit.ai/solutions/ambulatory-surgery-centers) and [assisted living](https://incidentkit.ai/solutions/assisted-living). State licensing rules apply on top of federal ones, so check yours.

## Sources

- [42 CFR 483.70, Administration (eCFR)](https://www.ecfr.gov/current/title-42/part-483/section-483.70)
- [42 CFR 483.12, Freedom from abuse, neglect and exploitation (eCFR)](https://www.ecfr.gov/current/title-42/part-483/section-483.12)
- [42 CFR 483.75, Quality assurance and performance improvement (eCFR)](https://www.ecfr.gov/current/title-42/part-483/section-483.75)
- [42 CFR 488.402, Remedies, plan of correction requirement (eCFR)](https://www.ecfr.gov/current/title-42/part-488/section-488.402)
- [CMS, Nursing home enforcement FAQ (plan of correction timing)](https://www.cms.gov/medicare/provider-enrollment-and-certification/surveycertificationenforcement/downloads/nh-enforcement-faq.pdf)
- [CMS, Form CMS-2567 Statement of Deficiencies and Plan of Correction](https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms2567.pdf)
- [42 CFR 416.41, ASC governing body and management (eCFR)](https://www.ecfr.gov/current/title-42/part-416/section-416.41)
- [42 CFR 416.43, ASC QAPI (eCFR)](https://www.ecfr.gov/current/title-42/part-416/section-416.43)
- [CMS State Operations Manual, Appendix PP (F689, F865, F868)](https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf)

## Related

- [Always Survey-Ready: Stay Prepared for Unannounced Surveys](https://incidentkit.ai/use-cases/always-survey-ready)
- [Abuse Reporting Deadlines for Nursing Homes: 2 and 24 Hours](https://incidentkit.ai/use-cases/abuse-reporting-deadlines)
- [QAPI Committee Meetings: Agenda, Data and Minutes](https://incidentkit.ai/use-cases/qapi-committee-meetings)
- [Incident routing and escalation by severity](https://incidentkit.ai/product/routing-and-escalation)
- [Incident reporting software for skilled nursing facilities](https://incidentkit.ai/solutions/skilled-nursing-facilities)
- [Incident reporting software for surgery centers](https://incidentkit.ai/solutions/ambulatory-surgery-centers)
- [Incident reporting software for assisted living](https://incidentkit.ai/solutions/assisted-living)
- [Incident reporting software pricing: free to start](https://incidentkit.ai/pricing)
- [Plan of correction (CMS-2567): elements and 10-day deadline](https://incidentkit.ai/compliance/survey-readiness/plan-of-correction)
- [Nursing home recertification survey: process and prep](https://incidentkit.ai/compliance/survey-readiness/snf-recertification-survey)
- [ASC survey readiness: what surveyors ask for and check](https://incidentkit.ai/compliance/survey-readiness/asc-survey-readiness)
- [Nursing home QAPI requirements: 42 CFR 483.75 explained](https://incidentkit.ai/compliance/cms-qapi/skilled-nursing-facilities)
- [F865 QAPI program and plan: what surveyors ask for](https://incidentkit.ai/compliance/f-tags/f865)
- [F868 QAA committee: members, meetings and evidence](https://incidentkit.ai/compliance/f-tags/f868)