A Performance Improvement Project isn't a committee exercise — for the full regulatory framework governing PIPs, see our QAPI Program Requirements guide. It's a structured, time-limited effort to fix a specific, measurable problem — with data collection before, during, and after to prove whether it worked. CMS requires PIPs under F867 as part of every SNF's QAPI program, but the requirement alone doesn't tell you what to run or how to run it.
These five PIPs cover the clinical areas where independent SNFs carry the most survey risk and quality exposure. Each one includes a problem statement you can adapt directly, a measurable goal with a specific target, a data collection method that doesn't require a data analyst, and intervention steps that a small team can actually execute. If you're building your QAPI program or looking for PIPs that will hold up to surveyor scrutiny, start here.
What Makes a PIP Surveyors Actually Respect
Surveyors reviewing your QAPI program under F867 aren't checking boxes — they're reading your PIPs to see if you identified a real problem, set a measurable goal, collected data, implemented changes, and tracked whether those changes worked. A PIP that checks all five boxes will pass review. A vague "improve falls" project with no baseline data and no closure date will not.
Every PIP in this guide follows the same structure CMS expects:
- Problem statement — specific, data-supported, tied to a real finding in your facility
- Measurable goal — a specific percentage, rate, or count target with a timeframe
- Data collection method — what you're tracking, how often, from what source
- Intervention steps — the actual changes you're making, with owners and timelines
- Documentation of results — data after the intervention compared to baseline, with a close-out or continuation decision
You don't need to run all five simultaneously. Pick the one or two most relevant to your current quality data, run them properly, and close them out with documented results. That's a QAPI program that surveyors respect.
Falls Reduction PIP
Falls remain the most frequently cited quality indicator in skilled nursing — and the most common PIP subject for good reason. A falls PIP done properly does double duty: it reduces harm and it demonstrates active QAPI engagement to surveyors. Done poorly, it's a liability that shows you knew about the problem and didn't act systematically.
In the past 90 days, [X] falls with injury have occurred among long-stay residents. The facility's fall-with-major-injury rate of [X%] exceeds our target of [Y%] and is above the state average. Root cause analysis of recent falls identified [e.g., call light delays, footwear issues, medication timing] as contributing factors.
- Monthly fall log review: total falls, falls with injury, location, time of day, shift, resident
- Post-fall root cause analysis completed within 24 hours for every fall
- Weekly interdisciplinary review of all falls in the prior 7 days
- Track fall rate per 1,000 resident days to normalize for census fluctuation
- Implement standardized post-fall huddle within 2 hours of any fall — nursing, therapy, and charge nurse
- Audit fall risk assessments for completeness within 24 hours of admission and after any fall event
- Review high-risk resident care plans for current, individualized fall prevention interventions
- Add non-slip footwear compliance check to every nursing shift handoff for fall-risk residents
- Evaluate call light response times — set a response target and track weekly
- Review antipsychotic and diuretic medication timing for high-fall-risk residents with pharmacy
Infection Control PIP
Infection control has been under intensified scrutiny since 2020, and it's not going back to pre-pandemic expectations. F880 (Infection Prevention and Control) is now one of the most frequently cited F-tags nationally. An infection control PIP demonstrates that your facility is proactively monitoring, not just reacting. The most defensible PIPs in this area focus on a specific measurable infection rate — UTIs, respiratory infections, or skin and soft tissue infections — rather than "infection control generally."
SNF F-Tag ReferenceThe facility's UTI rate for long-stay residents has averaged [X] per 1,000 resident days over the past two quarters, exceeding our internal benchmark of [Y] and the CMS national average of [Z]. Chart review identified inconsistent catheter care documentation, incomplete hydration monitoring, and delayed physician notification as contributing patterns.
- Monthly infection surveillance log — UTI count, catheter-associated vs. non-catheter, symptomatic vs. asymptomatic
- Weekly catheter care documentation audit: 10% random sample of catheterized residents
- Monthly hydration monitoring compliance review for at-risk residents
- Track antibiotic prescribing for UTI: culture obtained before treatment (yes/no rate)
- Standardize catheter care protocol — educate all nursing staff, post visual guide at supply stations
- Implement daily catheter necessity review on physician rounding checklist (remove if no indication)
- Introduce SBAR tool for nursing-to-physician UTI notification to reduce treatment delays
- Add fluid intake targets and documentation requirement for residents with recurrent UTI history
- Review antibiotic stewardship policy — require culture before treatment unless clinical urgency documented
Need the Full QAPI Framework, Not Just the PIPs?
The FacilityKit QAPI Program Kit includes PIP tracking templates, root cause analysis tools, QAPI committee meeting forms, and a complete F865–F886 compliance binder — ready to use on day one.
Hospital Readmissions Reduction PIP
Hospital readmissions are a quality measure, a reimbursement risk under value-based purchasing models, and a direct indicator of care coordination quality. CMS tracks 30-day readmission rates on Nursing Home Compare. For independent SNFs competing for hospital referrals, a high readmission rate is a business problem, not just a quality one. This PIP is high-impact and highly visible to both surveyors and referral partners.
In the past 6 months, [X] of [Y] short-stay admissions were transferred back to an acute hospital within 30 days of SNF admission, a readmission rate of [Z%]. Chart review of readmission events identified [e.g., medication reconciliation failures, delayed lab follow-up, unrecognized deterioration] as the most common precipitating factors.
- Monthly readmission log: count, reason for transfer, days since SNF admission, diagnosis group
- Post-transfer root cause review within 5 business days of each return hospitalization
- Medication reconciliation completion audit: percentage of admissions with completed reconciliation within 24 hours
- Track INTERACT Stop and Watch tool usage rate among nursing staff
- Implement INTERACT (Interventions to Reduce Acute Care Transfers) tools — SBAR, Care Path, Stop and Watch
- Require medication reconciliation completion within 24 hours of admission — document and audit weekly
- Establish daily nursing-to-physician check-in for new admissions during first 72 hours
- Create high-risk discharge identification process — flag residents with CHF, COPD, sepsis, or 2+ prior hospitalizations (FacilityKit Discharge Planner includes structured risk-identification templates)
- Add advance care planning review to admission process for all short-stay residents
Pressure Injury Prevention PIP
Pressure injuries are a sentinel quality event. A Stage 3 or Stage 4 pressure injury that develops in your facility — rather than being present on admission — is a direct line to an F686 citation and potential immediate jeopardy. They also affect your Five-Star rating. This PIP targets facility-acquired pressure injuries specifically, not pressure injuries present on admission, because that's the population you can actually influence.
In the past quarter, [X] facility-acquired pressure injuries have been identified across [Y] residents. The facility's rate of [Z%] for long-stay residents with Stage 2+ pressure injuries exceeds our target threshold. Root cause review identified [e.g., inconsistent repositioning documentation, delayed Braden reassessments after clinical status changes, incomplete skin assessment on admission] as contributing factors.
- Weekly wound rounds with wound care nurse — document all wounds, stage, and present-on-admission status
- Monthly audit: Braden scale completion rate within 24 hours of admission and after clinical status change
- Weekly repositioning documentation audit: 10% random sample of high-risk residents
- Monthly skin assessment completion rate — percentage of at-risk residents with documented head-to-toe assessment
- Establish weekly wound rounds protocol — wound care nurse rounds all at-risk and known-wound residents
- Require Braden reassessment within 24 hours of any clinical status change (hospitalization, new fever, significant decline)
- Add turning schedule compliance to nursing shift supervisor rounding checklist
- Implement dietary notification protocol for all residents with Braden score ≤ 18 — nutrition consult within 48 hours
- Update care plans within 24 hours of any new pressure injury — include specific prevention and treatment interventions
Medication Error Reduction PIP
Medication errors are cited under F758 (unnecessary medications) and F761 (medication labeling and storage), but they also surface in F684 (quality of care) and F755 (pharmacy services). More importantly, they cause real harm. This PIP targets the specific error types most common in SNFs — transcription errors on admission, missed doses, and wrong-time administration — and builds a measurement system to track them.
Internal medication error tracking over the past 90 days identified [X] reported errors, including [e.g., missed doses, wrong time, transcription errors on admission]. Additional pharmacy consultant review identified [Y] residents receiving medications without a documented current indication. These findings suggest gaps in admission reconciliation, MAR review, and monthly medication management.
- Monthly medication error incident report review — type, shift, nurse, resident, drug class
- Monthly MAR audit: 10% random sample — missed doses, late doses, documentation omissions
- Quarterly pharmacy consultant review of all residents on antipsychotics, anticoagulants, and sedatives
- Admission medication reconciliation completion audit: percentage completed within 24 hours
- Implement two-nurse verification for high-alert medications (warfarin, insulin, opioids) at administration
- Require pharmacist-reviewed medication reconciliation within 24 hours of each new admission
- Conduct monthly MAR accuracy review with charge nurses — share results, address patterns in staff meeting
- Add medication indication review to monthly physician progress note template — require documented clinical rationale for ongoing psychoactive medications
- Train all nursing staff on medication error reporting process — make clear reporting is expected and protected
How to Document PIP Results for QAPI Review
The PIP doesn't end when the interventions are implemented. CMS requires documented evidence that you measured results, compared them to your baseline, and made a data-informed decision about whether to close the project or continue it. Here's what that documentation needs to look like.
What to Include in Your PIP Close-Out
At the end of the PIP timeframe (typically 90–180 days), your QAPI committee meeting minutes should include:
- Baseline data — your starting measurement before interventions began
- Post-intervention data — the same metric measured over the PIP period
- Goal achieved? — yes, partially, or no — with the actual numbers
- Sustainability plan — if goal was met, what's the monitoring plan going forward
- Continuation or new PIP — if goal was not met, what changes to the intervention and a new target date
Surveyors cite facilities not for running bad PIPs but for running PIPs with no data. A PIP that says "we implemented huddles and falls went down" with no numbers doesn't hold up. Your QAPI meeting minutes must show the baseline rate, the measurement period, and the outcome rate — even if the outcome is disappointing. Honest data-tracking is the standard. Perfect outcomes are not.
For more on building a complete QAPI documentation system — including how to structure your annual QAPI plan, how to conduct and document a systematic analysis, and which records surveyors review under F865–F886 — see our QAPI Program Requirements guide. For survey readiness more broadly, the 30-Day Survey Prep Countdown includes QAPI as a full prep category.
Get the QAPI Program Kit
The five PIPs in this guide give you the structure. Running them well requires tracking forms, root cause analysis worksheets, QAPI committee meeting templates, and a documentation system that holds up to surveyor review. The FacilityKit QAPI Program Kit has all of it — built for independent SNFs, priced to be accessible without a large compliance department.
It includes PIP tracking worksheets for all five clinical areas covered here, a root cause analysis template, QAPI committee meeting agenda and minutes forms, the five required QAPI elements documentation, and the full F865–F886 self-assessment tool. Immediate download. No subscription required.
FacilityKit QAPI Program Kit — $59
Everything you need to run a compliant QAPI program — PIP templates, RCA tools, meeting forms, and a complete F865–F886 binder. Built for independent SNFs.