What a compliance and ethics program is, how to speak up about a concern, why honest records matter, and your part in QAPI.
ForNursing home staff
TimeAbout 65 minutes
Lessons7, each with a quick check
FinishA quiz (80% to pass) and a printable certificate of completion
What you will learn
Explain the purpose of a compliance and ethics program.
Know who your compliance contact is.
Chart only care you gave, when you gave it.
Avoid gifts, favors and money that could harm residents or you.
Explain QAPI in your own words.
Share ideas and concerns with the QAPI program.
Explain root cause in your own words.
Written by Pact Compliance from federal rules and CDC, CMS, OSHA and NIH guidance (sources under each lesson), checked October 2026. Where your facility's policy is different, follow your facility's policy.
Lesson 1: What a Compliance and Ethics Program Is
In this lesson you will:
Explain the purpose of a compliance and ethics program.
Know that the program covers all staff, contractors and volunteers.
Know that training on the program is required.
Doing it right
Every day
Every nursing home's operating organization must run a compliance and ethics program. In plain words, it is the system that helps everyone follow the law and do the right thing. The rule says the program must be designed to prevent and detect criminal, civil, and administrative violations. It must also promote quality of care.
What violations
Examples
What kinds of problems does it try to prevent? Things like billing for care that was not given, false records, abuse and neglect, theft of resident property, and breaking privacy rules. Some are crimes. Some, like failing to report a suspected crime against a resident, can lead to large fines and to being barred from health care work paid for by Medicare and Medicaid. All of them can hurt residents and the people who work there.
Show the answer
Yes. It covers staff, contractors and volunteers. The program's standards apply to individuals providing services under contract.
Who it covers
Everyone
The program covers the whole staff. It also covers people who work under contract, like agency aides, and volunteers, as fits their role. That means you, whether you are full-time, part-time, PRN, or from an agency. Everyone has a part in keeping the facility honest and safe.
Written standards
Know them
The program must have written standards, policies, and procedures. These are often called a code of conduct. They explain what is expected and what is not allowed. Your facility will give you its own code. Read it. Ask questions if something isn't clear. This course explains the basics that most programs share.
Required training
Communicated to all
The rule says the organization must take steps to communicate its standards to the entire staff, contractors, and volunteers. That can be training, orientation, or other practical ways that explain what is required. If the organization runs five or more facilities, training must happen every year. CMS expects facilities to track who took the training.
Leaders lead
Everyone helps
High-level leaders must oversee the program. They must have the resources and authority to make it work. Organizations with five or more facilities must also have a compliance officer and a compliance liaison at each facility. But the program only works if frontline staff speak up. You see what happens on the floor every day.
On your shift
Small choices
Compliance is not just big cases. It is small daily choices. Charting what you really did. Not signing someone else's name. Not taking a resident's snack. Not sharing a resident's story online. Reporting a problem instead of looking away. Each choice protects residents, and it protects you.
Yearly review
Rules change
The program is not written once and forgotten. The rule says the operating organization must review its compliance and ethics program every year. It must revise the program as needed when laws change, when the organization changes, or when it finds better ways to prevent and detect problems. So the rules you learn this year may be updated. Watch for updates, and ask when something changes.
Quick review
Prevent and detect
Let's review. Every nursing home organization must have a compliance and ethics program. It helps prevent and detect violations of the law, and promotes quality care. It covers all staff, contractors, and volunteers. It has written standards you must know and follow. And it depends on staff who speak up.
Every compliance program must name a contact person you can report suspected violations to. Find out who that is at your facility. It might be the administrator, a compliance officer, or a compliance liaison. Write the name and number down. If you see something wrong, this is one person you can go to.
Anonymous option
No name needed
The program must also have a way to report suspected violations anonymously, without fear of retribution. This is often a hotline, a website, or a locked drop box. Anonymous means you don't have to give your name. Find out how your facility's anonymous line works before you need it.
Show the answer
Use the facility's anonymous reporting line. Programs must have a way to report anonymously without fear of retribution.
No payback
You are protected
The rule says you must be able to report without fear of retribution. Retribution means payback, like losing shifts, being moved, or being treated badly. For suspected crimes against residents, the Elder Justice Act also bans retaliation against employees who report. If you are treated badly after reporting, report that too.
Failing to report
Has consequences
The program must have discipline for people who break the rules. The rule also says discipline can apply, when appropriate, to people who failed to detect and report a violation. So looking the other way is not safe. Silence can make you part of the problem.
What to report
When unsure
Report things like: charting care that wasn't done, billing for services not given, pressure to falsify records, theft, kickbacks or bribes, and abuse or neglect. Also report safety rules being ignored. You don't need proof. Report what you saw or heard, honestly. If you're not sure, ask your compliance contact.
Abuse is urgent
Use both paths
If your concern is abuse, neglect, exploitation, or theft from a resident, it is also urgent. Report it right away through the abuse reporting steps, which have 2-hour and 24-hour limits. Do not wait for a compliance hotline call-back. You can also tell the compliance contact, but never let that slow down the abuse report.
After you report
The facility acts
After a violation is found, the organization must take reasonable steps to respond and to prevent it from happening again. It may change policies, retrain staff, or discipline people. You may not hear every detail, because of privacy. That doesn't mean nothing happened. If you see the problem continue, report again.
On your shift
Making the call
Say you notice that a coworker clocks in for a friend who isn't there yet. It happens every week. You're not sure if it's a big deal, and you don't want to cause trouble. This is exactly what the anonymous line is for. You describe what you saw, the dates, and the times. You don't have to give your name. The program takes it from there.
Quick review
Speak up
Let's review. Know your compliance contact's name and number. Know how to report anonymously. You are protected from payback for reporting. Failing to report can lead to discipline. Abuse concerns go through abuse reporting right away. And if a problem continues, report again.
Nursing home records must be complete and accurately documented. Your charting is part of that record. It tells the next shift what happened. It tells the nurse what to watch. It is used to bill Medicare and Medicaid. It can be used in a survey or in court.
Chart the truth
When it happened
Chart only the care you gave. Chart it after you give it, not before. Chart what really happened, even if it's not what was planned. If a resident refused, chart the refusal. If you made a mistake in charting, fix it the way your facility says. Don't erase, white out, or delete. Never chart for someone else.
Show the answer
Billing for care that was not given. NIA lists charging for care not provided as health care fraud.
Health care fraud
What it is
NIA lists health care fraud as a kind of financial abuse. It includes charging for care that wasn't given, billing twice for the same service, overcharging, and falsifying Medicare or Medicaid claims. False records can lead to false bills. That is why charting care you didn't give is so serious.
Pressure
Say no
Sometimes people feel pressure to fill in blanks. 'Just chart it so the survey looks good.' 'Mark them all as done.' Say no. Say, 'I can only chart what I did.' Then report the pressure to your compliance contact or anonymous line. Your name is on your charting. Protect it.
Your login
Is your signature
In electronic records, your login is your signature. Never share your password, and never chart under someone else's login. Log out or lock the screen when you walk away. Records must also be kept confidential, so protecting your login protects residents' privacy too.
Missed care
Say so
If care was missed, the honest record helps. Chart what was and wasn't done, and tell your nurse. A record that shows a gap lets the team fix it. A record that hides a gap can hurt the resident, and it can be fraud.
On your shift
End of shift rush
It's the end of a hard shift. You have six residents' vitals and meals left to chart, and you're not sure about two of them. Don't guess. Chart what you know. For anything you didn't do or don't remember, say so and tell your nurse. It may feel worse to leave a blank. But an honest record is always the right record.
Why it's serious
Real harm
False charting is not just a paperwork problem. If a turn is charted but not done, the next aide may think the resident was turned and wait even longer. Skin can break down. If a meal is charted as eaten but wasn't, weight loss may be missed. Accurate records protect residents, because the whole team makes decisions based on what you write.
Quick review
Truth only
Let's review. Records must be complete and accurate. Chart only care you gave, after you give it. Chart refusals and missed care honestly. Never chart for someone else, and never share your login. Charting care that wasn't given can lead to fraud. Say no to pressure, and report it.
Avoid gifts, favors and money that could harm residents or you.
Protect resident privacy and property.
Use the 'would I be OK if this were seen?' test.
Ethics
Doing right
Ethics means doing the right thing, even when no one is watching. On the floor, ethics shows up in small choices about money, gifts, privacy, honesty, and respect. Your facility's compliance program and code of conduct help guide those choices. When the rules don't say exactly what to do, ethics fills in the gap.
Gifts
Follow policy
Residents and families may want to give you gifts. CMS says a gift can be misappropriation when a resident gives it to get care, because staff talked them into it. Consent is not valid if the resident can't understand, or if they agreed out of fear or pressure. Follow your facility's gift policy. When in doubt, say a kind no and tell your nurse.
Show the answer
Kindly say no, keep the ring with her things, and tell your nurse. A resident who can't understand cannot give valid consent.
Money and favors
Keep it clean
Never borrow money from a resident or family. Never ask residents for favors, rides, or loans. Never sell things to residents or ask them to invest in anything. Never use a resident's card, account, or personal information. CMS lists identity theft, and purchases made without a resident's OK, as misappropriation.
Privacy
Online too
Ethics includes privacy. Resident records and information are confidential. Never post about residents on social media, even without names. Never take photos of residents on your own phone unless your facility has a process for it and the resident agrees. CMS says sharing demeaning photos or recordings of residents is abuse.
Who can work here
Background checks
Nursing homes may not employ people who have certain findings against them. That includes people found guilty of abuse, neglect, exploitation, or theft from residents by a court. It also includes people with a finding on the state nurse aide registry, or a license action, for those reasons. That's why facilities check backgrounds and registries. If you know of a court action against a coworker that relates to this, the facility must report it.
The sunlight test
Ask yourself
When you're not sure, try the sunlight test. Ask yourself: Would I be OK if my supervisor saw this? If the resident's family saw it? If it was on the news? If the answer is no, don't do it. And if you see a coworker doing something that fails the test, speak up.
On your shift
A real choice
A resident's son hands you a $100 bill at the door and says, 'For taking such good care of Mom. Keep it quiet.' This fails the sunlight test. 'Keep it quiet' is a warning sign. Thank him warmly, say you can't accept money, and tell your nurse. You keep your integrity, and the family knows you care because of who you are.
Quick review
Small choices
Let's review. Ethics is doing right when no one is watching. Follow the gift policy, and say a kind no when in doubt. Never borrow money, ask for favors, or use residents' cards or information. Keep resident information and photos private. Use the sunlight test. And speak up when you see a problem.
Know that QAPI uses data and staff input to improve care.
QAPI
Quality plus improvement
QAPI stands for Quality Assurance and Performance Improvement. CMS says it has two parts that work together. The first part checks that care meets the standards. The second part finds ways to make care better. Every nursing home must have a QAPI program. It never stops, it covers everything, and it is based on data. It looks at how care turns out for residents, and at their quality of life.
Whole facility
All of it
QAPI covers the whole facility. The rule says it must cover every system of care and every way the place is run. It must include clinical care, quality of life, and resident choice. So QAPI is not just about nursing. Dietary, housekeeping, activities, maintenance, and the front desk are all part of it.
Show the answer
Quality assurance and performance improvement. QAPI combines checking that care meets standards with making care better.
Five elements
Building blocks
CMS names five parts, or elements, of QAPI. One: what the program covers, called design and scope. Two: the leaders who run it. Three: feedback, data, and keeping watch. Four: projects to make things better. They are called PIPs. Five: finding the real cause of a problem, and fixing the whole system. The next slides explain the ones you will see most.
Leaders
Make it safe
Leaders must give QAPI the staff time, tools, and training it needs. CMS says leaders should make it safe for staff to speak up. Staff should feel at ease when they report a quality problem or a chance to do better. Leaders must also say clearly what they expect about safety, quality, rights, choice, and respect.
Data
And feedback
QAPI runs on facts. The facility must collect facts and numbers from every department, and use them. It must have ways to hear from aides and nurses, other staff, residents, and the people who speak for residents. It must also track harm, called adverse events. That means things like a fall with an injury, or a mistake with a medicine. Each one is looked into every time, so it does not happen again.
The committee
Who meets
Each nursing home has a quality committee. It is often called the QAA committee. It has the director of nursing and the medical director, or someone the medical director picks. It has the infection preventionist. It also has at least three other staff, and one of them must be a leader. The committee meets at least every three months. It looks at the data and makes plans to fix problems.
Your facility
Its goals
Your facility's QAPI program has its own goals and its own projects right now. CMS says staff training should cover those goals, the parts of the program, and how the program will work. Ask your supervisor what your facility is working on now. It might be falls, infections, pressure injuries, or how fast call lights are answered.
Priorities
What gets worked on
A facility can't fix everything at once. So the rule says it must pick what comes first. It looks at what is high-risk, what happens a lot, and what goes wrong often. It looks at how often problems happen and how bad they are. And it looks at what affects health, safety, resident choice, and quality of care. That's why your facility's projects may look different from another's.
Quick review
Better every day
Let's review. QAPI means checking that care meets the standards, and finding ways to make it better. It covers the whole facility and every department. It has five parts, from design and leaders to projects and finding causes. It runs on data and feedback, and that includes yours. The QAA committee looks at the data and makes plans. And your facility has its own goals. You should know them.
The QAPI rule says the facility must have effective systems to get feedback from direct care staff. That's you. Your feedback must be used to find problems that are high-risk, happen often, or keep coming back. It must also be used to find chances to improve. You see problems first. You often see the fix first too.
How to share
Know the path
CMS says QAPI training should teach staff how to bring concerns, problems, or ideas to the QAA committee. That might be through your supervisor, a suggestion box, a huddle, a unit meeting, or a form. Find out how your facility does it. An idea that stays in the break room can't help anyone.
Show the answer
Yes, as a near miss, using your facility's process. Near misses show where systems are weak before harm happens.
Adverse events
Report them
The facility must track, investigate, and learn from adverse events. Those are things that cause harm, like falls with injury, medicine errors, or new pressure injuries. It must use that data to prevent future events. Report events using your facility's process, like an incident report. Report even when you think it was nobody's fault.
Near misses
Count too
Report near misses too. A near miss is something that almost caused harm, but didn't. For example, a resident almost got the wrong tray, or a wet floor almost caused a fall. Near misses show where a system is weak before someone gets hurt. They are some of the most useful information a QAPI program can get.
Safe to speak
No blame
CMS says QAPI leaders should create a place where staff feel comfortable identifying and reporting quality problems. Good QAPI looks for system problems, not someone to blame. So report honestly, including your own mistakes. The rule also says good-faith efforts by the QAA committee to find and fix problems will not be used as a basis for sanctions.
Join in
Projects
You may be asked to join a performance improvement project. That could mean collecting data, like counting call light times, or testing a new way of doing a task. Say yes when you can. Your experience on the floor makes projects work. When a change is tried on your unit, follow it, and tell the team what's working and what isn't.
On your shift
A good idea
Say you notice that residents in the dining room wait 20 minutes for their trays because the cart arrives before enough aides are free. You suggest staggering the cart by 10 minutes. That's QAPI. You saw a problem, you thought of a fix, and you shared it the right way. The team can test it, measure it, and keep it if it works.
Learning together
Share lessons
The rule says performance improvement must track medical errors and adverse resident events, look at their causes, and put prevention in place. It must also include feedback and learning throughout the facility. So when a change is made because of an event, you should hear about it. Ask in huddles: 'What did we learn from that fall last week? What are we doing differently?'
Quick review
You are QAPI
Let's review. QAPI must get feedback from direct care staff. Learn your facility's path for sharing ideas and concerns. Report adverse events and near misses. Report honestly. Good QAPI looks at systems, not blame. Join improvement projects, and tell the team what works.
Your facility's policy (ask your supervisor):
How staff submit QAPI ideas and concerns (huddle, form, box, supervisor)
Lesson 7: Fixing Systems: Root Causes and Improvement Projects
In this lesson you will:
Explain root cause in your own words.
Know that QAPI fixes systems, not just people.
Describe how a performance improvement project works.
Root cause
Why, why, why
A root cause is the real, underlying reason a problem happened. The QAPI rule says facilities must use a systematic approach to find the underlying causes of problems. CMS says facilities should be skilled in root cause analysis. A simple way to think about it is to keep asking 'why?' until you reach a cause you can fix.
An example
Asking why
A resident fell at night. Why? She got up to use the bathroom alone. Why? Her call light wasn't answered for 15 minutes. Why? Only one aide was on the hall, and she was in another room. Why? The night schedule leaves one aide on that hall from 2 to 4 a.m. The root cause may be staffing at that time, not the resident or the aide.
Show the answer
Look at the morning schedule and staffing, and change the system that causes the delay. Systems-level fixes prevent problems from coming back.
Systems
Not just people
The rule says corrective actions must be designed to change things at the systems level. The goal is to prevent quality of care, quality of life, or safety problems. Telling one aide to 'be more careful' rarely fixes a problem. Changing the system often does. That could mean a new schedule, a better checklist, moving supplies closer, or fixing equipment. Good fixes make it easier to do the right thing.
Improvement projects
PIPs
A performance improvement project, or PIP, is a focused effort on one problem. CMS says it involves gathering information to understand the problem, then making changes to improve. The rule says facilities must do at least one project each year that focuses on a high-risk or problem-prone area. Priorities focus on things that affect health outcomes, safety, resident choice, and quality of care.
Try, measure
Keep or change
A project usually works like this. Pick a problem. Measure how big it is. Find the root cause. Try a change. Measure again. If it works, keep it and make it part of the routine. If not, try something else. The rule says facilities must measure success and track performance, to make sure improvements last.
Your part
Data and honesty
Your part is important. Projects need honest data. If you're asked to track something, track it truthfully, even if the numbers look bad. Bad numbers at the start are how a project shows it worked later. Share what you see on the floor. You may spot a root cause nobody in an office would see. And when a change is made, give it a fair try.
On your shift
Small fix, big win
On one unit, aides kept running out of clean linens on evening shift, so beds were left unmade and residents waited. Asking 'why' showed the linen cart was only stocked in the morning. The fix was a second delivery at 3 p.m. Nobody had to 'try harder.' The system changed, and the problem went away.
Quick review
Fix the system
Let's review. A root cause is the real reason a problem happened. Keep asking why. QAPI fixes systems, not just people. A performance improvement project focuses on one problem: measure, find the cause, try a change, measure again. Facilities do at least one project a year on a high-risk or problem-prone area. Your honest data and floor knowledge make it work.
Answer every question. You need 80% to pass. You can try again as many times as you like.
Your quiz covers the lessons for: Nursing home ( questions). Change your setting
Please read
This free course gives you a certificate of completion from Pact Compliance. It is not continuing education (CE) credit and is not approved by any state.
Your employer decides whether it counts toward required in-service hours. Home health and hospice aide training must be given or supervised by the agency's registered nurse.
California: it does not count toward CNA or HHA renewal hours.
Your name and quiz answers stay in your browser and are never sent to Pact.
Pact Compliance LLC, Cordova, TN
Certificate of Completion
This certifies that
completed the online in-service course
Compliance, Ethics and QAPI for Frontline Staff
Setting
Completed
Seat time
Quiz score
Certificate ID
This free course gives you a certificate of completion from Pact Compliance. It is not continuing education (CE) credit and is not approved by any state. Your employer decides whether it counts toward required in-service hours. Home health and hospice aide training must be given or supervised by the agency's registered nurse. California: it does not count toward CNA or HHA renewal hours.
Part of this topic needs a hands-on check with your supervisor; this online course does not cover that part.
Pact does not keep a record of this certificate. Print it or save it as a PDF and give a copy to your supervisor. pactcompliance.com/free-training/compliance-ethics-qapi/
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