Strategic Analysis & Quality Management

Compliance Analysis & QMP Dashboard

Track policy commitments vs. implementation, identify recurring patterns, and manage your Quality Management Program

POC Tracking

Commitments vs Implementation

Pattern Analysis

Recurring findings & trends

QMP Dashboard

Quality Management Program

Full History

View compliance timeline
5
DOH Surveys
All closed
34
Total Findings
2018-2025
28
Resolved
82% success rate
6
Open Items
In progress
15
Policies Updated
Since 2018

POC Tracking: Commitments vs. Implementation

Track what we said we would do versus what we actually did

Survey/Finding POC Commitment Actual Implementation Status
DOH Re-Licensure Survey - September 2024 (5 Findings)
§611.51(a) - Hiring Prerequisites
6/6 PFs missing reference docs
  • • Update hiring policy with "eligible to start" date
  • • Create Care Coordinator position
  • • Implement onboarding checklist
  • Policy updated 10/10/24
  • CC position filled 11/1/24
  • Checklist in EVV system
COMPLETE
§611.52(b) - PATCH Criminal History
3/6 PFs missing timely docs
  • • Add background check to onboarding flow
  • • Use third-party verification service
  • • Automated expiration alerts
  • Integrated with EVV
  • Sterling Volunteers contracted
  • 30-day expiry alerts live
COMPLETE
§611.52(d) - Proof of Residency
PF#4 missing 2-year proof
  • • Require FBI check if <2 years PA resident
  • • Add residency verification to intake form
  • • Document requirements in policy
  • FBI check process documented
  • Intake form updated
  • Policy revised 10/15/24
COMPLETE
§611.55(a) - Competency Requirements
3/6 PFs missing competency exam
  • • Contract third-party competency testing
  • • Electronic training records
  • • Pre-assignment verification requirement
  • DirectCourse contracted
  • LMS system integrated
  • CC verifies before assignment
COMPLETE
§611.56(a) - TB Health Screening
4/6 PFs missing TB docs
  • • Require TB clearance before first shift
  • • Automated tracking system
  • • Annual rescreening reminders
  • Added to onboarding checklist
  • CareTime integration complete
  • 12-month reminders active
COMPLETE
DOH Re-Licensure Survey - August 2021 (4 Findings)
§611.52(c) - Federal Criminal History
PF#4 missing FBI check
  • • Update background check policy
  • • Admin form for tracking 2-year residency
  • • Quarterly audits of personnel files
  • Policy updated 8/20/21
  • Form implemented
  • Audits ongoing (quarterly)
COMPLETE
§611.55(a) - Competency
PF#5 missing training docs
  • • Contract third-party training vendor
  • • Electronic record keeping system
  • Contracted vendor (approved 8/23/21)
  • Electronic system live
COMPLETE
§611.56(a) - TB Screening
PF#1, PF#7 missing 2nd TST
  • • Update policy with automated notifications
  • • 14-day work eligibility cutoff
  • • Add symptom screen & risk assessment
  • Auto-notifications active
  • 14-day rule enforced
  • Forms added to onboarding
COMPLETE
35 P.S. §448.809(b) - Photo ID
Missing photo ID badge documentation
  • • Provide standardized ID badges
  • • Document badge issuance in personnel files
  • Badge system implemented
  • Issuance log maintained
COMPLETE
COMPLETE Fully implemented as committed
PARTIAL Some items pending
OPEN Not yet implemented

Pattern Analysis: Recurring Findings

Identifying systemic issues across multiple surveys

High-Risk Recurring Issues

Criminal Background Checks

4x cited

Found in: 2019, 2020, 2021, 2024

Root cause: Process gap between interview & start date

Solution: "Eligible to start" system + Care Coordinator role

Competency/Training Documentation

3x cited

Found in: 2020, 2021, 2024

Root cause: Manual tracking, no central system

Solution: Third-party vendor + LMS integration

TB/Health Screening

3x cited

Found in: 2020, 2021, 2024

Root cause: Missing 2nd TST, no automated tracking

Solution: 14-day eligibility rule + auto-reminders

Successfully Resolved Patterns

Critical Incident Management

Fixed 2022

Was cited: 2019, 2020, 2022

Fix: Project management software + 24-hour reporting protocol

Not cited since: 2022

Photo ID Badge Compliance

Fixed 2021

Was cited: 2020, 2021

Fix: Standardized badge system + issuance log

Not cited since: 2021

Record Retention

Fixed 2022

Was cited: 2021, 2022

Fix: Updated retention policy + digital archiving

Not cited since: 2022

Findings Trend Over Time

0
2018
5
2019
12
2020
10
2021
2
2022
0
2023
5
2024
0
2025
Peak in 2020 (12 findings) → Closed 2025 with all deficiencies corrected

Quality Management Program (QMP)

Track quality metrics, improvement initiatives, and performance indicators

QMP Dashboard Ready for Your Data

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Quality Goals
Targets & outcomes
Performance Metrics
KPIs & benchmarks
Improvement Plans
PDSA cycles & outcomes

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Data Storage Status

Compliance History Saved
~35% of local storage
QMP Data Empty
Ready for data
Available Space ~3MB
Plenty of room

Data Safety: Use the Export buttons on the Compliance History page to download backups. JSON format preserves all data including full content.