Modern professional office workspace
Active Quality

Continuous Quality Improvement (CQI) Policy

Silver Home Care – Ensuring safe, effective, and person-centered care through ongoing monitoring, evaluation, and enhancement of services.

Policy Number
QUAL-CQI
Effective Date
9/1/2025
Version
1.0
Approved By
Kelly Schmunk

Applies To

All Silver Home Care employees, supervisors, and administrative staff involved in service delivery, quality monitoring, and performance improvement.

I. Purpose

What this policy aims to accomplish

To establish a systematic approach to continuous quality improvement (CQI) that ensures safe, effective, and person-centered care through ongoing monitoring, evaluation, and enhancement of services, consistent with Pennsylvania regulations and payer requirements.

II. Scope

Who and what this policy covers

This policy applies to all Silver Home Care employees, supervisors, and administrative staff involved in service delivery, quality monitoring, and performance improvement.

III. Definitions

Key terms used in this policy

Continuous Quality Improvement (CQI)

An ongoing, systematic process to identify, analyze, and improve organizational performance and service delivery.

Quality Management Plan (QMP)

A written plan that outlines the agency's quality goals, monitoring activities, performance indicators, and improvement strategies.

Performance Indicator

A measurable value that demonstrates how effectively the agency is achieving key objectives.

Corrective Action Plan (CAP)

A documented plan to address identified deficiencies and prevent recurrence.

IV. Policy Content

The complete policy statements and requirements

A

General Standards

Silver Home Care is committed to continuous quality improvement in all aspects of service delivery.

Quality improvement activities are integrated into daily operations and organizational planning.

All staff are responsible for identifying opportunities for improvement and participating in CQI activities.

B

Quality Management Plan (QMP)

Silver Home Care maintains a written Quality Management Plan (QMP) that is reviewed and updated annually.

The QMP includes:

  • • Quality goals and objectives
  • • Performance indicators and benchmarks
  • • Monitoring and evaluation methods
  • • Roles and responsibilities for quality activities
  • • Methods to reduce preventable incidents
  • • Corrective action procedures

The QMP is approved by the Administrator and communicated to all staff.

C

Quality Monitoring Activities

Regular monitoring activities include:

Participant satisfaction surveys (quarterly)
Complaint & grievance trend analysis (quarterly)
Incident report review & root cause analysis
Staff performance evaluations (annual)
Record audits and documentation review
Compliance monitoring (regulatory & contractual)

Monitoring results are reported to the Quality Management Committee.

D

Quality Management Committee

The Quality Management Committee meets at least quarterly.

Committee responsibilities include:

• Reviewing quality monitoring data

• Identifying trends and areas for improvement

• Developing and tracking corrective action plans

• Recommending policy and procedure changes

• Reporting to leadership on quality performance

E

Corrective Action

When deficiencies are identified, a Corrective Action Plan (CAP) is developed.

CAPs include:

Root cause analysis, corrective actions, responsible parties, timelines, and effectiveness measures.

CAP implementation is tracked and verified by the Quality Management Committee.

F

Documentation & Reporting

Record Retention

Quality monitoring data, meeting minutes, and CAPs are documented and retained for seven (7) years (§ 52.15).

Regulatory Reporting

Quality performance is reported to payers and regulators as required.

V. Regulatory Citations

Legal and regulatory requirements this policy addresses

Regulation / Source Requirement Section
55 Pa. Code § 52.11 Health and safety; person-centered services IV.A–F
55 Pa. Code § 52.15 Documentation and record retention IV.F, VI
55 Pa. Code § 52.17 Incident management and prevention IV.C, IV.E
CHC-MCO Contracts Quality Management Plan requirements IV.B
UPMC Provider Agreement Preventable incident reduction IV.B, IV.E

VI. Review & Updates

Policy revision history

09/01/2025Approved

Reformatted into Silver Home Care template with audit notes. Approved by Administrator.

07/24/2025Created

CQI Policy with citations created.

This policy and the Quality Management Plan are reviewed annually and updated in response to regulatory changes, audit findings, or organizational needs.
Next Scheduled Review
September 2026

Policy Approval

Authorized signature confirmation

Kelly Schmunk, Administrator
September 1, 2025

This policy has been reviewed and approved by authorized personnel.

Need to Review or Update This Policy?

Access our policy management tools to review, analyze, or generate new policies.