COMPLETE STAFFING LLC
QUALITY ASSURANCE PLAN
Effective: January 1, 2026 | Review Cycle: Annual
1. PURPOSE & SCOPE. The Quality Assurance (QA) Plan of Complete Staffing LLC ("Agency") establishes a systematic, ongoing process to monitor, evaluate, and improve the quality of healthcare staffing services provided to contracted facilities, including Assisted Living Facilities (ALFs), Skilled Nursing Facilities (SNFs), Hospitals, and private-pay clients throughout Florida. This Plan complies with Florida Statute §400.494, §429.28, and applicable CMS Conditions of Participation.
2. QUALITY OBJECTIVES. Agency QA objectives include: (a) Ensure all placed personnel maintain current, valid licensure and required credentials; (b) Achieve and maintain a client satisfaction score of ≥4.5/5.0 as measured by quarterly facility feedback surveys; (c) Maintain a caregiver incident rate below 2% of total shifts per quarter; (d) Achieve 100% compliance with HIPAA privacy and security standards; (e) Resolve all reported grievances within 5 business days; (f) Conduct annual competency evaluations for all active caregivers.
3. CREDENTIAL MONITORING. Agency maintains a real-time credential tracking system that issues automated alerts 90, 60, and 30 days prior to license or certification expiration. Caregivers with expired credentials are immediately suspended from placement until renewal documentation is received. All credentials are verified through the Florida Department of Health (FLOH) license verification portal upon initial placement and quarterly thereafter.
4. INCIDENT REPORTING & REVIEW. All incidents occurring during Agency-placed shifts (including patient injuries, medication errors, abuse allegations, and workplace injuries) must be reported to Agency Administration within 2 hours of occurrence. Agency will: (a) Conduct a root-cause analysis within 48 hours; (b) Document findings in the Agency Incident Registry; (c) Notify applicable regulatory bodies (AHCA, FDLE) as required by Florida law; (d) Implement corrective action within 10 business days.
5. CAREGIVER PERFORMANCE REVIEW. Agency conducts performance reviews at 30 days, 90 days, and annually for all active caregivers. Reviews incorporate: facility satisfaction ratings (collected after each shift), punctuality and attendance data from the EVV system, in-service training completion records, and any disciplinary or incident history. Caregivers scoring below 3.0/5.0 on two consecutive reviews are placed on a Performance Improvement Plan (PIP) and may be suspended pending remediation.
6. CLIENT / FACILITY FEEDBACK. Contracted facilities receive a quarterly satisfaction survey measuring: caregiver professionalism, clinical competency, communication with facility staff, and responsiveness of Agency management. Survey results are reviewed by Agency leadership at quarterly QA meetings. Facilities with a satisfaction score below 4.0/5.0 trigger an immediate account management review.
7. IN-SERVICE & CONTINUING EDUCATION. Agency requires all active caregivers to complete a minimum of 12 hours of in-service training per calendar year, including: annual HIPAA refresher (2 hrs), infection control and bloodborne pathogens (2 hrs), dementia care (2 hrs), and role-specific skills updates (6 hrs). Completion is tracked through the Agency LMS. Non-compliance results in suspension from placement until training is completed.
8. CORRECTIVE ACTION PROCESS. When a QA deficiency is identified, Agency will: (1) Document the deficiency in writing; (2) Notify affected parties within 24 hours; (3) Develop a written Corrective Action Plan (CAP) within 5 business days; (4) Implement corrective measures within 30 days; (5) Monitor compliance for 90 days post-implementation; (6) Document closure of the CAP in the Agency QA registry.
9. QA COMMITTEE. Agency maintains a QA Committee comprising: President / Administrator, Director of Nursing (or Designee), Compliance Officer, and one senior caregiver representative. The Committee meets quarterly to review KPIs, incident reports, corrective actions, and survey results, and annually to update this Plan.
10. DOCUMENT CONTROL. This Quality Assurance Plan is reviewed annually and updated as required by regulatory changes, accreditation standards, or significant operational changes. All versions are retained for a minimum of 5 years. Distributing, posting, or otherwise publishing this document without Agency authorization is prohibited.