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LMS Caregiver Progress

Track Acumen CNA training completions across all caregivers.

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Electronic Visit Verification — GPS-verified clock-in/out records.

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Analytics & Reporting

KPIs, revenue trends, and exportable reports for Complete Staffing & Acumen.

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.

SECTION 1 — PATIENT MEDICAL EMERGENCY.

If a patient under your care experiences a medical emergency (cardiac arrest, stroke, fall with injury, respiratory distress, or sudden change in condition): (1) Call 911 immediately if the patient is unresponsive, not breathing, or in life-threatening distress; (2) Initiate CPR/BLS if trained and the patient has no pulse or is not breathing, per your certification; (3) Notify the facility's charge nurse or on-call supervisor immediately; (4) Do NOT leave the patient unattended; (5) Contact Complete Staffing Agency Management at (904) 555-0100 within 30 minutes; (6) Complete an Incident Report in the Agency portal within 2 hours of the event.

SECTION 2 — FALL PREVENTION & RESPONSE.

If a patient falls: (1) Do not move the patient until assessed for injury; (2) Call for facility nursing assistance immediately; (3) Follow facility fall protocol; (4) Document the event fully in both the facility record and Agency Incident Report system; (5) Notify Agency within 2 hours. To prevent falls: use bed alarms and call lights as directed, ensure pathways are clear, follow patient-specific fall-prevention care plan at all times.

SECTION 3 — ABUSE / NEGLECT REPORTING.

Florida Statute §415.1034 and §39.201 require mandatory reporting of suspected abuse, neglect, or exploitation of vulnerable adults and children. As a caregiver you are a mandatory reporter. If you witness or suspect abuse or neglect: (1) Ensure the patient's immediate safety; (2) Do NOT confront the alleged abuser; (3) Call the Florida Abuse Hotline: 1-800-962-2873 (available 24/7); (4) Notify Agency Management immediately at (904) 555-0100; (5) Do NOT discuss the report with facility staff beyond your direct supervisor; (6) Document your observations in the Agency Incident Report system.

SECTION 4 — FIRE / EVACUATION.

If you discover or are notified of a fire or hazardous emergency at a facility: (1) Follow the facility's RACE protocol — Rescue (patients in immediate danger), Alarm (pull nearest fire alarm), Contain (close doors), Evacuate (per facility evacuation plan); (2) Assist patients to designated evacuation assembly area per facility floor plan; (3) Never use elevators during a fire; (4) Report all clear or continued evacuation status to charge nurse; (5) Notify Agency when safe to do so.

SECTION 5 — SEVERE WEATHER / HURRICANE PROTOCOL.

Florida hurricane season is June 1 – November 30. In the event of a hurricane watch or warning: (1) Agency will contact all placed staff by phone/text with assignment status; (2) Do not report to a facility if local authorities have issued a mandatory evacuation order; (3) Facilities under hurricane watch remain fully staffed per FL AHCA emergency operations requirements — Agency will coordinate staffing surges as needed; (4) Staff assigned during emergency conditions receive an Emergency Premium of +$10/hr; (5) All Agency communications during weather emergencies come directly from Agency Management — do not rely on social media updates.

SECTION 6 — WORKPLACE INJURY (CAREGIVER).

If you sustain an injury during an assignment: (1) Report the injury to the facility's charge nurse and fill out a facility incident report immediately; (2) Call Agency Management at (904) 555-0100 within 1 hour; (3) Seek medical attention — Agency's Workers' Compensation carrier will be notified; (4) Do NOT return to the assignment if you have been advised not to work; (5) Complete Agency's online Injury Report form within 24 hours. Workers' Compensation coverage is provided per Florida Statute §440 for all injuries occurring during authorized Agency assignments.

SECTION 7 — EXPOSURE TO INFECTIOUS DISEASE / BLOODBORNE PATHOGEN.

If you experience a needlestick, blood exposure, or potential exposure to an infectious pathogen: (1) Immediately wash the affected area with soap and water for ≥15 minutes; (2) Notify the facility charge nurse immediately; (3) Call Agency at (904) 555-0100; (4) Seek evaluation at an occupational health clinic or ER within 2 hours; (5) Post-exposure prophylaxis (PEP) is most effective when initiated within 2 hours. Do not delay; (6) Complete an Agency Exposure Incident Report within 24 hours.

SECTION 8 — ELOPEMENT (MISSING PATIENT / RESIDENT).

If a resident or patient elopes (leaves without authorization): (1) Alert facility charge nurse immediately; (2) Follow facility elopement protocol — initiate facility lockdown per policy; (3) Call 911 if the resident cannot be located within 15 minutes; (4) Notify Agency Management within 30 minutes; (5) Document all actions taken with times in the Agency Incident Report system.

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