Self Survey Policy
The facility will conduct a comprehensive self‑survey review of compliance with all current QUAD A standards annually, prior to the expiration date of its accreditation, during each of the two years between QUAD A onsite surveys
Purpose
To ensure continuous compliance with all QUAD A accreditation standards and to maintain a structured process for identifying, correcting, and monitoring areas of non-compliance between onsite QUAD A surveys.
Policy Statement
The facility will conduct a comprehensive self‑survey review of compliance with all current QUAD A standards annually, prior to the expiration date of its accreditation, during each of the two years between QUAD A onsite surveys. All required documentation will be completed, maintained, and integrated into the facility’s quality improvement programs.
Procedure
Annual Self‑Survey Requirement
The facility will complete a full self‑survey review of all applicable QUAD A standards once every year in each of the two years between QUAD A onsite surveys.
The self‑survey must be completed prior to the accreditation expiration date each year.
The following documents must be completed and retained for each annual self‑survey:
Completed QUAD A Self‑Survey Checklist
All standards must be reviewed and marked compliant or non‑compliant.
Plan of Correction (POC) for each standard identified as non-compliant
Must include corrective actions, responsible personnel, and target completion dates.
Evidence of Implementation of Each Plan of Correction
Examples include, but are not limited to:
Updated policies or procedures
Training records
Audit results
Meeting minutes
Corrected logs or documentation
Evidence of Quality Improvement Review
The Governing Body must review findings from the self‑survey and all corrective actions and maintain documentation of these reviews.
Documentation Retention
All self‑survey documentation—including the checklist, plans of correction, evidence of corrective action, and QI review documentation—must be retained for a minimum of three (3) years. Records will be stored in a secure, accessible location designated by the Administrator/Compliance Officer.