Gap Analysis
3
Open Gaps
2
In Progress
1
Resolved
Compliance Gaps
| Standard | Section | Description | Severity | Status | Actions |
|---|---|---|---|---|---|
| CARF 1.A.1 | Leadership | Mission statement does not align with CARF requirements | critical | open | |
| CARF 1.B.3 | Governance | Board meeting minutes incomplete for last quarter | major | in-progress | |
| CARF 2.A.2 | HR | Staff credential verification process needs documentation | major | open | |
| CARF 2.C.1 | Training | Annual training compliance below threshold | critical | in-progress | |
| CARF 3.A.4 | Health & Safety | Emergency drill documentation incomplete | minor | open | |
| CARF 3.B.2 | Rights | Patient rights posting not in all required areas | minor | resolved |