egress_inspection_v3.docx

Owner: Dr. Elena Rostova

Uploaded: 19 Jul 2026

Version: v2

Size: 703.2 MB

0%Quality

Document Gaps Summary:1 Gaps FoundCritical: 0Major: 0Minor: 1

Quality Assessment

This document satisfies the core requirement baseline but would benefit from a refreshed review signature before survey.

Classification:egress inspection

Effective year:2025

Review due:Q2 2027

Measurable element alignments and explainability trace

PFR.2Major Gap (GAP-1028)

Patient and family rights — control 2: documented process, responsible owner and evidence of practice (paraphrased)

PFR.2

egress_inspection_v3.docx

Documented Policy Evidence

Verification Gap Detected

medium

GAP-1028

Open

Documentation gap in egress_inspection_v3.docx: Policy requires verified committee endorsement and alignment with JCI PFR Measurable Elements.

Target requirement: PFR.2