The Quarterly Cycle
Four lightweight cycles per year. Carry-forward default — the Coordinator only inputs what changed. No compliance fatigue.
Quarterly Schedule
| Element | Q1 | Q2 | Q3 | Q4 |
|---|---|---|---|---|
| Full self-assessment | ✓ | — | ✓ | ✓ |
| Updates on changed criteria only | — | ✓ | ✓ | — |
| Evidence declaration (every YES) | ✓ | ✓ | ✓ | ✓ |
| Improvement Plan | Full | Progress | Progress | Final |
| Coordinator attestation | ✓ | ✓ | ✓ | ✓ |
| Director sign-off | ✓ | — | ✓ | ✓ |
| Monitor verification | — | Partial (online) | — | Full (in-facility) |
The Evidence Declaration
Every YES answer requires a mandatory evidence statement — what document or observation supports this answer. The tool will not accept YES without it. This transforms the self-assessment from a checkbox into an evidence declaration.
Q2 — Online Monitor Review
Remote. Document review plus video call with Coordinator. Covers gap closure against Q1 Improvement Plan. No travel. No facility disruption. Approximately 3–4 hours.
Q4 — In-Facility Monitor Verification
One full day at the facility. The Monitor independently verifies 100% of criteria against observable evidence. Every criterion receives a status: Verified / Requires Evidence / Disputed. The Q4 report is the primary evidence base for the annual supervision visit and ADC decision.
