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Sample Auditing and Monitoring Plan for Resident Safety

  1. Specifically target and identify what you are monitoring.

    a. Task: audit and monitor the following aspects of the facility’s program(s) to prevent resident abuse and neglect:
    • Do we explain to all staff, volunteers, contractors and family members the facility’s obligation to prevent resident abuse and neglect and each resident’s right to be free from abuse and neglect?
    • Do we train staff on how to recognize this risk of and actual incidents of resident abuse, including signs of abuse occurring where the abuse may be unobserved by staff?
    • Do we train family members and visitors on how to recognize signs of abuse and of the facility’s legal obligation to prevent and report abuse even by family members or visitors?
    • Is our training on these issues periodic? Do we repeat it frequently enough to ensure that even new staff, new visitors or occasional family/other visitors are aware of these obligations?
    • How do we accomplish periodically reminding both staff and visitors of these obligations (formal training, posted notices and reminders, online education for staff, volunteers and contractors)?
    • Do we carefully avoid steering, coaching, requiring or requesting that residents select a particular Part D plan (because, for example, that Plan is offered by one or more pharmacies with which we have a contract)?
    • Do we have mechanisms as part of the admissions process and ongoing periodic assessments (both scheduled and as needed based on changes in residents’ condition) to screen for potential resident-to-resident abuse, and what are those systems?
    • Are our care plans sufficient to respond to the potential for resident-to-resident abuse where this occurs and/or the potential for it arises after admission of the affected residents?
    • If the result of resident-to-resident abuse involves transfer or discharge of involved residents, do we have systems to ensure we have tried alternatives to discharge and documented those efforts?
    • With respect to potential staff-to-resident abuse, do we have in place systems for proper and comprehensive screening of potential staff members to weed out those found guilty under state law of abusing, neglecting or mistreating staff and/or with a finding of abuse, neglect or misappropriation of resident property on a state nurse aide registry?
    • Do we have systems in place, including in our employment application, interviews, and related hiring processes to determine as best we can all states where potential employees have previously worked so we can check available state criminal records and state nurse aide registries?
    • Do we have systems in place to ensure that we fully evaluate and confirm, with appropriate documentation, that all staff (both potential and existing) has met the requisite educational, experience, licensure, certification and/or accreditation requirements of their position?
    • Do we have in place systems to periodically confirm that these requirements are met on an ongoing basis, particularly with respect to professional licenses, certifications and required (by law or facility policy) in-service training and continuing education credits?
    • Do we have in place proper systems for reporting, consistent with applicable law and facility policy allegations or suspicions of abuse, neglect or misappropriation of property, which include the ability to make such reports anonymously?

  2. Design the specific steps that will make up the monitoring process for the particular issue you are auditing.

    a. Review applicable policies and procedures addressing the issue of resident abuse, neglect and misappropriation of property.

    b. Review existing employee screening procedures for the issues identified above.

    c. Review admissions documents and procedures to ensure the facility’s obligations to prevent resident abuse, neglect and misappropriation of property are included, properly emphasized, and properly explained, including addressing these issues with family members or other legal representatives.

    d. Observe (insert frequency or by random number of observations on a defined schedule) facility staff or contractors explaining these obligations to residents, other staff and family members/visitors. Identify failures to describe these obligations accurately or completely, failures to respond to incidents of suspected abuse or neglect.

    e. Review periodically (on a defined schedule) the facility’s complaint log, survey reports or other reports where allegations or suspicions of abuse, neglect or misappropriation of property are recorded (including official state reports), along with the facility’s quality assurance committee records, to assess how the facility is doing in terms of meeting these obligations.

    f. Analyze these reports to determine the frequency with which staff who does not meet applicable requirements slip through the facility’s screening processes and why this occurs?

    g. Analyze these reports to determine how frequently our resident screening processes fail to detect residents who, at admission, reflected tendencies towards resident-to-resident abuse and how this happens.

    h. In addition to formal training for staff, contractors, volunteers and family members/visitors, assess whether the facility has in place mechanisms to constantly remind these individuals of the prohibition on abuse, neglect and misappropriation of resident property and specifically what those mechanisms are.

    i. With respect to each of the above steps, identify (by position title(s), who will perform these audit functions, and how frequently, and commit these details to written facility policy and procedure, with mechanisms to review them periodically for effectiveness and current application.

  3. Decide how your company or facility will use the information obtained as a result of auditing and monitoring.

    a. The results of the above inquiries will be provided on a regular basis to facility administration and the facility’s quality assurance committee for discussion and revision as needed, with appropriate training or re-training as indicated.

    b. Applicable policies and procedures (admission, employment screening, etc.), including training of staff and family members/visitor will be revised as appropriate to respond to identified failures in existing systems. External reminders of the facility’s obligations to protect residents will be evaluated on a defined schedule to ensure they are effective and current to the extent possible.

    c. As appropriate, the Compliance Officer will discuss the results of such audits with senior management and/or the Board of Directors (or owners) and determine whether any additional measures are required or recommended, whether additional compliance safeguards should be instituted at the facility (including more frequent auditing of applicable procedures), whether training of employees and/or contractors is recommended and such other corrective and monitoring activities are appropriate.
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