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Self-Evaluation Liability Checklist

This checklist is intended to be a tool you can use to begin the process of identifying risks in your organization. It is not a complete listing of all
risks your organization may face. Risk identification is a continuous and ongoing task that is an important responsibility of senior management in
every organization.

Management/ Administration

  • Written policy and procedure provides guidelines for contract management.
  • All agreements are in writing.
  • There is a process for annual review and evaluation of all contracts.
  • Certificates of insurance for all contractors are available and updated annually.
  • Contracts include hold harmless language and requirements to participate in PI and follow organization’s policies and procedures.
  • There is a written incident reporting procedure.
  • Incidents are reviewed, trended and analyzed.
  • Patient/Family complaint reports are trended as part of the event reporting process.

Medical

  • The medical director takes an active role in establishing medical care standards.
  • The medical director participates in staff training.
  • The medical director takes an active role in monitoring care quality.
  • There is a credentialing process in place for all employed and/or contracted physicians that includes: maintenance of current license, DEA number, and certificate of insurance. There is primary source verification of physician education, training and license.
  • Paper and/or electronic records are kept confidential and secured.
  • Patient medical records are kept current.
  • Medical records are maintained in a consistent format and order.
  • Only approved abbreviations are used in documentation. Entries are dated, timed and signed.
  • Handwriting on all medical records is legible. Telephone contacts are documented in the medical record.
  • Approved methods for correcting documentation errors are used.
  • Patient refusals of treatments and/or services are documented.
  • There are written policies and procedures on abuse prevention and reporting.
  • All staff has access to and knows the status of the patient’s advance directive.
  • A care plan is present for each patient. It includes:
    • Start of care interdisciplinary care plan
    • Revised and updated interdisciplinary care plans as needed
    • Review of care plan at IDT meetings
  • All staff follows the plan of care.
  • All staff, paraprofessionals and volunteers provide care that is keeping with training and competency.
  • Medication is stored appropriately in secured area.
  • Medication storage areas are inspected on at least a monthly basis.
  • Only qualified staff administers medications.
  • Physician orders are obtained for changes in medications, prior to the change.
  • Verbal orders are validated with physician signature and date within agency policy guidelines.
  • Staff and volunteers know the patient complaint process and encourage patients who voice complaints to share their concerns with management of the organization.
  • The quarterly utilization audits provide meaningful information and data.
  • Pain assessment is conducted and documented at each visit.
  • If research activities or clinical trials are conducted there is a procedure for research approval and evidence of informed consent.

Patient Handling

  • All care staff and volunteers are trained in patient lifting and transfer techniques.
  • Our organization has a restraint policy and provides restraint education to:
    • Staff
    • Volunteers
    • Patients
    • Family Caregivers
  • Families are taught that securing patients in wheelchairs and beds is a form of patient restraint.
  • A fall prevention plan is in place. Plan includes assessment of risk to fall upon admission.
  • There is a standard procedure for bed to chair and chair to bed transfers. Patient beds are kept in the low position and bed rails are used.
  • There is a standard procedure for chair or bed to toilet and toilet to chair or bed transfer. Patients who are confined to bed are provided with a means to summon assistance.
  • All care staff and volunteers are trained in standard procedures for patient:
    • Transfers
    • Realignment/repositioning in bed
    • Walking/ambulation
    • Climbing stairs

Employees and Volunteers

  • Background checks are conducted on:
    • Prospective employees
    • Prospective volunteers
  • Current job descriptions are available for:
    • All staff positions
    • All volunteer positions
  • There is a drug free workplace policy in place.
  • Job descriptions are reviewed with staff and volunteers at:
    • Time of hire
    • Time of any revisions
    • Time of annual performance review
  • Supervisors to employee/volunteer ratios are sufficient to assure adequate supervision.
  • Employees and volunteers understand policies and procedures relevant to their roles.
  • Annual evaluations are completed on all employees and volunteers.
  • Written policies address:
    • Progressive discipline
    • Sexual harassment
    • Grievance procedures
    • Sexual abuse prevention
  • If temporary or agency staff are utilized there is a process in place or orientation and evaluation.

Driving

  • State motor vehicle department checks are routinely run on:
    • Prospective employees
    • Prospective volunteers
  • Individuals with poor driving records found during state motor vehicle department checks are neither hired nor accepted as a volunteer in positions where driving is a requirement.
  • State motor vehicle department record checks are run annually on:
    • Employees
    • Volunteers
  • Employees and volunteers are discouraged from:
    • Transporting patients
    • Using cell phones while driving
  • Employees and volunteers are instructed not to drive when taking certain prescription and non-prescription medication.
  • Employees and volunteers are instructed to always wear seatbelts when traveling in a motor vehicle.
  • Verify that employees and volunteers who drive their personal vehicles while performing duties on your behalf have personal auto insurance (of at least $100,000 CSL).
  • Employees and volunteers are trained in safe driving techniques at least annually.

Safety

  • There is a designated Safety Officer and an active Safety Committee.
  • Office spaces are free of electrical cords and trip hazards, as well as clutter.
  • File cabinet doors are opened one at a time and closed when work is finished.
  • Exits are:
    • Clear of obstacles
    • Well lit
    • Unlocked for egress
  • Visitors are logged in and out.
  • Walkways and parking areas are:
    • Well maintained
    • Kept free from ice and snow where applicable
    • Well lit
  •  Records are maintained of the date/time of ice and snow removal where applicable.
  • Lighting is adequate.
  • Hazardous wastes are stored in designated areas.
  • Environmental Safety rounds are completely on a regular basis and reported to the Safety Committee.
  • Flammable liquids and cleaning products are stored in fire resistant cabinets.
  • Smoke and heat alarms are maintained in working order.
  • Fire extinguishers are:
    • Readily available
    • Inspected regularly
  • Medical and other confidential records are kept under lock.
  • Preventive measures are taken to reduce slips and falls on the property.
  • Written emergency preparedness plans are in place.

Standards and Regulations

  • Requirements of licensing bodies with jurisdiction over operations met:
    • Fefderal
    • State
  • Requirements of regulatory bodies with jurisdiction over operations are met:
    • Federal
    • State
  • A survey by either JCAHO or another accrediting body has been conducted within the past three years.
  • Recommendations of licensing and accrediting body have been addressed.
  • OSHA and CDC regulations are integrated into the organization’s Safety and Infection Surveillance Programs.
  • Licensure and credential verification is conducted on all employees whose position requires licensure or specific credentials:
    • Time of hire
    • Ongoing