Tool:

Abuse Prevention Policy and

Procedure Checklist

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 Tool: Abuse Prevention Policy and Procedure Checklist

483.12: Freedom from abuse, neglect and exploitation

The resident has the right to be free from abuse, neglect, misappropriation of resident
property, and exploitation, including freedom from corporal punishment, involuntary seclusion
and any physical or chemical restraint not required to treat the resident’s medical symptoms.
Purpose and Intent of 483.12
To develop a comprehensive Abuse Prevention Management and Reporting Program
encompassing individual residents, facility resident population, resident representatives, facility
staff, vendors and/or contractors as well as the facility environment.
To assure that the individual facility has followed all the required steps for the development
and implementation of a comprehensive Abuse Prevention Management and Reporting
Program in accordance with the new Requirements of Participation (RoP), the following
checklist captures specific action items for successful completion. The far left column
represents the actual Requirements of Participation (RoP) language and the right column
indicates specific leadership strategies for successful completion and implementation of the
revised RoP. When preparing updated policies and procedures, it is recommended to include
actual RoP language as applicable. Please note that CMS has not issued its interpretative
guidance for the new Requirements of Participation (RoP), therefore additional updates may be
necessary once the guidance is released.

Suggested Checklist: Comprehensive Abuse Prevention

Management and Reporting Program and Policy and Procedure

Regulation Recommended Actions

(a) The facility must- ☐Review, revise and institute an Abuse Policy and
(1) Not use verbal, mental, sexual, or physical Procedure in accordance with the new RoP. See
abuse, corporal punishment, or involuntary
regulatory requirements as well as template
seclusion;
policy and procedure.

☐Update all definitions and new terms: abuse,

verbal abuse, sexual abuse, physical abuse,
mental abuse, involuntary seclusion, exploitation,
misappropriation, mistreatment, neglect, injuries
of unknown origin, immediately, resident
representative, covered individual, person-
centered care.

This document is for general informational purposes only.

It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
© Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - Requirements of Participation P&P Manual 2017
Regulation Recommended Actions
☐All Staff training on the revised Abuse Policy
and Procedure. Update training for orientation,
annual, agency staff, as needed. Provide training
to staff on the freedom from abuse, neglect, and
exploitation requirements.

☐Review, revise and conduct Resident and

Resident Representative training on Abuse Policy
and Procedure and Facility Grievance Procedure

☐Conduct updated training for Management

Personnel on supervising and monitoring for
abuse per the new RoP requirements as
indicated.

☐Update Abuse Prevention Posters outlining

definitions, reporting and requirements. Update
postings in accordance to the Elder Justice Act.

(2) Ensure that the resident is free from physical ☐Review and update the Policy and Procedure for
or chemical restraints imposed for purposes of
the use of Physical Restraints
discipline or convenience and that are not
required to treat the resident’s medical
symptoms. When the use of restraints is ☐Review the Restraint/Device Assessment and
indicated, the facility must use the least re-evaluation Form
restrictive alternative for the least amount of
time and document ongoing re-evaluation of the ☐Review and update the Policy and Procedure for
need for restraints. the use of Psychotropic Medications/Chemical
Restraints outlining use, alternatives and
reduction plans

☐Policy on Gradual Dose Reductions for

Psychotropic Medications/Chemical Restraints

☐Review and update Behavior Program policies

and procedures

(3) Not employ or otherwise engage individuals ☐Proof of background checks for new employees
who- prior to employment and ongoing verification for
all existing employees

This document is for general informational purposes only.

It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
© Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - Requirements of Participation P&P Manual 2017
Regulation Recommended Actions
(i) Have been found guilty of abuse, neglect,
exploitation, misappropriation of property, or ☐Policies and Procedures for Pre-Employment
mistreatment by a court of law:
Screening (Background checks and verification of
(ii) Have a Finding entered into the State nurse
certification, licensure, etc.)
aide registry concerning abuse, neglect,
exploitation, mistreatment of residents or ☐Proof of verification with the State nurse aide
misappropriation of their property; or registry with no findings of abuse, neglect,
(iii) Have a disciplinary action in effect against his exploitation, mistreatment or misappropriation
or her professional license by a state licensure
body as a result of a finding of abuse, neglect, ☐Proof of verification with the State Licensing
exploitation, mistreatment of residents or Board of valid licensure with no disciplinary
misappropriation of property action in effect as a result of a finding of abuse,
neglect, exploitation, mistreatment or
misappropriation

☐Proof of background checks for agency staff

(4) Report to the State nurse aide registry or ☐Documentation on how facility will notify the
licensing authorities any knowledge it has of
State nurse aide registry or licensing authorities
actions by a court of law against an employee,
with any knowledge it has of actions by a court of
which would indicate unfitness for service as a
law indicating unfitness for service as a nurse
nurse aide or other facility staff.
aide or licensed professional

(b) The facility must develop and implement ☐Abuse Policy and Procedure outlining all
written policies and procedures that:
elements identified in 483.12(4)(b)
(1) Prohibit and prevent abuse, neglect, and
exploitation of residents and misappropriation of
resident property ☐Proof of resident assessment process to
(2) Establish policies and procedures to determine risk and/or vulnerability to include:
investigate any such allegations, and • Preadmission assessment
(3) Include training as required • Vulnerability Assessment, including
(4) Establish coordination with the QAPI program Wandering and Elopement
(5) Ensure reporting of crimes occurring in • Behavior Assessment
federally-funded long-term care facilities in • Cognitive Assessment
accordance with section 1150B of the Act. • Comprehensive dementia assessment
The policies and procedures must include but are
not limited to: ☐Resident to Resident Altercation/Abuse Policy
(i) Annually notifying covered individuals, as
and Procedure
defined in section 1150B(a)(3) of the Act, of that
individual’s obligation to comply with the
following reporting requirements. ☐Documentation of education on facility
comprehensive dementia program

This document is for general informational purposes only.

It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
© Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - Requirements of Participation P&P Manual 2017
Regulation Recommended Actions
(A) Each covered individual shall report to the
State Agency and one or more law enforcement ☐Update internal Resident One to One Policy
entities for the political subdivision in which the
and Procedure as applicable
facility is located in any reasonable suspicion of a
crime against any individual who is a resident of,
or is receiving care from, the facility.
(B) Each covered individual shall report
immediately, but not later than 2 hours after
forming the suspicion, if the events that cause
the suspicion result in serious bodily injury, or not ☐Cross reference and update all internal Abuse
later than 24 hours if the events that cause the Prevention policies to include the provisions of
suspicion do not result in serious bodily injury. the Elder Justice Act Requirements and general
(ii) Posting a conspicuous notice of employee maltreatment reporting requirements as well as
rights as defined at section 1150B(d)(3) of the state specific requirements for notification,
Act. reporting and response
(iii) Prohibiting and preventing retaliation, as
defined at section 1150B(d)(1) and (2) of the Act. ☐Education with sign in sheets identifying proof
of annual notification of covered individuals of
their obligation to comply with reporting
requirements

☐Documentation on how the facility verify

reporting to the State Agency and local law
enforcement of a reasonable suspicion of a crime
in the required timeframes

☐Posting of notice of employee rights as defined

at Section 1150B(d)(3) of the Act in a conspicuous
place in the facility

☐Evidence of training for Facility Management,

Front-Line Staff and Residents/Resident
Representative on the prohibition and prevention
of retaliation as defined at section 1150B(d)(1)
and (2) of the Act.

☐Incorporate Resident Abuse Prevention into

QAPI program. Update QAPI P&P to reflect
changes and requirements as indicated in the
RoP Phase 3 implementation requirements.

This document is for general informational purposes only.

It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
© Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - Requirements of Participation P&P Manual 2017
Regulation Recommended Actions

( c ) In response to allegations of abuse, neglect, ☐Update Abuse Policy and Procedure to include
exploitation, or mistreatment, the facility must:
updated reporting, investigation, and protection
(1) Ensure that all alleged violations involving
requirements per new RoP
abuse, neglect, exploitation or mistreatment,
including injuries of unknown source and
misappropriation of resident property, are ☐Education with sign in sheets identifying proof
reported immediately, but no later than 2 hours of annual notification of covered individuals of
after the allegation is made, if the events that their obligation to comply with reporting
cause the allegation involve abuse or result in requirements to include immediate notification
serious bodily injury, or not later than 24 hours if of the facility Administrator and if suspicion of a
the events that cause the allegation do not crime resulting in serious bodily injury, reporting
involve abuse and do not result in serious bodily to the State Agency and Local Law Enforcement
injury, to the administrator of the facility and to must occur no later than 2 hours after suspicion
other officials (including to the State Survey or allegation and if the allegation/suspicion of a
Agency and adult protective services where state crime does not result in serious bodily injury, a
law provides for jurisdiction in long-term care report to the State Agency and Local Law
facilities) in accordance with State law through Enforcement agency must be completed no later
established procedures. than 24 hours.
(2) Have evidence that all alleged violations are
thoroughly investigated. ☐The facility must have evidence (documentation
(3) Prevent further potential abuse, neglect, forms) of a thorough investigation including
exploitation, or mistreatment while the resident statements, witness statements, staff
investigation is in progress. statements, environmental review, resident
(4) Report the results of all investigations to the physical assessment, etc., including a timeline of
administrator or his or her designated events.
representative and to other officials in
accordance with State law, including to the State
☐The facility must have evidence that the
Survey Agency, within 5 working days of the
incident, and if the alleged violation is verified resident(s) is protected during the investigation
appropriate corrective action must be taken (i.e. documentation with time clock verification
of employee clocking out and leaving the
building)

This document is for general informational purposes only.

It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
© Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - Requirements of Participation P&P Manual 2017
 Regulation Recommended Actions
☐Documentation system to substantiate
reporting of the results of the investigation to the
administrator and other officials in accordance
with State law and the State Survey Agency
within working days

☐Documentation, including verification from

employee personnel file, of corrective action
taken as a result of the investigation

The below areas serves as a cross reference for facility leaders to conduct addition policy and procedure
review across departments to incorporate the changes set forth in 483.12: Freedom from abuse,
neglect and exploitation. This listing is not all encompassing however should serve as a
resource for leaders as they update their internal policies, procedures and operational
processes.
Resident Rights
CMS Definitions
Employee Orientation
Annual Training Requirements
Quality Assurance and Performance Improvement
Caregiver Background Checks
Hiring Protocols
Staff Training and Education
Comprehensive Dementia Program
Pre- Admission and Admission Policies
Elopement Policy
Incident Accident Policy and Procedure
Behavior Management
Physical Device and Chemical Restraint Policy and Procedure
Problem Resolution/Grievance Process

This document is for general informational purposes only.

It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
© Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - Requirements of Participation P&P Manual 2017