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