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Operations

Policy Templates

Administrator-level policy shells for abuse prevention and reporting, grievance handling, admission and transfer/discharge, infection prevention and staffing.

Templates

Each policy follows the same structure — purpose, policy, procedure, documentation and approval — so your manual reads consistently to a surveyor.

42 CFR 483.12 — F600, F607, F609, F610

Abuse Prevention & Reporting Policy

Covers all seven required components with the 2-hour and 24-hour reporting timelines.

POLICY: ABUSE, NEGLECT AND EXPLOITATION PREVENTION AND REPORTING
Facility: [NAME]    Effective: [DATE]    Review: annually    Owner: Administrator

PURPOSE
Residents have the right to be free from abuse, neglect, misappropriation of
property and exploitation. This policy establishes the seven required components.

POLICY
1. SCREENING — Criminal background checks and registry verification (nurse aide
   registry, licensing boards, OIG exclusion list) before hire and as required
   thereafter. No individual with a substantiated finding is employed.
2. TRAINING — All staff, contractors and volunteers are trained at orientation
   and at least annually on recognizing and reporting abuse and neglect.
3. PREVENTION — Adequate staffing and supervision, resident risk identification,
   behavioral support planning and environmental safeguards.
4. IDENTIFICATION — Staff report any suspicion; sources include observation,
   grievances, injuries of unknown origin and resident/family reports.
5. INVESTIGATION — The administrator or designee begins investigation
   immediately, interviews witnesses, secures evidence and documents findings.
6. PROTECTION — The resident is protected during the investigation; the accused
   individual is removed from resident contact pending outcome.
7. REPORTING AND RESPONSE —
   - Report to the administrator immediately.
   - Report to the state survey agency and other required officials immediately,
     but not later than 2 hours if the allegation involves abuse or results in
     serious bodily injury, and not later than 24 hours for all other allegations.
   - Submit investigation results within 5 working days of the incident.
   - Take corrective action if the allegation is verified.

DOCUMENTATION
Incident report, witness statements, investigation summary, notifications log,
resident and representative notification, and corrective action.

RETALIATION
No staff member is retaliated against for reporting in good faith.

Approved by governing body: ____________________  Date: ______

42 CFR 483.10(j) — F585

Grievance Policy & Procedure

Grievance official, written decisions, timelines and retention in one document.

42 CFR 483.15(a) — F620

Admission Policy

Non-discrimination, third-party guarantee prohibition and required admission disclosures.

42 CFR 483.15(c) — F622, F623, F625

Transfer & Discharge Policy

The six permissible reasons, 30-day notice content and bed-hold notification.

42 CFR 483.80 — F880, F881, F882

Infection Prevention & Control Policy

Surveillance, standard and transmission-based precautions, stewardship and the IP role.

42 CFR 483.35 — F725, F726, F727, F732

Staffing & Competency Policy

Acuity-based staffing, competency validation, RN coverage and daily posting.

These templates are educational starting points, not legal advice. Have counsel and your medical director review any policy before adoption, and align it with your state licensure requirements.

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