A System for Addressing a Deficiency


The following is a example of a system to address an abuse, neglect, and exploitation (ANE) deficiency:

  • The unit management team will review all facility incident reports on a daily basis. 
  • The incident management team will review incidents that involved injuries (including those of an unknown cause and non-reportable injuries) or allegations of abuse or neglect on the next business day. 
  • QIDPs are expected to convene interdisciplinary team (IDT) meetings to address all injuries and allegations of abuse or neglect within 24 hours of the date of discovery.
  • QIDPs must submit a copy of the IDT meeting minutes to the unit director and quality assurance director. 
  • QIDPs must ensure that the IDT considers the following:
    • all the facts gathered to date;
    • history of similar incidents/allegations; and
    • programs designed to address the situation