HC-SOP-003: Caregiver background screening, registries and recheck

Standards › Standard 29 › Standard operating procedures (SOPs)

Procedure · HC-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 29.6

At a glance

Each caregiver’s criminal record check is verified against a unique identifier, not a name search alone (STF-FRM-001).
Abuse and neglect registries are checked for every country the caregiver has worked in.
Any care-worker exclusion registry is checked specifically (29.8).
Screening is repeated on a set schedule for every active caregiver (29.9).
Stop and get help straight away if: a caregiver is hired on a name match with a different person’s record.

1. Purpose

To make sure each caregiver is screened on verified identity, across countries, and rechecked (29.6 to 29.9).

2. Scope

Applies to	Clinical and support staff in the hospital
Locations	All wards, clinics and departments of the facility
When	Whenever the activity described is carried out
Does not apply to	Activities covered by another document listed in section 15

3. Definitions

Term	Meaning
Clinical lead	The doctor or nurse in charge of the area at the time

4. Background

A criminal record check that matches only a name can miss a person or pick up the wrong one. A check against a unique identifier, such as an ID number, is reliable.

5. Responsibilities

Role	Responsibility	Competence
Home care service lead	Owns the screening process	Clinician or manager
Recruiting manager	Carries out and records each check	Manager

6. Materials and equipment

Item	Requirement	Condition
Records and forms named in this document	Current version	Checked before use

7. Safety

Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.

8. Before you start

Confirm the forms and equipment named in this document are available and current.

9. Procedure

Step 1. Verify identity.

Verify the record against a unique identifier, and record it on HC-FRM-005.

Key point: Verified.

Step 2. Check registries.

Check the abuse registry and any exclusion registry for each country worked; where none exists, verify with prior employers.

Key point: Checked.

Step 3. Recheck.

Repeat the screening on the set schedule for active caregivers.

Key point: Rechecked.

10. Decision points

No decision points in this procedure.

11. Special situations

Situation	Action
Out of hours	Follow the same steps. Use the on-call contact on the wall of the area.

12. Escalation

Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.

13. Monitoring

Measure	Target	Frequency	Owner	If not met
Caregivers screened on verified identity with registry checks	100%	Quarterly	Home care service lead	Escalate to medical director

14. Records

Record	Kept in	Retention
Record named in this document	Patient record or the area file	the period set by the facility’s records policy years

15. Training

Staff are trained in this document at induction and refreshed each year, with a recorded competency check.

16. Related documents

ID	Title	Use
HC-FRM-005	Caregiver screening record	Record
STF-FRM-001	Staff verification register (existing, reused)	Register

17. Evidence

Reference	Note
E-009	Based on the WHO Global strategy and action plan on ageing and health 2016-2030, WHO Integrated care for older people (ICOPE) guidelines (2017), and WHO guidance on migrant health.
E-006	ASF Policy Framework v1.2. Adapted.
E-009	ASF Expert Committee consensus.

18. Change history

Version	Date	What changed	Approval
1.0	the date of approval	First version	set Expert Committee approval

E-learning for this document

Credentialing, Competence and the Training Matrix (T-14)

References

Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)

Download this document as PDF