Standards › Standard 29 › Standard operating procedures (SOPs)
Procedure · HC-SOP-012 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 29.40
At a glance
- When a caregiver’s work authorisation changes, the service gives transition time and support.
- Client care is covered before the caregiver’s last day.
- No caregiver is stopped the same day without a transition plan.
- The change and the support given are recorded.
- Stop and get help straight away if: a caregiver’s permit expires and they stop work the same day, leaving a client alone.
1. Purpose
To handle a caregiver’s status change with support, not abruptly (29.40).
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 caregiver whose own work permit is about to expire can lose their job suddenly, which leaves the client without care. Planning ahead for a change in status protects both.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Home care service lead | Owns the transition rule | Clinician or manager |
| HR or recruiting manager | Arranges the transition and records it | 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. Identify early.
- Track permit and authorisation dates for each caregiver.
Key point: Tracked.
Step 2. Plan transition.
- Arrange client cover and a transition period before the change takes effect.
Key point: Planned.
Step 3. Record.
- Record the support and the cover in place.
Key point: Recorded.
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 |
|---|---|---|---|---|
| Authorisation changes with a transition plan | 100% | Monthly | 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 |
|---|---|---|
| STF-SOP-001 | Staff credential verification and recheck (existing, reused) | Procedure |
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
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)