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It’s Time To Talk About Policy And Procedure Manuals Again. Have You Done Anything Different Since Last Survey?

policy and procedure manuals

Having been in the home health and hospice industry through many decades, I have seen lots of changes. One thing that remains consistent at survey time is the need for an updated policy and procedure manual. Why do you think that is? After everything else that changes over time, the need to establish policies and keep them updated has remained constant. Let’s look at why it remains an issue for agencies at survey time and how to make your manual better.

Biggest Issues At Survey:

Surveyors pull out your manual and look at every regulation for the home health and hospice industry to see if it is present in your manual. Then, they look to see if the way you comply with it makes the grade. I will never forget a CHAP survey where a couple policies were questioned and she looked directly at me and said, “Ok, convince me how you comply”. Here’s the thing. I didn’t want to have to convince her. I thought I was good to go. But, it made me step back and think about how things in the manual were written. Needless to say, it never happened after that. Let’s look at top reasons citations come at survey time.

  • Regulation Isn’t In Policy: This happens more that we would like to admit. Agency administration must keep up with regulatory changes as they occur on the state and federal level as well as with accreditation. After the COPs changed, the number of calls we got from agencies cited who never did emergency preparedness plans and did not know you had to have a designated clinical manager was kind of shocking. Make sure you have checks and balances in your agency to monitor for regulatory changes and get them into place.
  • Agency Doesn’t Follow Policy: Your policy and procedure manual should be able to tell the story of how you run the agency. From regulations to operations, your manual should allow someone to come in and know how to step into the shoes of an employee. Many times, we see that operations don’t go according to policy because no one changed the policy when the operational change happened. This will also get you cited.
  • Programs and Positions Aren’t Updated: As you add positions or change current ones, your policy manual should change too. Maybe you had a psych nurse position and program in place at one time, but your psych nurse left and was not replaced. However, your policies still speak to referrals to the psych nurse for patients on certain medications or with certain diagnoses. You need to pull what doesn’t apply.
  • Manual Was Purchased And Never Customized: Buying an updated online manual is much easier than starting from scratch. However, you have to edit it to your agency. Many agencies make the mistake of buying a manual and never going through it. Often times, a purchased manual goes above and beyond with what policies are available in order to make sure any type of agency is covered. This doesn’t mean those additional policies are necessary for you. You must customize your online manual to your agency.

It may seem pretty obvious to maintain a policy and procedure manual, but reality is that many agencies don’t use it properly. It should be the guide to day-to-day business, operations, and personnel management. When it’s not, agencies are at risk at survey and have a higher chance of not following policy. When there are employee disputes, you will always lose when those in leadership do not follow policy. Leadership on every level should be utilizing the policy manual as part of decision making.

Check Out Our Updated Policy And Procedure Manuals:

At Kenyon Homecare Consulting. we have online updated customizable manuals for all lines of service. Whether you are a home care, home health, or hospice, we have a manual online for purchase and we are accreditation ready should you decide that is what you need. Call us today at 206-721-5091 or contact us online to see how we can help get your manual up-to-date.  Join us October 7th. 2020 for our latest free ICD 10 coding webinar, Are You Leaving Money On The Table? Register today to reserve your seat!

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