Let's Talk Policy And Procedure Manuals: Do You Know What's In Yours Or Is It Just A Big Book You Stare At Everyday?
September 4, 2021
If you follow this blog, you have seen that lately we have focused on items specifically related to surveys and the citations in them. The reality is so much falls back on how your policies are written and carried out within your agency. When you look back at your last 3 surveys, how many had to do with policy error or lack of execution of a current policy? Let's look at some policy dos and don'ts and prevent there being an issue at your next survey.
5 Considerations For You Policy and Procedure Manual:
- Are all the regulations in there? Now, there is no quick way around this. Look at each regulation in your state for the service you provide. Can you link your policy back to each one? Many agencies will reference the exact state or federal regulation at the bottom of the policy or have an index of regulations with the corresponding page where that regulation can be found.
- Is every part of the regulation listed? Again, this is time consuming but you need to make sure all elements of the regulation are clearly stated. As we are on site with agencies helping with operations or survey prep, we see this all the time. 90% of the regulation is present and the other missing and now it is a citation. Methodically go down each regulation and if you can't find each element in your manual, then add it and get it approved by your board of directors.
- Does your manual clearly state how you follow policy? The elements of a clear and satisfactory policy not only state the regulation, but how your agency complies with it.
Let's consider your complaints. Who manages them at your agency? Can anyone take a formal complaint or do you move it up the administrative chain to supervision? Who is responsible to sign off on resolution and document it?
- Do you follow your policies they way they are written? This often catches agencies by surprise, especially when a policy manual has been purchased but never edited. For example, let's look again at complaints. The surveyor asks about your complaint log and how you manage your complaints. As you speak to how a complaint is handled within your agency, it directly conflicts with your policy. You need to edit your manual to match operations.
- How often do you truly update your manual and who is responsible to keep it up-to-date? Some agencies have a designated person to update the policy and procedure manual when things change. Then, that person is responsible for communicating the changes to the board of directors and getting approval on the books. In other agencies, it is not as clear. Someone needs assigned the gatekeeper of monitoring regulatory change. Maybe your HR manager needs assigned changes related to OSHA and the clinical manager follows clinical changes and writes those changes. Maybe the CEO or administrator needs to be the gatekeeper for everything. Regardless, there has to be someone who is monitoring websites and state and federal guidance.
Kenyon Homecare Consulting Can Help:
If you are getting ready for survey and realize your manual is so far out-of-date, you do not need to reinvent the wheel. At Kenyon Homecare Consulting, we have online manuals for all lines of service and we also have accreditation ready manuals if that is what you need. Call us today at 206-721-5091 or contact us online
so see which manual meets your needs. Our manuals
can be downloaded directly from our website.
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