FAQs on Systems for LTC Policies and Procedures
Policies and procedures are far more than written guidelines – they provide a backbone of safety and consistency. Skilled nursing policies and procedures outline expectations and play a crucial role in regulatory compliance, providing quality of care, and staff empowerment. Well-developed policies provide clear direction to staff, protect residents’ rights, and reduce the risk of errors, while procedures translate these policies into practical, day-to-day actions. In our highly regulated and rapidly changing environment, maintaining accurate, current, and accessible policies and procedures is imperative. Let’s review FAQs surrounding best practices to move beyond paper compliance toward structured policy and procedure processes to ensure success….
Q: When should policies and procedures be reviewed and revised?
A: Minimally, current policies and procedures should be reviewed on an annual basis. Other situations warranting review and potential revision include regulatory updates, standard of practice changes, adverse events, or if auditing indicates compliance concerns.
Q: Who should be involved in the review, revision, and approval process?
A: The facility’s interdispinary team and QAA committee are required to be involved in the process. Additionally, federal regulatory guidelines, effective April 28, 2025, call for the medical director to be directly involved in the development and implementation of clinical policies and procedures. Final approval must be obtained by the facility’s administrator and governing body.
Q: What are best practices related to document control and accessibility?
A: Policies should contain initiation and revision dates, with easy access for staff to current versions. Prior versions should be archived based on the facility’s retention practices. Note, master documents with approval signatures of required individuals should be maintained and outlined in QAA Committee minutes.
Q: What steps should be taken related to survey readiness?
A: Documentation of review dates, update logs, and any training attendance sheets or acknowledgement forms should be maintained and readily available as part of the survey readiness plan.
Q: How do policies and procedures relate to quality assurance performance improvement initiatives?
A: When audit or other performance improvement findings trigger policy changes, the QAPI process should be followed. Root cause analysis reviews should include assess relevant policies and procedures after adverse events or citations. Additionally, policies should be integrated into PDSA cycles to ensure they are working as intended.
Next Steps:
- Join Proactive for a Policies and Procedure focused webinar August 19, 2025 part of the Reducing Litigation Risk for SNF & AL series
- Contact Proactive for expert assistance in reviewing and refreshing Policies and Procedures
- Access up to date Policy and Procedure manual templates in the Proactive Solutions Center including the nursing home 2025 Appendix PP Revisions Package
Written By:
Liz Wheeler, BSN, RN, CHPN, IPCO, QCP, CDP
Clinical Consultant
Proactive LTC Consulting
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