Article contributed by AAPACN Solution Provider The Compliance Store
By Michele Mummert, RN, RAC-CT, RAC-CTA, DNS-CT
In long-term care (LTC) settings – including nursing homes, assisted living facilities, and residential care centers – well-crafted policies are the backbone of quality care, staff accountability, and regulatory compliance. These policies do more than guide internal processes; they also serve as evidence of the facility’s commitment to state and federal regulations, quality standards, and ethical practices.
LTC facilities are under constant scrutiny from oversight by agencies such as the Centers for Medicare and Medicaid (CMS), the Occupational Safety and Health Administration (OSHA), and state departments of health. As a result, the development, review, and maintenance of comprehensive, compliant policies is not just a best practice – it is a necessity. When writing effective policies, the emphasis should focus on aligning them with regulatory frameworks and promotion of excellence in care delivery.
Getting Started
Before beginning to write a policy, it is vital to understand the regulatory context in which your facility operates. Regulations may be derived from many sources including:
- CMS requirements for long-term care which are outlined in the State Operations Manual (SOM), Appendix PP, and provides interpretive guidance on federal regulations (F-tags).
- State licensing requirements that spell out their own set of rules covering topics such as staffing ratios, resident rights, infection control, medication administration, and more.
- OSHA standards that provide regulatory information related to workplace safety for both residents and staff.
- Health Insurance Portability and Accountability Act (HIPAA) in relation to compliance with security and privacy of residents’ protected health information (PHI).
- Civil rights and nondiscrimination laws ensuring equitable care and services for all residents, regardless of race, gender, disability, or sexual orientation.
When writing these policies, it is vital to ensure that they reflect the most current versions of applicable laws and guidelines. Failure to do so can result in citations, fines, or even loss of licensure or certification.
Key Components of a Strong Policy
Policies should be structured in a clear, consistent, and actionable way that ensures staff can follow procedures consistently and surveyors can easily verify compliance when conducting inspections. Components of a strong policy include:
- Policy Title: Concise and specific (e.g., “Infection Prevention and Control Policy”).
- Purpose: A short paragraph outlining why the policy exists and what it aims to achieve.
- Scope: Defines which departments, roles, or situations the policy applies to.
- Definitions: Clarifies any terms that might be ambiguous or technical.
- Policy Statement: A general overview of the organization’s position or requirement regarding the issue.
- Procedures: Detailed, step-by-step instructions for staff to follow. These should include who is responsible for what and when tasks are to be completed.
- Regulatory References: Citations of laws or standards.
- Review Date and Approval: Indicates when the policy was last reviewed and approved, and by whom.
Policy Development
Depending upon the organizational make-up of the facility, policy development may differ across settings. Some policy development may occur at a corporate level while some may be more at an individual facility level. Regardless, it should be a team effort when developing policies to meet organizational operations and compliance requirements.
Needs Assessment
When considering what policies are needed, the organization or facility should conduct a needs assessment. This assessment should include areas of high-risk, such as medication administration, infection control, falls management, pressure injury prevention, abuse reporting, and emergency preparedness, as well as operational guidelines.
Assemble a policy committee that includes members of the interdisciplinary team such as the Director of Nursing (DON), Administrator, Medical Director, Risk Manager, Human Resources, and department heads. Also, garner input from direct care staff which can provide practical insights. Once the committee is formed, review any federal, state, or local regulatory guidance that is associated with an intended policy topic.
Once that is reviewed, draft a policy using plain, professional language, avoiding overly technical or legal jargon unless necessary. Write clearly to ensure understanding by all levels of staff. Define who is responsible for compliance and document the flow of procedures. Once completed, have the policy reviewed by your legal counsel or compliance officer if necessary. When the policy is finalized, it should be approved by the facility’s governing body or leadership team.
Effective Communication
For the policy to be effective, it has to be communicated to the staff through education and training. Any new or revised policies should be included in onboarding activities or ongoing in-service trainings. Utilize case scenarios and competency assessments to reinforce learning. But it doesn’t stop there. Ongoing monitoring of policies is vital to ensure that they are being adhered to. Establish mechanisms such as internal audits, resident outcome tracking, and staff feedback to check for adherence to the policies and provide additional education or training if adherence is not being met.
Policy Review
Annual reviews of policies should be conducted. If regulatory information or guidance changes, policies should be reviewed and revised as necessary. Have documentation in place and available that demonstrates review dates and revision histories. Consider methods of storing old policies that have been removed or revised should the case arise that it may need to be brought back up for legal or regulatory review reasons.
The State Operations Manual (SOM) Appendix PP provides the federal regulations for compliance for LTC settings. These regulations cover the minimum requirements for facilities to be in compliance. Specific state regulations may be more stringent and should be adhered to if so noted. Common topics where facilities should have policies in place include resident rights and abuse prevention, infection prevention and control, medication management, discharge and transfer planning, staffing and competencies, behavioral health and restraints, and emergency preparedness. Other topics may include business office practices, dietary requirements and guidance, therapy practices, human resources, and physical plant and life safety code measures.
Avoid the Pitfalls of Policy Writing
Policy writing is not an easy task and even the most well-intentioned policy writers can make mistakes. Avoid the following pitfalls when writing policies:
- Overgeneralization: Policies should be tailored to your facility’s actual resources, resident population, and staff roles
- Outdated References: Citing expired or superseded regulations can lead to noncompliance.
- Overly Complex Language: Policies should be easy to read, understand, and followed by staff.
- Inconsistency Between Policy and Practice: Ensure what is written matches what is done. Discrepancies are a red flag during surveys and you can be cited for not following your policies.
- Neglecting Staff Input: Policies that ignore frontline realities may not be practical or enforceable.
Be Survey Ready
Survey is not the time to be looking to see if you have a policy in place or if you are adhering to the policies you have. Facilities must always be “survey ready” ensuring that they are following their established policies. Conducting periodic mock surveys helps to determine whether current policies are being followed, need revision, or new ones need to be developed. Well-written policies support the culture of survey readiness by facilitating consistent care, providing documentation, training survey prep teams, and demonstrating quality improvement. Maintaining a master policy and procedure manual that is updated, organized, and easily accessible, whether manually or electronically, is essential for regulatory inspections and staff reference.
Embrace Technological Support
As technology has evolved, many facilities have transitioned to electronic policy management systems. Many of these systems can track changes and ensure staff have access to the latest versions, as well as ensure that only authorized personnel can edit policies. These electronic systems can also make searching for relevant policies easier for both staff and surveyors, saving lots of time and energy in the process. Some systems may also integrate staff education by linking policies with staff education modules and tracking completion of that education. Electronic systems may also provide audit trails that can be useful during legal or regulatory reviews.
Conclusion
Writing effective policies is more than a bureaucratic exercise – it is a foundational strategy for delivering safe, ethical, and compliant care. Policies ensure that regulatory expectations are met, resident rights are protected, and staff actions are guided with clarity and consistency.
To succeed, policy development must be a collaborative, informed and ongoing process. LTC providers must stay ahead of the ever evolving and changing regulatory landscape, adapting their policies to new realities while preserving their core mission: providing compassionate and competent care for every resident.
By investing in strong policy frameworks, long-term care facilities not only safeguard their operations – they also elevate the quality of life for those they serve.
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