Home Health & Hospice

Understanding policies and procedures

Homecare Insider, January 13, 2014

Every agency struggles with the amount of things it needs to do in a very limited amount of time. In the ever-changing world of homecare, it can be difficult to not only comply with new regulations, but also make sure that they are implemented into the agency's policies and procedures. However, this action is crucial because your policies must be reviewed and updated annually, and survey issues can arise if this is not being done and if your agency is not following its documented policies and procedures.
To make this cumbersome task easier, agencies must not wait until the last minute, but instead create a system for updating their policies and procedures. It is important to start with the basics: what the Conditions of Participation (CoP) say about an agency's program and annual evaluation and what exactly these terms (policy and procedure) really mean. From there, your agency can create a system of implementing changes as they happen and spend less time on its annual review. Creating a system for compliance is essential for the success of your agency.
The basics: What the CoPs say
Before understanding the best way to create a system for reviewing and adding policies and procedures, it is important to understand the basics. Keep in mind that an annual policy and procedure review is mandated by the CoPs.
CoP §484.52, evaluation of the agency's program, states: "The HHA has written policies requiring an overall evaluation of the agency's total program at least once a year by the group of professional personnel (or a committee of this group), HHA staff, and consumers, or by professional people outside of the agency working in conjunction with consumers. The evaluation consists of an overall policy and administrative review and a clinical record review."
It further states that the evaluation "assesses the extent to which the agency's program is appropriate, adequate, effective, and efficient. Results of the evaluation are reported to and acted upon by those responsible for the operation of the agency and are maintained separately as administrative records."
Standard (a) of §484.52 requires that the policies and administrative practices of the agency are reviewed "to determine the extent to which they promote patient care that is appropriate, adequate, effective, and efficient."
The basics: Defining policies and procedures
You also must understand what policies and procedures are. These may seem like simple definitions, but often a firm understanding of what you are dealing with can make things easier.
Policy: A policy is best defined as a nonnegotiable directive. Policies are the rules or mandatory directions that agency staff must follow in governing the agency and providing care. In home health care, many nonnegotiable directives come from federal, state, and local regulations and practice acts, as well as accrediting bodies. Your agency may designate a particular course of action as one of its own nonnegotiable directions, such as defining services or time frames.
Procedure: A procedure serves as a guide for care delivery. Procedures provide step-by-step guidance for your agency's staff. They must reflect your agency's standards and practices as defined in agency policy statements. Unlike policies, procedures should be flexible to allow your agency's caregivers to individualize patient care. 
It is important that whoever is responsible for reviewing and updating policies at your agency understands the difference between a policy and a procedure. The relationship between the two is sometimes difficult to understand. For example, consider regulation 484.48 in the CoP, which states that the clinical record must include a discharge summary. This is a nonnegotiable directive. However, the way your agency implements this regulation is negotiable. The specific look and content of the discharge summary form, who completes it at the agency and when, where it is filed, and other implementation directives can vary. Thus, the procedure for the completion of the discharge summary must be agency-specific. You agency must follow an established process for development and implementation of procedures.