With the new Conditions of Participation (CoPs) going into effect January 13th, QIRT consultants have been receiving multiple calls from current and potential clients requesting that we provide them with a new policy and procedure manual that covers the new COPs. On the surface, this seems like an easy enough request – for a fee, QIRT delivers policies and procedures that follow the federal regulations, and then the agency works with that new CoP Policy and Procedure Manual – but upon further inspection, it’s not quite so simple.
Can’t I just search the internet for a P&P manual with new CoPs?
Yes, home care or hospice agencies can easily run an internet search for home care/hospice policy and procedure manual and find many websites that sell them. Manuals vary widely in pricing, with costs from ranging from $900 to over $7,000. Some sites provide an editable document, some email a link where purchasers can download a pdf file for printing, and others will send a digital or printed version directly to the agency. The glaring issue our experts find with these manuals is that they are not customized to your agency. If purchased in editable formats, these manuals must be tailored specifically to your agency’s needs by a knowledgeable employee. If you cannot customize them internally, your organization becomes dependent upon the manual source for updates.
Why is this a problem?
Because your agency’s policy and procedure manual is a living document that should be looked at, updated, and reviewed weekly, monthly and yearly. Every agency employee and contractor must know the policies and procedures of the agency. If you do not adjust the basic P&P to your agency’s needs, it does not reflect what you do.
Within QIRT’s Clinical Consulting division, client size varies from small startups just-getting-started to large home care agencies with branches in multiple states. Clients also include organizations across fifty very differently regulated states with different (or non-existent) levels of accreditation (JCAHO, CHAP, and ACHC). For an accredited agency located in a heavily regulated state, the policy and procedure manual will look entirely different than one without accreditation established where there are few regulations. Often states also require other service regulations, resulting in additional customization.
Unless an agency is a startup, QIRT clinical consultants advise clients of the importance of having a policy and procedure manual that not only covers all state and federal regulations but is also customized to the agency and how they work day in and day out. Maintaining a manual is no easy task, and QIRT recommends using outside professionals for maintenance or designating one internal employee who is responsible for manual updates.
With the new COPs looming, now is an excellent time to consider updating your manual to reflect the CoP changes and to reflect how your agency runs. You must customize your manual to your organization. QIRT receives many phone calls from agencies in trouble from surveyors regarding their manual. Upon review of the manual, our experts find they are often out of date, not being followed or understood, and not being enforced. It is not uncommon to find a manual that has never been opened by agency owner(s) or employee(s) since the agency began.
What is the point of a manual, really?
Agencies must realize that a good manual does not only cover regulations to prevent troubles with a surveyor. The P&P manual is the written instructions on how your agency runs and policies included must reflect essential issues that affect the agency. While we do have a Basic P&P Manual available, instead of simply selling difficult-to-update manual, QIRT prefers to focus on helping our customers update their current manuals or providing them a basic COP updated manual that can then be customized by our consultants to what other regulations they must follow and tailored to their agency. No two P&P manuals – or agencies – are identical. Each P&P manual is a unique document that provides instructions and guidance to your employees on the rules, procedures, and guidelines on how the agency runs.
How important is this?
The importance of P&P manual updates cannot be overstated. Unfortunately, QIRT has seen too many organizations get in trouble or cease operations because they did not have proper policies and procedures in place or did not follow the requirements. While obtaining and customizing the manual might seem pricey in the beginning, if the manual is updated and someone has ownership of it, your agency will not suffer fines or punishment down the road.
Allison Cannon, QIRT Cheif Administrative Officer
Contact QIRT today and speak to one of our consultants about your agency needs.