Surveyors will ask for policies. They don’t want a shelf of binders; they want to see that you have written procedures for the areas the CoP and state rules require, and that you’re actually following them. Experienced DONs and compliance leads keep policies aligned with practice and use them as training tools,so when a surveyor pulls a chart or asks a clinician “what do you do when…,” the answer matches the policy.
Policies surveyors typically ask for
Patient rights, comprehensive assessment and OASIS, plan of care, quality of care, infection control, emergency procedures, and personnel (orientation, competency, supervisory visits). Some states have a required list; check yours. Each policy should say who’s responsible, what’s done, and how often. “We do X within Y days” is better than “We ensure X.” Surveyors will pick two or three and dig in,if your OASIS policy says “within 5 days” and your charts show 7, that’s a deficiency. So write policies you can live by and then live by them.
Keeping them current
Policies that sit in a drawer and never change will drift from practice. Assign an owner (often the DON or compliance lead) to review them at least annually and whenever a reg or process changes. When you update one, date it and note the change. Surveyors will look at a few; if those are current and match what staff say in an interview, you’re in good shape. Many agencies tie policy review to their QAPI calendar,one policy per month or per quarter,so it’s built in, not ad hoc.
Using policies in training and audits
New staff should be trained on the policies that affect their role; document that training. When you do an internal audit (e.g. chart review for documentation or intake), use the policy as the standard: “Policy says we verify F2F before SOC,did we?” If you find gaps, fix the process or clarify the policy. A clear outline of which policies exist and what they cover makes it easier to onboard staff and prep for survey. Having a template and sample wording speeds up drafting so you’re not starting from a blank page.
We have a policy outline plus sample policies you can download and adapt: the sections surveyors expect and language you can tailor to your agency. Use the button below to get it.