Policy/Procedure book update

[trudy88]

I've been assigned to update our facility's Policy/Procedure books. Any sites, ideas, products to recommend? trudy

[Daytonite, BSN, RN]

there are a couple of things that you need to do. you need to ask the don for a copy of the state and federal laws that you absolutely have to be aware of with regard to any policies and procedures. i can give you a link to the medicare laws for ltc, but you'll have to find out where to get a copy of your state laws.

• http://www.cms.hhs.gov/certificationandcomplianc/12_nhs.asp and these are the medicare conditions of participation (title 42, section 483 of the federal law) that apply to ltc nursing - to view the actual laws, click on the "42 cfr part 483" link at the bottom of this web page.

you should also ask to see what the jcaho standards are as well. the facility, if they are surveyed by jcaho should have a standards manual and you need to read through it.

so, when reviewing each policy and procedure, you need to make sure that they are in compliance with the law and jcaho.

after that, insofar as updating the way they are actually performed, i would be using current fundamentals of nursing resources such as textbooks and journal articles. you may need to go to a library to do this. something else you can do is to approach various other ltc facilities and acute hospitals and explain to them who you are and the project you are undertaking. there is a unwritten professional obligation in healthcare to share these things among each other. you can't demand it, but you would hope that other facilities would be willing to share some of their policies and procedures with other professionals. there are also professional organizations for ltc that offer guidance with the establishment of policies and procedures, so you should also ask your don or administrator if they belong to any of these organizations and if it is possible to see what kind of assistance you can get from them. another resource you should consider is contacting the department of public health who probably is responsible for doing your state surveys. while most are a bit afraid of the surveyors and the survey process, this group of people also has a responsibility to educate. if any group knows where to find facilities that have good examples of policies and procedures, they will.

have fun!