Q: At our facility, we use corporate policies and procedures from our health services vendor. How will NCCHC evaluate site-specific policies during our next survey?
A: Policies and procedures are the working set of documents that staff use to illustrate what they are doing and how they are doing it – the foundation to assessing compliance with NCCHC standards.
Each survey team reviews policies and procedures to establish that those policies and procedures are applicable to the standards. They do not critique the written policies for specific wording but do review the policies to ascertain whether they are in accordance with the standards and that the facility is following them.
When the NCCHC surveyor team cites noncompliance in this area, it often has to do with corporate policies that do not reflect what is happening at that facility. For example, some corporate policies cover services that are not offered at the facility being surveyed, without indicating which services do not apply. Those policies, therefore, are not site specific.
While corporate policies are a great starting point to support facility operations, it is important that each facility take time to review the corporate policies and adapt them to their individual setting, noting what is different and not applicable. Customization of the corporate policies can be accomplished by placing verbiage in a text box whenever there is a variance or an addendum explaining that variances can be added to the policy. If a corporate policy presents options such as “if infirmary level care is provided,” it is essential that the policy states whether infirmary level care is or is not provided at that facility.
The site-specific policies should be viewed as documents that would provide clarity as to what services are provided at the facility if read by an individual who knows nothing about your operation (e.g., new hires, attorneys, surveyors).
Amy Panagopoulos, MBA, BSN, is NCCHC’s vice president of accreditation. Send your standards-related questions to accreditation@ncchc.org.
