{"ref":"DC-HH-GOV-04","title":"Written Policies and Procedures and the Governing Body’s Annual Evaluation","category":"Governance","summary":"Requires a complete written policy manual approved by the governing body and available to staff, patients, and the public as the rules require, and sets out the governing body’s annual review and evaluation of all policies, including feedback from a sample of District patients and a review of every complaint.","inShort":["Our policy manual is always available to you. Ask the office if you cannot find a policy.","Patients and families may ask to see any of our policies. Pass the request to the office.","Every year the governing body reviews all our policies, asks a sample of patients for feedback, and reviews every complaint.","If you think a policy should change, tell your supervisor. Your ideas help the yearly review."],"primaryCitation":"22-B DCMR §3903.2(c)","citations":["22-B DCMR §3903.2","22-B DCMR §3905.1","22-B DCMR §3905.2","22-B DCMR §3905.3","22-B DCMR §3905.4","22-B DCMR §3912.5","29 DCMR §5012.6","29 DCMR §5012.7"],"federalCitations":["42 CFR §484.65"],"surveyorAsks":["Show me your policy manual. Where do staff find it during the day and at night?","Show me your last annual evaluation. How many District patients gave feedback, and how did you choose them?"],"forms":[{"ref":"DC-HH-GOV-04-A","title":"Annual Evaluation Report to the Governing Body"},{"ref":"DC-HH-GOV-04-B","title":"Patient Feedback Survey"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (22-B DCMR §3903.2(c) and §3905)","5. Policies the Rule Requires","6. Access to the Policy Manual","7. The Annual Evaluation","7.1 Choosing the feedback sample","7.2 Reviewing every complaint","7.3 What else the evaluation covers","7.4 The written report and the governing body’s action","8. Changing a Policy","9. Responsibilities","10. Records and Compliance Monitoring","11. Staff Training","12. References","13. Related Policies and Forms","14. Approval","15. Revision History"],"version":"1.0","sample":false,"pack":"dc-hha","state":"Washington, DC","service":"Home health","guides":[{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}