Start from the rules for your license, not from a template. List every rule that asks for a written policy, and write one policy for each subject. Each policy says what the agency does and why (the policy) and who does what, when and how (the procedure). Write it the way your agency really works, name the rule it follows, have your governing body approve it, train your staff on it, and review it on a schedule. Surveyors check that what your staff do matches what your policies say, so write only what your agency will actually do.
Step 1: Find the rules that apply to your license
Your state's licensing rules come first. If your agency is Medicare-certified, the federal Conditions of Participation apply as well: 42 CFR Part 484 for home health and Part 418 for hospice. Look for every place a rule says "written policies" or lists what your policies must cover. Some states give a list:
- District of Columbia home care agencies need a written policy on at least 12 topics, from personnel and admission to infection control and the management of incidents (22-B DCMR §9908.2).
- In North Carolina, the governing body or its designee establishes and implements written policies governing the agency's operation, including the ones the rule lists (10A NCAC 13J .1001(a)).
- Texas requires agencies to adopt and enforce written policies on subjects such as staffing and infection control (26 TAC §558.245 and §558.285).
The guides to the policies required for home care, home health and hospice list the subjects for each license.
Step 2: Know the difference between a policy and a procedure
- A policy states what the agency does and why: for example, that staff report suspected abuse at once.
- A procedure says who does what, when and how: who the staff member calls, what they write down, and when the report goes to the state.
- It is simplest to keep both in one document, with the policy statement first and the procedure steps after it.
Step 3: Use the same structure for every policy
| Section | What it holds |
|---|---|
| Terms of reference | Who issued the policy, who owns it, who it applies to, how often it is reviewed and who approves changes |
| Purpose and scope | Why the policy exists and what it covers |
| Definitions | The terms a reader needs, in plain words |
| Policy statement | What the agency does, with the rule it follows |
| Procedure | The steps: who does what, when and how |
| Responsibilities | Each role's part |
| Records | What is written down, where it is kept and for how long |
| Training | Who is trained on the policy, and when |
| References and forms | The rules cited and the forms that go with the policy |
| Approval and revision history | Who approved it and when, and every change since |
Cura Core policies follow this structure, so staff and surveyors find the same thing in the same place in every policy.
Step 4: Write it the way your agency works
- Use your agency's name, the job titles you actually have, and the people who hold them.
- Write each time frame precisely, and say where it comes from: the rule, or your agency's own choice. A stricter time frame you set yourself is fine, as long as your staff can meet it.
- Write in plain language and short sentences, so a new caregiver can follow it.
- Name the rule each part follows, so your staff and a surveyor can check it.
- Do not copy a requirement from another state or license. Rules differ, and a policy that cites the wrong rule shows it was not written for your agency.
Step 5: Approve, train and review
- Approval: have the governing body, or the person it names, approve each policy, with a version number and an effective date. For home health and hospice, the governing body holds full legal authority and responsibility for the agency (42 CFR §484.105(a) and §418.100(b)).
- Training: train staff on the policies for their job, and keep a signed, dated record. See how read-and-sign works.
- Access: keep the manual where staff can reach it at any time. Some states require this, for example the District of Columbia (22-B DCMR §9908.3).
- Review: review each policy on a schedule and whenever a rule changes, and keep the old versions. See how often policies should be reviewed.
Writing it yourself, or starting from a manual
A full manual runs to dozens of policies, so writing one from nothing takes time. A manual written to your state's rules gives you a starting point, but you still need to check that it matches how your agency works before you approve it. Every Cura Core manual is written to one state's rules for one license, in the structure above, with a plain-English summary on each policy and the rule section it follows. Your agency's details fill in throughout, and your staff read and sign each policy on their phone.
Next step
Pick your state and license on the policy manuals by state page to see its manual and read three of its policies free.