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Written Policies and Procedures and the Governing Body’s Annual Evaluation

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.

Preview: full text with a package
About this policy
Policy number
DC-HH-GOV-04
Version
1.0
Main rule
22-B DCMR §3903.2(c)
Library
Washington, DC home health · 58 policies
Category
Governance
Sections
20

In short

  • 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.

What's inside

20 sections. The full text comes with the One-time Policy Pack.

Full text with a package
  • 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

An inspector may ask

  • 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?

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