A policy and procedure manual is a key tool that is very useful if correctly devised and implemented. Policies and procedures are required for a variety of purposes including, but not limited to the following: compliance with regulations, internal controls, operating requirements, risk management, and ongoing efficiencies.

In the United States, assisted living facilities are expected to develop and implement written policies and procedures to ensure that the assisted living facility can effectively and immediately regulate all major decisions, actions, and principles of the establishment.

This document is meant to provide authority and necessary guidance to the facility on topics like –  admission criteria, hiring practices, bank accounts, dress code, etc. The procedures must address the care of residents occupying the facility and all methods used to communicate policies in action for the daily operation of an organization.

Together, policies and procedures make sure that a decision held by the management of the assisted living facility is translated into steps that result in effective working and communication. Note that this may include wellness checks by assisted living facility staff to monitor for signs of dehydration and heat injury; or a provision for obtaining medical intervention from emergency services for residents whose life safety is in jeopardy.

Have it in mind that every assisted living facility is expected to maintain the written policies and procedures in a manner that makes them readily available at the licensee’s physical address for review by a legally authorized entity. If the policies and procedures are maintained in an Electronic format, assisted living facility staff must be readily available to access the policies and procedures and produce the requested information.

Policy and procedure manuals can take on a variety of formats from a general overview of the facility’s policies to detailed processes/procedures. If a formal manual is not in place, the best way to start is with a general overview and then proceed to documenting the specific details in each area – such as payroll, disbursements, receipts, monthly close process, etc.

Every establishment faces difficulties within the workflow of its business cycle and requires documentation of its structured methodology, a framework of the establishments’ philosophy, its mission, and vision that ensures visibility. Note that this is the purpose of a policy and procedure manual.

4 Steps to Take Before Writing an Assisted Living Facility Policy and Procedure Manual

Writing a policy and procedure manual for an assisted living facility is a complicated yet important task. Always remember that this manual needs to be made to ensure that the facility and all employees behave in a legal, ethical, and compliance conscious manner. Also note that these manuals are referenced once an employee is confused about taking a step or making a decision, thus it is imperative to get them right.

These policies and procedures can vary from facility to facility so there is no template which every facility can simply copy and use. To create a policy and procedure manual that is truly able to deliver a blueprint for the assisted living facility culture, it is pertinent to take a few steps before writing anything down.

1. Know your legal needs and requirements

There are two important facets of policies and procedures – the legal requirements and the parts that ensure that the facility’s vision is followed. Note that every care facility has their own policies which depend on the management style and goals of the establishment.

Howbeit, there are also a lot of policies and procedures which exist not because of what the facility wants but because the facility is legally required to comply with several laws and regulations. So it is imperative you get a lawyer involved, preferably a lawyer that has or is working with your assisted living facility. Also note that local lawyers will be more conversant with laws concerning your care facility and will be able to provide consultation on creating the manual.

2. Involve stakeholders

Not just for Assisted Living Facilities, employees in other fields also try to avoid or sidestep the policies and procedures written down in the manual. That is why most businesses simply reprimand the employee for not following the rules, but that is not enough.

In theory the manual should list the best practice approach towards every procedure. Once employees are trying to ignore or sidestep the manual it is a sign that what is written down in the manual is not practical or efficient.

So it is imperative to include more stakeholders in the discussion about creating the manual. Nurses who work at the ground level and at the front line have insights which the people working in management may not actually have. Have it in mind that if the manual is only made with input from management, it may not express an accurate picture of the working environment and there may be situations where the manual is not applicable.

3. Collaboration is crucial

Also note that including all stakeholders in the discussion is basically not enough. There also needs to be proper workflow management which gives people the platform to collaborate. A document management system is necessary.

These systems can let multiple people view, review, edit, and share the same document while tracking the changes made by everyone. Also note that it allows people to leave comments, make edits and leave then in for approval, and effectively collaborate on creating a policy and procedure manual that works for all stakeholders of the facility.

Note also that just forwarding the documents via email and asking everyone to contribute does not work. People cannot see updates as they happen, so it is possible that two people may make conflicting edits. In addition, it is very inconvenient and slow to send files back and forth. Document management systems can be used to eliminate the need for sending files or updates completely and allows people to focus on making the latest version of the document better.

4. Leverage the right tools

Have it in mind that policy and procedure manuals are intrinsically linked to governance, risk, and compliance management, thus there are many GRC based tools for policy and procedure management. Note that these tools go above and beyond normal document management systems especially since they have been designed specifically to be used to manage policies and procedures. These tools are not hard to use or acquire – the cloud based tools simply need to be subscribed to.


An effective policies and procedures manual reflect an assisted living facility’s method of communicating, getting the service performed, and boosts employee productivity. It allows people to work together to resolve day – to – day issues without requiring unnecessary supervisory involvement.

Formalizing policies and procedures may seem like a large undertaking, but it is well worth the effort. Keep in mind that these policies are not set in stone, but rather are dynamic and must be updated from time to time as changes are needed.

Ajaero Tony Martins