Do You Actually Know What’s in Your Policies and Procedures?
Let’s talk about something that gets a lot of ALF operators in trouble — policies and procedures.
Every facility knows they’re required to have them.
But here’s what most people don’t realize:
It’s not just a regulation to have written policies and procedures —
It’s a regulation to follow them.
And that’s where a lot of facilities get caught.
When Your Policies Become Your Regulations
I see this all the time.
An owner or administrator gets a full set of policies and procedures — maybe for free from another facility, a friend, or a consultant.
They put them in binders, label them neatly, and never actually read them.
The problem?
The moment you adopt those policies and procedures as your own, they become your internal regulations.
That means AHCA can hold you accountable to every word inside those binders — even if you didn’t write them or don’t know what they say.
When AHCA Investigates
Here’s what happens during an investigation or survey.
If AHCA is looking into an incident — maybe a fall, a medication error, or a complaint — they don’t just ask what happened.
They ask:
“What do your policies and procedures say about how this should have been handled?”
Then they review whether your staff and administrator actually followed what’s written.
If you didn’t, you’ll be cited.
Your policies might even go beyond what state regulations require — and if you don’t follow them, that’s still a violation.
I’ve Seen It Too Many Times
I’ve seen surveyors sit down, open a facility’s policy binder, and read the policy back to the administrator — then ask them to explain how it’s implemented in the building.
And far too often, the administrator can’t answer the question because they’ve never actually reviewed it.
That’s not just awkward — it’s an instant red flag.
What You Should Be Doing
- Read your policies and procedures.
Don’t assume they’re accurate or current just because they came from a consultant or another facility. Make sure they reflect how your building actually operates. - Review and update them regularly.
Laws change. Your building changes. Your policies should too. - Train your staff.
Every staff member should know the key policies that affect their day-to-day work. If they don’t, that’s on you. - Match policy to practice.
Don’t include unrealistic promises like “all falls are documented within one hour” if that’s not consistently happening.
Write policies your team can actually follow.
Final Thought
Having policies and procedures isn’t enough.
Knowing them, following them, and keeping them updated is what matters.
Your policies are your playbook — and in AHCA’s eyes, they’re the law for your facility.
So before your next survey or complaint, grab those binders, read them, and make sure they truly represent how your facility operates.
Because in this business, what you don’t know can — and will — be cited.