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Wesley Pines

AGENCY PROJECT PRESENTATION

Background
 Terry Townsend began working at Wesley pines as

the Director of Social Services a number of years ago.
Since then, there have been many changes in policies
and lots of "implied" rules and regulations. It has
been suggested by her that I update and revise the
agencies policy handbook and the admission packets
as my field agency project.

Purpose
 This is to ensure that the information being provided

to the residents and to the departments are is easily
accessible and within a reasonable and workable
timeframe. By updating the policy handbook it will
aid all disciplines within the Wesley Pines facility.
Included in the revisions holds the rights under
supervision and consultation of my supervisor to add
any additional policies and procedures needed to
better serve the residents of their community and
overall wellbeing

Agreement
 I, Tabitha Russ propose to update and revise the

policy handbook for Wesley pines retirement
community. I will provide a finished product by
December 1st, 2014.
 Must be written in clear and concise language and
will have a review date not to exceed three years; as
changes to policy or procedures occur, policies are to
be updated to reflect these changes. The current
policy will remain in force during the review and
updating process.

Agreement
 Development of policies will be a collaborative process

involving representatives from all areas that have
responsibility to carry out the policy. Policy development
or updates should be collaborated in such a manner to
ensure that all required input is obtained prior to
signature and distribution.
 Retirement community policies are limited to those
policies that affect multiple services, reflect a
fundamental direction of the facility, or are related to
high risk, high cost, or problem prone endeavors. Policies
that affect a single service are to be maintained as
service-level policies.

Process
 Review retirement community policies prior to signature

to ensure accuracy and content are consistent with CMS
and licensing standards and state law/administrative
rules.
 Review all hospital policies prior to signing to ensure
consistent format and established guidelines are
followed.
 Ensure appropriate and applicable third party standards
and State Statute are listed under the reference section in
all policies.
 Review and approve all hospital policies and ensure all
employees follow all policies consistently.

Continued
 Assure technical accuracy of the content of all policies

originating from their department/service. It may be
necessary to collaborate with a number of
departments/services to ensure accuracy. The policy
must be consistent with current standards and
requirements of the Department of Public Health and
Human Services, external surveying bodies such as CMS,
state licensing bodies, and state statute/administrative
rules
 Coordinate the update and revision of all hospital
policies assigned to the department/service in such a
manner that policies are reviewed and reissued on or
before the renewal date.

Continued
 Maintain a filing system of all revised and rescinded

policies to ensure accessibility of non-current
policies.
 Ensure new or revised policies are accessible to all
UMRH-Wesley Pines staff via the computerized
policy manual (shortcut on desktop), Email and
hard copy.
 Generate email notifications of all new or revised
policies to all Wesley Pines staff.

Agency Project
Competency

Practice Behavior

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