SAMPLE POLICY WORK

– Verification: Staff participation is recorded, and feedback is collected to continually improve the training process. – Outcome: A consistently updated and well-informed staff ensures that non-compliance risks are minimized.

C. Change Management and Documentation 1. Document Revision Procedures:

– Step 1: Any proposed change to regulatory guidelines or internal policies must be submitted in writing to the Policy Coordinator. – Step 2: The Compliance and Regulatory Affairs Team reviews requested changes, examines regulatory updates, and assesses the impact on current operations. – Step 3: Approved changes are documented, and revision histories are maintained in a centralized digital repository. – Step 4: Updated documents are disseminated to all relevant departments via email, internal bulletins, and training updates. – Outcome: This ensures that all policies remain current and reflective of the latest regulatory requirements. 2. Feedback and Incident Reporting Mechanism:

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Process: •

All staff are encouraged to report any compliance-related issues or observed deviations via our structured feedback system. • Reports are submitted to supervisors, who then engage with the Compliance Team for follow-up and resolution. – Outcome: A structured incident reporting system allows for prompt corrective actions and continuous process improvements. e. Regulatory Reference Materials and Continuous Improvement The foundation of our compliance program is built upon consistently referencing and integrating current regulatory standards. This approach ensures our operations remain in alignment with both state and federal mandates.

• Comprehensive List of Regulatory Documents:

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Tennessee CAC Waiver (TN.0357.R05.00) TennCare Rule 1200-13-01-.28 Relevant State Licensing Regulations

– Federal Compliance Standards (including HIPAA, ADA, etc.)

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Continuous Improvement Mechanisms: