Annual Policy Review: Why It’s Required and How to Do It Right

In the ever-evolving landscape of hospice care, regulatory compliance is not optional—it is essential. Among the many mandates required by the Centers for Medicare & Medicaid Services (CMS), one crucial but often overlooked responsibility is the annual review of policies and procedures. This routine task is far more than a formality; it is a cornerstone of quality assurance, patient safety, and agency accountability.

At SummitRidge, we specialize in guiding hospice agencies through the nuances of compliance, ensuring their documentation and operations meet state and federal requirements. Below, we explain why annual policy reviews are required and how to carry them out effectively.

Why an Annual Policy Review is Required

Hospice agencies participating in Medicare are bound by the Conditions of Participation (CoPs) outlined in federal regulations. These CoPs cover every aspect of patient care, personnel qualifications, infection control, quality improvement, and much more. To remain compliant, hospice providers must maintain up-to-date policies that reflect:

• Current CMS regulations

• Evidence-based best practices

• Internal operational changes

• Changes in local, state, or federal law

• Observations and recommendations from previous surveys

Annual policy review is not explicitly labeled as a standalone requirement in the regulations—but it is implicitly required through multiple CoPs that reference “ongoing compliance,” “performance improvement,” and “current and accurate policy implementation.” Surveyors routinely expect to see documentation confirming that all operational policies have been reviewed and updated within the past 12 months.

Failure to keep policies current may lead to citations during routine surveys or complaint investigations, particularly when outdated policies result in inconsistent care or staff confusion.

How to Conduct an Effective Annual Policy Review

Conducting an annual policy review is not just about reading through a binder. It is a structured process that should involve leadership, clinical teams, compliance officers, and any departments responsible for implementing those policies. Here's how to do it right:

1. Develop a Master Policy Index

Start by compiling a master list of all agency policies, categorized by department (e.g., clinical, administrative, human resources, quality improvement, emergency preparedness, etc.). This index should include:

• Policy title

• Effective date

• Last review date

• Responsible department or individual

2. Assign Review Responsibility

Each policy should be assigned to a department head or subject matter expert who is responsible for reviewing its content, assessing relevance, and recommending updates based on:

• New CMS guidance or memos

• Changes in clinical protocols

• Feedback from surveys or audits

• Recent incidents or adverse events

3. Cross-Reference with Survey Protocols

Use CMS survey protocols (such as those found in the State Operations Manual) to identify policies most likely to be scrutinized during surveys. These include:

• Infection control

• Hospice aide supervision and training

• Emergency preparedness

• Clinical record management

• Care coordination and patient rights

If the policy content does not reflect current federal language or fails to describe practical implementation steps, it should be revised immediately.

4. Involve the Interdisciplinary Group (IDG)

Certain policies—particularly those related to patient care, symptom management, and bereavement services—should involve input from the hospice’s interdisciplinary team. This ensures that documentation reflects real-world practices and not just theoretical procedures.

5. Document Everything

For each policy reviewed, documentation should include:

• Reviewer’s name and title

• Review date

• Summary of changes (if any)

• Approval signatures

• Date of next scheduled review

This documentation becomes essential during surveys and revisits, particularly if policy adherence is questioned.

6. Educate Staff on Revisions

Once a policy is updated, ensure that affected staff are notified and trained accordingly. Use sign-off sheets or electronic acknowledgment forms to confirm that staff have received and understood the revisions.

Common Mistakes to Avoid

Even well-intentioned agencies can fall into traps during annual reviews. Avoid these common pitfalls:

• Assuming no changes are needed: Regulatory language or best practices may have shifted, even if your internal processes haven’t.

• Forgetting new policies: Be sure to include newly adopted policies in the review cycle.

• Neglecting attachments or forms: Many policies include forms or logs—ensure these are updated as well.

• Lack of board or administrative sign-off: Certain policies, especially those tied to compliance, may require approval from executive leadership or the governing body.

How SummitRidge Can Help

The annual policy review is more than a paperwork drill—it’s a reflection of your agency’s dedication to quality care, risk management, and regulatory excellence. At SummitRidge, we provide full-spectrum consulting support for hospice agencies, including:

• Creation and revision of policy manuals

• Mock surveys that identify outdated procedures

• Documentation audit and alignment with CoPs

• Staff education and training rollouts

• Emergency preparedness planning and updates

Our team stays ahead of changing CMS expectations and ensures that your internal policies do too.

Don’t let outdated policies put your hospice at risk. Contact SummitRidge today to schedule a compliance consultation or request assistance with your agency’s annual policy review.