Spring Cleaning: Time to Freshen Up Policies & Procedures

cleaning supplies

Organize and sort areas of your practice that need changes or updates

By Nancy J. Beckley, MBA

Even the mention of policies & procedures will cause practice owners at best to sigh or groan, or at worst to push it off to another day, often a day that never seems to arrive.

Sound familiar? This spring season offers the time to inventory policies and procedures, sort and organize policies according to areas of practice concern such as administrative, clinical, compliance, environmental, operations, and human resources, as well as to check your policies for regulatory requirements, updates, and changes.

No matter the position on the spectrum for your practice, there is no time like the present to get started on policies and procedures spring cleaning. Over the past three years you have likely added policies, procedures, and processes to address response to COVID-19, the federal Public Health Emergency (PHE), various state public health emergency declarations, and changes in other non-PHE regulations regarding your practice. During the PHE areas of practice were changed or “redefined” in accordance with various flexibilities and waivers issued1 by the Department of Health and Human Services (HHS) that most notably included changes regarding direct supervision of physical therapist assistants, relaxed HIPAA requirements, and also added Medicare telehealth coverage for physical therapists to name a few.



Often I am asked the question “what policies and procedures are required?” My response is always to inquire further in order to make an accurate assessment and an informed response. Identified below are selected areas of “situational specific” requirements for policies and procedures presented as a starting point, rather than a comprehensive resource.

Part A Provider: Policies and procedures will be required, and evidence of compliance with these policies and procedures if you are a Part A therapy practice certified as a Rehabilitation Agency or a Comprehensive Outpatient Rehabilitation Facility (CORF). This is a good starting place to assess the required policies and procedures specified under the respective Conditions of Participation (Code of Federal Regulations) and Interpretive Guidelines (CMS State Operations Manual) for a Rehab Agency or a CORF. If your last State survey or Accreditation survey has been over three years, prior to the initiation of the PHE, there are significant updates to Infection Control, Emergency Preparedness, Personnel, and Administration involving significant demonstration of policy implementation. In fact, the updates have been “updated” as the PHE has evolved.

Therapy Network Participation: If your practice participates in a regional or national therapy network for the purpose of either quality reporting and/or insurance contracting there are generally requirements for adherence to compliance including specific policies, procedures, and practices. Check your Contract to identify what is required, as well as inquire if you have the most recent Contract update/version of the requirements.

State Laws & Regulations: Starting with a comprehensive review of the State Practice Act and Administrative Rules may seem too obvious, but it is often an overlooked area for policy development and adherence. For participating providers in Medicaid/MediCal or managed Medicaid products verify any rules and regulations that require additional policies. Verify state law requirements for medical record retention and cross reference with other payer requirements. For example, your state may require a 6-year retention, however, CMS requires Medicare Advantage plans to retain records for 10 years.

table 1

Federal Health Care Laws, Regulations, and Sub-regulatory Requirements: Review of this area might be best saved to “spring-break” week! The False Claims Act, Anti-Kickback Statute, Civil Monetary Penalties Law, Stark Law, and Exclusions Statute all have implications for policies and procedures. Other areas for review importance are regulations governing beneficiary inducement and Medicare mandatory claims submission. This may be an area for a subject matter expert to assist policy identification and development. The OIG offers compliance guidance on their website, which is an ideal starting point to find the summary obligations.2

Local, State, and Federal Health, Safety & Environmental Regulations: The past several years has seen these areas of rules and regulations replete with policy recommendations, albeit some policies awash with controversy. Some local PHE requirements have now transitioned to optional compliance with a policy or tiered to a specific documented or identified threat level in the community. This is a top area for spring cleaning and review to assess environment and safety regulations as well as OHSA compliance.

HIPAA Privacy and Security Rule: HIPAA compliance is an area that should be targeted for a full “dust up.” Given significant cyber-security risks and the proliferation of apps that share protected health information (PHI), “easements” in enforcement by HHS when using non-compliant apps/portals, a breach or ransom hijacking may only be a digital click away. While the Privacy and Security Rules themselves outline requirements, establishing specific policies requires more subject matter expertise. This is one area where policy help from a HIPAA subject matter expert may be in order.

Civil Rights Laws: Section 1557 of the Affordable Care Act (ACA) requires those practices receiving federal financial assistance (in the form of Tricare or Medicaid payment) to be in adherence with Civil Rights Laws with specific policy guidance for implementation. Section 1557 application is anticipated to include Medicare Part B reimbursement under the definition of “federal financial assistance once the Proposed Rule is finalized.3


A spreadsheet solution may help to identify, sort, and organize, starting with current policies and procedures. This easy-to-see visual allows for a snapshot view and updating of the progress during the spring-cleaning process.


For therapy practices that are Rehab Agencies, CORFs or CARF accredited the policy template should be designed to identify important parameters.

When using the above Sample Policies & Procedures, or similar, the body of the policy generally should contain headings for Policy Statement, Purpose (if not contained in Policy Statement), Definitions (a “must” when dealing with regulations), and Procedure in a numbered format.

For smaller practices, an approach that is not as formal could present policies and procedures in a “handbook” type format. This option offers a starting point for getting started and may be ideal for a very small practice.


table 2

Policies and procedures can serve as a double-edged sword. Caution should be exercised on over-obligating a practice. For example, a Rehab Agency reported that they were required to write a plan of correction following their updated State certification survey in part because their policy stated they would conduct a fire drill quarterly, when in fact they only conducted it annually. It was always their intent to conduct an annual fire drill. However, the policy was not followed as written, and during annual policy updates, this was overlooked.

Under the Office of Inspector General (OIG) Annual Work Plan therapy practices have historically been in the cross hairs for work completed by the Office of Audit Services. In one instance the OIG found that the practice had policies that it did not follow, and had they followed them, the errors would have been precluded.

  • Medical reviewers determined that [the Practice] did not always follow Medicare requirements or FI guidance. The [Practice] had written policies and procedures that, if followed, would have precluded the errors the medical reviewers identified. The [Practice] did not adhere to its policies and procedures for ensuring that plans of care contained all required elements, for documenting that plans of care were reviewed at least every 60 days, or for documenting that services were actually provided.4

In other OIG Reports completed under the Annual Audit Work Plan for physical therapy services, the OIG most often found that a therapy practice had either insufficient or inadequate policies and procedures in place.

  • The OIG recommended in an audit report for a Missouri physical therapy practice they strengthen its policies and procedures to ensure that outpatient physical therapy services are billed in accordance with Medicare requirements.5
  • In an audit report for a Florida physical therapy practice the OIG found that deficiencies occurred because the therapy practice did not have adequate policies and procedures in place to ensure that it billed for services that complied with Medicare requirements.6


Over the years I’ve read thousands of therapy policies in hundreds of manuals, as well as having written policies and procedures. There is always a “blooper” to be found. Themes of the more common bloopers found this past year include policy on the therapy threshold, policy of billing for group therapy, and “purchased” policies that forget to complete the [insert your name here] throughout.

  • Policy on Medicare Cap: “Have patient sign ABN that indicates if Medicare does not pay for therapy over the cap, the patient is responsible.”
  • Policy on Medicare Benefits: “When the patient reaches the therapy cap, they will be offered cash payment options to continue therapy.”
  • Policy on Double Booking: “When treating two patients at the same time, use the Group Code for Medicare patients, and Therapeutic Exercise code for non-Medicare patients.”
  • OSHA Policy: “It is the policy of [Insert Name of Practice] to provide a safe and healthy work environment and to comply with the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard (29 CFR 1910.1030).”


Set a calendar date(s) for reviewing and updating your practice’s policies and procedures. Identify those team members who will be directly involved in working through this process. Determine your policy management system. And perhaps most important is to set a training time for staff. All in all, you are off to a successful spring cleaning! 

Nancy J. Beckley, MS, MBA

Nancy J. Beckley, MS, MBA, is a compliance consultant located in Milwaukee, WI. She can be reached at nancy@nancybeckley.com and @nancybeckley.

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