Written Policies and Procedures
Policy 381-180 · Volume 1 · Governance & Administration · Issued: 10/07/2025 · Updated: 10/14/2025
This policy deals with Harbor\u2019s requirement to develop, implement, and maintain a comprehensive set of written policies and procedures approved by the Governing Body that covers all administrative, operational, financial, personnel, and admission/discharge topics required by 12VAC5-381-180 and that ensures Harbor’s licensed operations are governed by…
Harbor Home Healthcare LLC (“Harbor”) shall develop, implement, and maintain a comprehensive set of written policies and procedures approved by the Governing Body that covers all administrative, operational, financial, personnel, and admission/discharge topics required by and that ensures Harbor’s licensed operations are governed by documented, current, and accessible standards. (; ; Ref: 4; Ref: 5)
This policy serves as the master index and compliance framework for Harbor’s entire policy library. It identifies every topic required by , D, E, and F, maps each required topic to the specific Harbor policy that implements it, establishes the annual review and Governing Body approval cycle, and ensures policies are available to staff at all times and to clients upon request. (; Ref: 5.1; Ref: 5.2; Ref: 5.3)
Requirements
- 1.1 Harbor shall implement written policies and procedures that have been approved by the Governing Body. No policy shall be implemented without Governing Body approval. (; Ref: 5.2)
- 1.2 All policies and procedures shall be reviewed at least annually, with recommended changes submitted to the Governing Body for approval as necessary. (; Ref: 5.2)
- 1.3 Harbor shall maintain written policies and procedures covering all administrative and operational topics required by (18 required topics). (; Ref: 5.3)
- 1.4 Harbor shall maintain written financial policies and procedures covering the topics required by (6 required topics). (; Ref: 5.4)
- 1.5 Harbor shall maintain written personnel policies and procedures covering the topics required by (7 required topics). (; Ref: 5.5)
- 1.6 Harbor shall maintain written admission and discharge/termination policies and procedures covering the topics required by (4 required topics). (; Ref: 5.6)
- 1.7 Policies shall be made available for review, upon request, to clients and their designated representatives. (; Ref: 5.7)
- 1.8 Policies and procedures shall be readily available for staff use at all times. (; Ref: 5.8)
1.1 Definitions
- Written Policies and Procedures means the complete set of Governing Body-approved, controlled documents that govern Harbor’s administrative, operational, financial, personnel, and clinical functions. ()
- Policy Library means the organized collection of all current Harbor policies maintained in the policy management system (WordPress policy library), with controlled versions, effective dates, and revision history. ()
- Annual Policy Review means the process by which the Administrator compiles all policies for review, identifies recommended changes, and presents the review package to the Governing Body for approval at least once every 12 months. ()
- Policy Crosswalk means the master index mapping each required topic under , D, E, and F to the specific Harbor policy number and title that implements it. ( Ref: 5.3–5.6)
- Controlled Document means a Harbor policy maintained with version control, an effective date, and (when changed) a revision note, so the current authoritative version can always be identified. ()
- Governing Body Approval means documented review and approval by the Governing Body, evidenced by meeting minutes or a written annual approval record. (; )
Implementation Guidance
- A1 This policy is the “master regulation” policy — it sits on top of the entire policy library. When a VDH surveyor opens and starts checking boxes, this policy and its crosswalk tables (Section 5) are Harbor’s survey defense document. Every required topic maps to a specific Harbor policy. ()
- A2 Harbor maintains its policy library electronically on its WordPress site (policy library page) with role-based access for staff. Print copies or offline access may be maintained as backup to meet the “readily available at all times” requirement. (; Ref: 5.8)
This policy applies to the Governing Body, Administrator, and all personnel responsible for developing, reviewing, approving, implementing, distributing, or maintaining Harbor’s written policies and procedures. (; ; ; Ref: 4)
This policy governs the entire policy lifecycle — from development and Governing Body approval through annual review, revision, staff access, and client availability — for all policies required by and any additional policies Harbor maintains to support compliant operations. (; Ref: 5)
Requirements
- 2.1 All Harbor policies, regardless of volume or topic area, are subject to the annual review and Governing Body approval cycle established in this policy. (; Ref: 5.2)
- 2.2 All personnel shall have access to current policies and procedures at all times, either electronically through the policy library or through maintained print copies. (; Ref: 5.8)
- 2.3 Clients and their designated representatives shall be able to review Harbor’s policies upon request. (; Ref: 5.7)
- 2.4 When Harbor participates in Medicaid programs, policies shall also address applicable DMAS manual requirements and be available for DMAS audit review. (DMAS provider requirements; Ref: 5.3)
Implementation Guidance
- A3 Harbor’s policy library is organized by volume: Volume 1 (Governance & Administration), Volume 2 (Operations & Service Delivery), Volume 3 (Human Resources & Competency), Volume 4 (Quality, Compliance & Risk), and Volume 5 (Financial & Billing). This structure aligns with the 180 C/D/E/F categories while supporting Harbor’s operational workflow. (; Ref: 5.3)
- A4 New personnel receive orientation on how to access the policy library and are expected to review policies applicable to their role. The Administrator or designee ensures access credentials are provided during onboarding. (; Ref: 5.8)
is the foundational regulation that requires Harbor to develop, implement, and maintain Governing Body-approved written policies and procedures covering administrative and operational topics (C.1–C.18), financial topics (D.1–D.6), personnel topics (E.1–E.7), and admission/discharge topics (F.1–F.4), and to make policies available to staff at all times (H) and to clients upon request (G). ()
Every other policy in Harbor’s library exists because requires it. This policy serves as the compliance bridge between the regulation’s requirements and Harbor’s implementing policies. Detailed citation mapping, policy traceability, and internal cross-references are maintained in Section 8: References & Regulatory Citations (authoritative citation index for this policy). ( Ref: 8)
Implementation Guidance
- A5 During licensure surveys, VDH surveyors use as their primary checklist. They open each subsection (C.1 through C.18, D.1 through D.6, etc.) and ask to see the corresponding Harbor policy. This policy’s crosswalk tables (Section 5) provide the answer key — the Administrator can present it to the surveyor at the entrance conference. ()
- A6 If Harbor adds a new service or function that creates a new required policy topic under 180, the Administrator drafts the policy, obtains Governing Body approval, and updates the crosswalk tables in this policy before the service begins. (; Ref: 5.2)
4.1 Governing Body
- 4.1.1 Approve all written policies and procedures before implementation. No Harbor policy is effective until the Governing Body has approved it. (; )
- 4.1.2 Review all policies and procedures at least annually and approve recommended changes as necessary. (; ; Ref: 5.2)
- 4.1.3 Document annual policy review and approval in meeting minutes or a written annual approval record. (; ; Ref: 6)
4.2 Administrator
- 4.2.1 Develop, draft, and maintain all written policies and procedures, ensuring each required topic under , D, E, and F is addressed by a current Harbor policy. (; ; Ref: 5.1)
- 4.2.2 Coordinate the annual policy review process: compile the review package, identify recommended changes, present to the Governing Body for approval, and document the outcome. (; Ref: 5.2)
- 4.2.3 Maintain the policy library (WordPress policy system) with controlled versions, effective dates, and revision history for each policy. (; Ref: 5.8)
- 4.2.4 Ensure all personnel have access to current policies at all times and that orientation includes instruction on how to access the policy library. (; Ref: 5.8)
- 4.2.5 Ensure policies are available for client review upon request, consistent with client rights requirements. (; Ref: 5.7)
- 4.2.6 Maintain and update the policy crosswalk tables (Section 5) whenever policies are added, removed, renamed, or renumbered to ensure the master index remains current. (; Ref: 5.3)
4.3 All Personnel
- 4.3.1 Access and review policies applicable to their role and duties. ()
- 4.3.2 Follow implemented policies and procedures in daily operations and service delivery. ()
- 4.3.3 Report to the Administrator if a policy appears outdated, unclear, or in conflict with current practice. ( Ref: 5.2)
Implementation Guidance
- A7 When the Administrator and Owner are the same person, the Administrator prepares the annual review package and the Owner (acting as Governing Body) reviews and approves it. The documentation must show both actions occurred — preparation and approval — even when performed by the same individual in different capacities. (; ; Ref: 6)
5.1 Policy Development and Approval
- 5.1.1 The Administrator drafts new policies or policy revisions based on regulatory requirements, operational needs, or quality improvement findings. (; ; Ref: 6)
- 5.1.2 Draft policies are submitted to the Governing Body for review and approval before implementation. (; Ref: 6)
- 5.1.3 Upon Governing Body approval, the Administrator assigns an effective date, publishes the policy in the policy library, and communicates the new or revised policy to applicable personnel. (; Ref: 5.8; Ref: 6)
5.2 Annual Review and Governing Body Approval
- 5.2.1 At least annually, the Administrator compiles a policy review package that includes: (a) a complete list of all current Harbor policies with effective dates and last revision dates; (b) any recommended changes, additions, or retirements; (c) a summary of regulatory changes that may affect policies; (d) confirmation that all required topics under , D, E, and F are addressed. (; Ref: 6)
- 5.2.2 The Administrator presents the review package to the Governing Body. The Governing Body reviews the package, approves policies (with or without changes), and documents the approval in meeting minutes or a written annual approval record. (; ; Ref: 6)
- 5.2.3 The annual approval record identifies: the date of review, the policies reviewed (may reference “all policies” if the complete library was reviewed), whether changes were approved, and the approving authority (Governing Body). (; Ref: 6)
- 5.2.4 When the annual review results in no changes, the approval record states: “All policies reviewed — no changes; current versions reaffirmed” with the date and Governing Body approval. (; Ref: 6)
5.3 Administrative & Operational Policy Crosswalk —
The following crosswalk maps each required administrative and operational topic to the Harbor policy that implements it. The Administrator maintains this crosswalk and updates it when policies are added, renamed, or renumbered.
| 180 C Ref | Required Topic | Harbor Implementing Policy |
|---|---|---|
| C.1 | Administrative records | Policy 381-280 — Client Record System |
| C.2 | Admission and discharge/termination criteria | Policy 381-230 — Client Rights & Required Disclosures |
| C.3 | Informed consent | Policy 381-230 — Client Rights & Required Disclosures |
| C.4 | Advance directives, including DNR orders | Policy 381-230 — Client Rights & Required Disclosures |
| C.5 | Client rights | Policy 381-230 — Client Rights & Required Disclosures |
| C.6 | Contract services | Policy 381-220 — Contracted Services |
| C.7 | Medication management (if applicable) | Not applicable — Harbor does not provide medication management services |
| C.8 | Quality improvement | Policy 381-250 — Quality Improvement Program |
| C.9 | Mandated reporting of abuse, neglect, exploitation | Policy 381-150 — Management & Administrative Services (Section 5.4) |
| C.10 | Communicable and reportable diseases | Policy 381-260 — Infection Control Program |
| C.11 | Client records, including confidentiality | Policy 381-280 — Client Record System |
| C.12 | Record retention, including termination of services | Policy 381-280 — Client Record System (retention provisions) |
| C.13 | Supervision and delivery of services | Policy 381-360 — Personal Care Services |
| C.14 | Emergency and on-call services | Policy 381-150 — Management & Administrative Services (Sections 5.2, 5.3) |
| C.15 | Infection control | Policy 381-260 — Infection Control Program |
| C.16 | Handling consumer complaints | Policy 381-230 — Client Rights & Required Disclosures (complaint procedures) |
| C.17 | Telemonitoring | Not applicable — Harbor does not currently provide telemonitoring services |
| C.18 | Approved variances | No approved variances at this time. Harbor will create a variance policy if a variance is requested and approved by VDH. |
5.4 Financial Policy Crosswalk —
| 180 D Ref | Required Topic | Harbor Implementing Policy |
|---|---|---|
| D.1 | Admission agreements | Policy 381-230 — Client Rights & Required Disclosures (admission agreement provisions) |
| D.2 | Data collection and verification of services delivered | — Electronic Visit Verification; Policy 381-280 — Client Record System |
| D.3 | Methods of billing for services (organization and contractors) | — Authorization & Billing; Policy 381-220 — Contracted Services (payment terms) |
| D.4 | Client notification of changes in fees and charges | Policy 381-230 — Client Rights & Required Disclosures (fee notification provisions) |
| D.5 | Correction of billing errors and refund policy | — Authorization & Billing (error correction procedures) |
| D.6 | Collection of delinquent client accounts | — Authorization & Billing (collection provisions); Harbor financial procedures |
5.5 Personnel Policy Crosswalk —
| 180 E Ref | Required Topic | Harbor Implementing Policy |
|---|---|---|
| E.1 | Written job descriptions (authority, responsibility, qualifications) | Policy 381-200 — Personnel Requirements (Section 5.2); Policy FND-030 — Organizational Structure |
| E.2 | Accurate, complete, current personnel records | Policy 381-200 — Personnel Requirements (Section 6) |
| E.3 | Verifying professional licensing/certification and training | Policy 381-200 — Personnel Requirements (Section 5.2) |
| E.4 | Annual employee performance and competency evaluation | Policy 381-200 — Personnel Requirements; Policy 381-360 — Personal Care Services (RN supervisory visits) |
| E.5 | Verifying contractors meet personnel qualifications | Policy 381-220 — Contracted Services (Section 5.4); Policy 381-200 — Personnel Requirements |
| E.6 | Criminal background checks and drug-free workplace | Policy 381-200 — Personnel Requirements (Section 5.2); Policy 381-110 — Background Checks |
| E.7 | Reporting licensed personnel for violations to DHP | Policy 381-200 — Personnel Requirements; Administrator responsibility per |
5.6 Admission and Discharge Policy Crosswalk —
| 180 F Ref | Required Topic | Harbor Implementing Policy |
|---|---|---|
| F.1 | Criteria for accepting clients for services offered | Policy 381-230 — Client Rights & Required Disclosures (admission criteria) |
| F.2 | Process for obtaining a plan of care or service | Policy 381-360 — Personal Care Services (RN assessment and plan of care) |
| F.3 | Criteria for discharge/termination and referral | Policy 381-230 — Client Rights & Required Disclosures (discharge provisions) |
| F.4 | Process for notifying clients of discharge/termination or referral (oral/written notice, referral info, documentation) | Policy 381-230 — Client Rights & Required Disclosures (discharge notification procedures) |
5.7 Client Access to Policies
- 5.7.1 Harbor makes policies available for review to clients and their designated representatives upon request, consistent with client rights requirements. (; Ref: 7)
- 5.7.2 The Administrator or designee provides access within a reasonable timeframe when a request is received, either electronically or by providing a print copy for on-site review. ()
- 5.7.3 Clients are informed of their right to review policies as part of the client rights disclosure during admission. (; Ref: 7)
5.8 Staff Access to Policies
- 5.8.1 All current policies and procedures are maintained in Harbor’s policy library (WordPress policy system) and are accessible to all personnel with login credentials at all times. (; Ref: 6)
- 5.8.2 New personnel receive orientation on how to access the policy library, including login credentials and navigation instructions. (; Ref: 6)
- 5.8.3 The Administrator ensures the policy library is operational and accessible. If electronic access is interrupted, the Administrator provides alternative access (print copies or backup electronic access) until normal access is restored. ()
5.9 Policy Versioning and Controlled Documents
- 5.9.1 Each policy in the library is maintained as a controlled document with: policy number, title, effective date, last updated date, status (Active/Draft), responsible executive, and primary regulatory citation. (; Ref: 6)
- 5.9.2 When a policy is revised, the Administrator updates the effective date, records a revision note, and publishes the new version. Prior versions may be retained consistent with Harbor’s record retention practices. (; Ref: 6)
- 5.9.3 The version displayed in the policy library is the current, authoritative version. Any printed copies are uncontrolled unless verified against the library version. (; Ref: 6)
Implementation Guidance
- A8 The crosswalk tables in Sections 5.3 through 5.6 are Harbor’s survey answer key. When a surveyor asks “Where is your policy on [topic]?”, the Administrator opens this policy’s Section 5 and identifies the implementing policy immediately. The Administrator should print this section for entrance conferences. ()
- A9 “Not applicable” entries in the crosswalk (C.7 Medication Management, C.17 Telemonitoring) should be documented with a brief statement explaining why the topic does not apply. If Harbor later adds these services, the corresponding policy must be developed and approved before the service begins. ()
- A10 The annual policy review may be combined with the Governing Body’s annual governance review so all required annual approvals are completed in one session. (; ; Ref: 5.2)
Documentation related to this policy shall include, at a minimum, when applicable:
- Complete policy library with all current policies maintained as controlled documents with effective dates. (; Ref: 5.9)
- Annual policy review package submitted to the Governing Body, including policy list and recommended changes. (; Ref: 5.2)
- Governing Body meeting minutes or written annual approval record documenting policy review and approval. (; ; Ref: 5.2)
- Current policy crosswalk mapping all , D, E, and F required topics to Harbor implementing policies. (; Ref: 5.3–5.6)
- Orientation records showing new personnel received policy library access and orientation instructions. (; Ref: 5.8)
- Records of policy-related communications to staff when new or revised policies are published. (; Ref: 5.8)
Policy library, crosswalk, and governance approval records are maintained securely and retained in accordance with Harbor record management and retention standards. (; Ref: 6.1; Ref: 7)
6.1 Forms & Tools
The tools below map each documentation requirement to the form/tool used; Harbor may adjust names and formats as long as required content is maintained.
| Section 6 Requirement | Form(s) / Tool(s) Used |
|---|---|
| Maintain complete policy library. | WordPress policy library with controlled versions, effective dates, and role-based access. (; Ref: 5.8; Ref: 5.9) |
| Document annual policy review and GB approval. | Annual policy review package (policy list, recommended changes); Governing Body minutes or annual approval record with date and approval noted. (; ; Ref: 5.2) |
| Maintain policy crosswalk. | Policy crosswalk tables (this policy, Section 5.3–5.6) mapping 180 C/D/E/F topics to Harbor policies, updated when policies change. (; Ref: 5.3) |
| Document staff policy access. | Orientation checklist noting policy library access and login credentials provided. (; Ref: 5.8) |
| Document policy communications. | Staff communication record (email, meeting note, or acknowledgment) when new or revised policies are published. (; Ref: 5.8) |
Implementation Guidance
- A11 Harbor’s WordPress policy library serves as both the controlled policy system and the “readily available to staff” access point required by 180 H. The Administrator maintains this system and ensures it is accessible at all times. (; Ref: 5.8)
- A12 The annual approval record should specifically reference “all written policies and procedures reviewed per ” to create a clear audit trail linking the approval to the regulatory requirement. (; Ref: 5.2)
This section serves as the authoritative regulatory citation index for this policy and supports compliance with applicable Virginia home care licensure requirements, including:
| Regulation | Regulatory Requirement (Summary) | How Used in This Policy / Internal Cross-References |
|---|---|---|
| Organization shall implement written policies and procedures approved by the governing body. | GB approval required before policy implementation. Sec 1.1; Sec 4.1.1; Sec 5.1; Sec 5.2 | |
| All policies reviewed at least annually; recommended changes submitted to GB for approval. | Annual review cycle and GB approval documentation. Sec 1.2; Sec 4.1.2; Sec 5.2; Sec 6 | |
| Administrative and operational policies (18 required topics: C.1–C.18). | Crosswalk table mapping each C topic to Harbor implementing policy. Sec 1.3; Sec 5.3 | |
| Financial policies (6 required topics: D.1–D.6). | Crosswalk table mapping each D topic to Harbor implementing policy. Sec 1.4; Sec 5.4 | |
| Personnel policies (7 required topics: E.1–E.7). | Crosswalk table mapping each E topic to Harbor implementing policy. Sec 1.5; Sec 5.5 | |
| Admission and discharge/termination policies (4 required topics: F.1–F.4). | Crosswalk table mapping each F topic to Harbor implementing policy. Sec 1.6; Sec 5.6 | |
| Policies available for client review upon request. | Client access to policies. Sec 1.7; Sec 5.7 | |
| Policies readily available for staff use at all times. | Staff access via policy library; orientation on access. Sec 1.8; Sec 5.8; Sec 6 | |
| Governing Body reviews and approves written policies annually. | Governing Body annual approval cycle. Sec 4.1; Sec 5.2; Sec 6 | |
| Administrator responsibilities for policy development and implementation. | Administrator develops, maintains, and coordinates policies. Sec 4.2; Sec 5.1 |
Harbor shall maintain current versions of this policy as a controlled document within the policy and procedure manual and make them available as required for oversight, audit, payer review, or licensing survey activities. (; Ref: 6)
Implementation Guidance
- A14 Harbor reviews citations at least annually to ensure the referenced regulation sections remain current and updates this section when regulations are revised or renumbered. (; Ref: 6)
- A15 Section 8 serves as the citation index for this policy. The crosswalk tables in Section 5 serve as the citation index for the entire policy library — connecting every 180 requirement to its implementing Harbor policy. (; Ref: 1; Ref: 5; Ref: 6)
Controlled document if viewed online. Uncontrolled if printed.