As we move into a new year, reviewing and updating your facility policies and procedures is more critical than ever. In recent years—and particularly over the past 12–24 months—federal regulatory agencies have issued a steady stream of new rules, guidance, and enforcement priorities that directly affect facility operations. Policies and procedures that have not been revisited recently may no longer reflect current regulatory expectations, placing facilities at increased risk during surveys, audits, and investigations.

An annual policy and procedure review is not simply an administrative exercise. It is a necessary response to ongoing federal oversight changes and an essential component of maintaining compliance, reducing risk, and supporting quality resident care.

The Growing Impact of Federal Regulatory Changes

Federal agencies continue to refine expectations for skilled nursing facilities in response to public health concerns, resident safety issues, staffing challenges, and quality-of-care initiatives. Guidance from agencies such as Centers for Medicare & Medicaid Services and Centers for Disease Control and Prevention has significantly expanded and evolved, particularly in areas such as infection prevention, emergency preparedness, quality assurance, staffing practices, and resident rights.

Facilities that rely on older policy language risk referencing outdated standards, timelines, or processes that no longer align with how surveyors evaluate compliance. Even when operational practices have adjusted to new requirements, failure to update written policies can result in citations for noncompliance due to inconsistencies between policy and practice.

Why Policy and Procedure Updates Are Essential Going into the New Year

The start of a new year is an ideal time to ensure your facility policies and procedures accurately reflect the current regulatory environment. Federal updates are often released incrementally throughout the year, making it easy for policy libraries to fall behind if reviews are postponed or handled inconsistently.

Updating policies allows facilities to:

• Incorporate new federal rules and interpretive guidance
• Align written expectations with current survey focus areas
• Reduce the risk of citations tied to outdated documentation
• Demonstrate an active and responsive compliance program

Surveyors increasingly expect facilities to show not only that they are aware of regulatory changes, but that those changes have been formally incorporated into facility policies and staff training.

Prioritize Policies Most Affected by Federal Guidance

Not all policies carry equal regulatory risk. Best practice is to prioritize review of policies most directly impacted by recent federal updates and enforcement trends.

High-priority areas often include:

• Infection prevention and control
• Emergency preparedness and disaster response
• Quality assurance and performance improvement (QAPI)
• Abuse, neglect, and exploitation prevention
• Resident rights and grievance processes
• Staffing, competency, and training requirements

Focusing first on these areas ensures that the most scrutinized policies are current and defensible.

Validate facility Policies Against Current Regulatory Expectations

During the review process, facilities should carefully compare existing policies against current federal requirements and guidance. This includes verifying that:

• Regulatory references are current and accurate
• Required timeframes, reporting thresholds, and documentation standards are correct
• Procedures reflect updated enforcement priorities

Policies that reference rescinded rules, outdated emergency declarations, or obsolete processes should be revised or retired. Clear alignment with current expectations helps staff understand their responsibilities and supports consistent implementation.

Align Written Policies with Actual Facility Practices

Federal agencies expect your policies to reflect what is actually happening in the facility. One of the most common compliance vulnerabilities occurs when policies describe procedures that no longer match daily operations.

As part of the update process, facilities should:

• Confirm that procedures match current workflows
• Ensure roles and responsibilities are accurately assigned
• Validate that documentation processes are feasible and in use

If operational changes were made in response to federal guidance but never formally documented, policies must be updated to reflect those changes.

Update Language for Clarity and Consistency

As policies evolve in response to federal updates, language clarity becomes increasingly important. Over time, policy documents can become cluttered with layered revisions, conflicting terminology, or unclear instructions.

Best practice includes:

• Using clear, consistent terminology across all policies
• Removing ambiguous or outdated language
• Clearly defining expectations, escalation paths, and accountability

Clear policies support effective staff training and reduce the likelihood of errors or misinterpretation during implementation.

Ensure Training and Communication Reflect Policy Updates

Federal agencies not only expect updated policies—they expect staff to be trained on them. When policies are revised, facilities should evaluate whether updates require:

• New or refresher training
• Revised competencies or in-services
• Updated orientation materials

Documenting staff education and acknowledgment of revised policies strengthens compliance efforts and provides evidence of implementation during surveys.

Document Review, Approval, and Version Control

A formal review and approval process is essential. Facilities should ensure that policies clearly document:

• Review and revision dates
• Leadership approval
• Version history or change summaries

This documentation demonstrates organizational oversight and a proactive approach to regulatory compliance.

Using the New Year as a Compliance Reset

The new year provides a natural opportunity to reset expectations, reinforce compliance priorities, and ensure the facility’s policy framework reflects the current federal regulatory landscape. A structured, well-documented policy and procedure review signals to regulators, staff, and stakeholders that the facility is actively managing compliance—not reacting to deficiencies.

By prioritizing federal regulatory changes and ensuring policies and procedures are fully aligned, skilled nursing facilities position themselves for stronger survey outcomes, reduced risk exposure, and improved operational consistency in the year ahead.

The Compliance Store Can Help

With the most up-to-date federal guidance documents searchable and highlighted across every agency, along with fully customizable policies and procedures updated on a continuing basis, The Compliance Store is your ultimate destination for resident-focused Policies and Procedures. We have the tools you need to keep your facility compliant today and throughout the year. For more information, contact us online or call us at 1-877-582-7347.