In long-term care, your activity department’s policy and procedures manual isn’t just a binder on a shelf—it’s your lifeline during state survey. A strong manual protects you, guides your staff, and ensures your residents receive consistent, meaningful programming. But what exactly needs to be inside to satisfy surveyors and keep your department audit-ready year-round?
Here are the five essentials every activity manual must include:
1. Clear Department Policies
Surveyors want to see written evidence that your department is guided by professional standards. Your manual should outline:
- Mission and philosophy of your activity program
- Resident rights and participation policies
- Department goals aligned with federal/state guidelines
Tip: Review and update policies annually. Outdated policies are a red flag to surveyors.
2. Standardized Procedures
Procedures turn policies into action. Document exactly how your department operates:
- Scheduling and calendar planning
- Volunteer coordination
- Handling resident refusals or behavioral challenges
- Documentation process for activity participation and outcomes
Tip: Train staff on these procedures so anyone stepping in can follow them consistently.
3. Survey-Ready Forms
A policy manual without the right forms is incomplete. Surveyors often request to see:
- Attendance and progress tracking sheets
- Care plan templates
- Monthly calendars
- Volunteer sign-in sheets
- Department audits or quality assurance logs
Tip: Keep all forms organized, dated, and easy to access. Digital fillable versions can save time and reduce errors.
4. Staff Training & Orientation Materials
Surveyors want proof that your team is trained and consistent. Include:
- Orientation checklists
- Continuing education policies
- Staff meeting documentation
- Emergency procedures
Tip: Make sure every staff member has signed off on these policies. Surveyors love to see signed acknowledgments.
5. Compliance & Regulatory References
Show that your department aligns with regulations:
- Federal CMS activity requirements
- State-specific guidelines
- Facility-specific protocols
Tip: Keep a printed or digital copy of your state’s regulations in the same binder for quick reference.
Keeping Your Manual Up to Date
- Set a review schedule: At minimum, update annually or when regulations change.
- Make it a living document: Encourage staff to suggest updates as procedures evolve.
- Train from it regularly: Use it in staff meetings and orientation so it becomes a practical tool, not a forgotten binder.
Conclusion
A strong policy & procedures manual is more than paperwork—it’s protection for your department, your staff, and your residents. With the right policies, procedures, and forms, you can walk into any survey with confidence knowing your program is organized, compliant, and resident-focused.
👉 Building a compliant manual from scratch can take months. That’s why we created the Activity Director Bible: Policy and Procedures Manual—our best-selling resource packed with editable policies, survey-ready forms, and proven procedures designed for activity professionals.
Get your copy here and make your next survey stress-free.
