Maintain an Up-to-Date Policy and Procedure Manual

Submitted by admin on Tue, 05/04/2021 - 15:37
Policy: 

The F/EA <<Quality Assurance Administrator>> is responsible for maintaining the accuracy of the Policy and Procedure Manual. Specific duties of the Quality Assurance Administrator as related to the Policy and Procedure Manual include, but are not limited to:

  1. Assist management with development of policies and procedures as required.
  2. Assist management with updating and maintaining the Fiscal/Employer Agent policies and procedures to ensure relevance and compliance with F/EA’s contractual obligation to clients.
  3. Establish an annual work plan and budget (with collaboration with <<Staff Title>>) to test compliance with all Fiscal/Employer Agent contract deliverables. This work plan must include compliance testing on Corrective Action Plans from previous audit findings. 
  4. Implement the agreed upon work plan and report in writing any non-compliance to <<Staff Title>> and <<Other Staff Titles>>.
  5. Work with Fiscal/Employer Agent staff to develop a plan to correct any areas of non-compliance, and monitor implementation of such plan.
  6. Any non-compliance will be escalated to <<Staff Title>>.
  7. Ensure that communication with department staff occurs routinely and appropriately whenever there is a policy or procedure change.
  8. Assist with retraining staff on policies and procedures for all Fiscal/Employer Agent functions and reports that are not meeting compliance.
Procedure: 

Review Policy and Procedure Manual Quarterly

On a quarterly basis, the Quality Assurance Administrator performs the processes in each Policy and Procedure sub-chapter, to “test” the sub-chapter, thereby ensuring that documented procedures accurately reflect completion of quality processes. “Dummy” tasks must be performed in instances where completing the actual task would be detrimental to F/EA operations. A control document is updated tracking review and update of the each Policy and Procedure sub-chapter.
 
The Quality Assurance Administrator compares the output produced by the procedure with the most recent output produced as part of normal processes. Any discrepancies in output are noted and researched with staff with primary responsibility for the task. Any areas of the sub-chapter that are not sufficiently documented to allow successful completion of the task are reviewed with staff with primary responsibility for the task. A corrective action plan is developed to:
 
  • Update the Policy and Procedure Manual sub-chapter
  • Train staff on updated Policies and Procedures
  • Reconcile Policy and Procedure Manual sub-chapter to contract requirements
 
After completing each process, Quality Assurance Administrator compares the sub-chapter to the relevant sections of the contract between Program Administrator and F/EA, as well as any addenda to the contract or other guidance as provided by Program Manager.  Any discrepancies between the Policy or Procedure and the contract are noted and solutions integrated into the corrective action plan. 
 
As changes to policy or procedure are implemented, the Quality Assurance Administrator will be fully informed. The Quality Assurance Administrator is in attendance at relevant meetings where policies and procedures are discussed and receives copies of applicable correspondence and documentation of policy or process changes. The Quality Assurance Administrator works with assigned staff to understand changes to the policy or process. The Quality Assurance Administrator updates the manual accordingly on an ongoing basis.
 
  1. On a quarterly basis, Quality Assurance Administrator will use each sub-chapter to perform the process described in the manual.
  2. Quality Assurance Administrator opens Policy and Procedure Manual Review Control Sheet YYYY saved at:
  • For each sub-chapter tested, Quality Assurance Administrator updates the following fields:

Sub-Chapter Number
Review Date
Reviewer Initials
Process Completed
Process Discrepancies Identified
Output Produced
Output Reviewed by Primary Staff
Output Discrepancies Identified
Compared to Contract
Contract Comparison Discrepancies Identified
Sub-Chapter Updated per Discrepancies
 
 
  1. Quality Assurance Administrator selects a sub-chapter from the manual
  2. Quality Assurance Administrator performs the process outlined in the Policy and Procedure Manual sub-chapter
  3. Quality Assurance Administrator highlights any areas that are not sufficient to perform the process
  4. After completing process, Quality Assurance Administrator compares output to the output produced by staff with primary responsibility for the task as part of normal processes
  5. Quality Assurance Administrator’s output should be identical (or appropriately similar, depending on the process) to the output produced as part of normal operations
  6. Staff with primary responsibility for the task reviews Quality Assurance Administrator’s output and notes any discrepancies
  7. Quality Assurance Administrator compares sub-chapter to relevant parts of the contract, contract addenda and other guidance issued by workers Program Manager
  8. Discrepancies are noted and reviewed with <<Staff Title>> or other assigned staff as applicable
  9. Any discrepancies in Policy and Procedure Manual sub-chapter are corrected
  10. After reviewing all Policy and Procedure sub-chapters, Quality Assurance Administrator compares reviewed sub-chapters listed in Policy and Procedure Manual Control Document to Table of Contents
  11. Quality Assurance Administrator cross references to ensure that all Policy and Procedure Manual sub-chapters have been reviewed and updated
  12. Quality Assurance Administrator prints Policy and Procedure Manual Control Document
  13. Quality Assurance Administrator signs and dates next to “Prepared By:”
  14. <<Staff Title>> reviews Policy and Procedure Manual Control Document
  15. <<Staff Title>> signs and dates next to “Reviewed By”
  16. Policy and Procedure Manual Control Document is scanned as saved to H:\Policies and Procedures\Review Control Sheets
  17. The scanned file is saved with the quarter and year in the file name
Internal Controls: 

The internal controls used by F/EA to monitor this process establish responsibility, segregate duties, document procedures and ensure independent internal verification.

  1. A control document is used to track the review and update of the Policy and Procedure Manual.
  2. Staff with primary responsibility for the task for which the sub-chapter is being tested review the output produced by the ‘test’ process to ensure it complies with output produced as part of normal operations.
  3. A corrective action plan is developed for any discrepancies or deviations from the sub-chapter.
  4. Any non-compliance is escalated to <<Staff Title>>
  5. Any continued non-compliance is escalated to the <<Staff Title>>
  6. The Quality Assurance Administrator cross-references the Policy and Procedure Manual Review Control Document with the Policy and Procedure Manual Table of Contents to ensure that all sub-chapters were reviewed.
  7. The Quality Assurance Administrator signs and dates the control document after reviewing all sub-chapters.
  8. The <<Staff Title>> signs and dates the control document after reviewing the control document.
  9. The control document is scanned and saved on the network drive for a minimum of 7 years per File Retention Policy.