Policies & Procedures Development for Assisted Living

PROJECT TITLE
Tennessee Behavioral Health Compliance Consultant / Professional Policy & Procedure Writer — 10-Binder ASRF Project

Project Description

Three Pillars Residential LLC is seeking an experienced healthcare compliance consultant or professional policy and procedure writer to develop, review, revise, and finalize a comprehensive ten-binder policies and procedures system for our six-bed Adult Supportive Residential Facility (ASRF) in Tennessee.

Our facility is preparing for licensure through the Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS).

We have existing draft documents and organized binder materials. We need a qualified professional to evaluate these materials, identify regulatory deficiencies, rewrite or complete missing policies, and develop professional, facility-specific documentation suitable for state licensing inspection.

The work must address all applicable Tennessee rules in effect during 2026, including regulatory amendments effective May 25, 2026.

## Required Binders and Scope of Work

Binder 1 — Executive, Licensure & Governance
- Corporate governance, management responsibilities, organizational structure, and delegation of authority
- Governing body responsibilities and documentation
- Licensure preparation and regulatory correspondence
- Administrative oversight, policy approval, and document control
- Required management and regulatory compliance records

Binder 2 — Human Resources, Hiring & Personnel
- Employee hiring, screening, background checks, and personnel files
- Staff qualifications, job descriptions, and supervision
- Orientation, mandatory training, and continuing education
- Employee conduct, professional boundaries, and disciplinary procedures
- Staffing coverage, scheduling, personnel evaluations, and required documentation

Binder 3 — Master Policies & Procedures
- Comprehensive company-wide administrative and operational policies
- Resident rights, confidentiality, privacy, and grievance procedures
- Financial management, resident funds, fees, and refunds
- Abuse, neglect, exploitation, and incident reporting
- Professional ethics, transportation, quality improvement, and regulatory compliance
- Cross-references to specialized procedures maintained in other binders

Binder 4 — ASRF Residential Operations, Admissions & Resident Records
- Resident eligibility, screening, assessments, and admission criteria
- Intake, orientation, resident agreements, and discharge procedures
- Residential supervision, daily living assistance, and community integration
- Resident files, service documentation, progress notes, and care coordination
- Resident property, personal funds, personal needs, and transition planning
- Residential recordkeeping and individualized service requirements

Binder 5 — Mental Health Outpatient & Clinical Services
- Coordination with contracted mental health professionals and psychiatrists
- Mental health referrals, clinical communication, and continuity of care
- Clinical assessment and documentation responsibilities, as applicable
- Behavioral health crisis response and clinical escalation
- Service coordination and contracted professional oversight
- Separately licensed outpatient procedures only if such services are actually included in the facility's approved scope

Binder 6 — Medication Management & Health Services
- Registered nurse medication assessments and oversight
- Independent and supervised medication self-administration
- Individualized written medication supervision plans
- Medication storage, documentation, logs, and reconciliation
- Medication errors, missed doses, adverse reactions, and emergency response
- Infection prevention, communicable disease procedures, and health monitoring

The initial operating model limits admissions to residents assessed as capable of independent or appropriately supervised medication self-administration. Policies must reflect this model and must not assume that staff routinely administer medications.

Binder 7 — Fire, Safety, Emergencies, Incidents & Quality Assurance
- Fire prevention, evacuation planning, and emergency preparedness
- Disaster response, severe weather, and resident protection
- Facility safety inspections, hazards, and corrective actions
- Emergency drills and staff responsibilities
- Critical incident reporting, investigation, and follow-up
- Quality assurance, internal audits, and corrective action procedures

Binder 8 — Operational Logs & Inspection Records
- Daily, weekly, monthly, and quarterly operational monitoring
- Facility inspection and housekeeping documentation
- Fire drill and emergency preparedness logs
- Training records, operational checklists, and review schedules
- Quality assurance tracking and corrective action records
- Editable inspection-ready forms and recordkeeping instructions

Binder 9 — Tennessee State Rules & Regulatory Reference
- Applicable Tennessee licensing rules and regulatory requirements
- Rules relating to ASRF operations, residential care, governance, personnel, and safety
- Regulatory compliance cross-reference matrix
- State inspection preparation and documentation guidance
- Regulatory update tracking and version control
- References to official Tennessee government rules and forms

Binder 10 — Title VI & Civil Rights Policies, Procedures & Compliance Reference
- Nondiscrimination and equal access policies
- Applicable Title VI and related civil rights compliance requirements
- Language assistance and limited-English-proficiency procedures
- Disability access and reasonable accommodations
- Civil rights notices, complaint procedures, and non-retaliation
- Complaint investigations, documentation, monitoring, and training
- Required notices and compliance documentation based on applicable funding and legal obligations

The selected professional must provide:

1. Ten completed, organized binders containing facility-specific policies and procedures.
2. Editable Microsoft Word documents for every policy and procedure.
3. Separate editable forms, logs, and checklists for applicable binders.
4. Consistent section numbering, tables of contents, document titles, approval fields, and revision controls.
5. Citations or a compliance crosswalk identifying the Tennessee requirements addressed by each policy.
6. A written gap analysis describing missing documentation, compliance concerns, and recommended corrections.
7. Clear identification of documents requiring management approval, staff training, professional review, or additional facility information.
8. Corrections and reasonable revisions following our review.

All documentation must be professional, black-and-white, printer-friendly, suitable for physical binders, and appropriate for a small residential facility.

Our facility plans to use secure paper-based resident records and physical binders rather than requiring an electronic health records system at opening.

The final work must be individualized to Three Pillars Residential LLC and must not be generic, copied, or designed for a different type of licensed facility.

No fabricated inspections, completed training records, governing body approvals, signatures, or historical compliance evidence may be included.

Our goal is to obtain a complete, accurate, professionally organized, and facility-specific regulatory documentation system that supports initial licensing readiness and ongoing compliance for Three Pillars Residential LLC.

I have example binders but I don't like how they were done so you can just go off what I have already and make it look more professional, must be done by the end of next week.