Policies and procedures at Saint John’s have not previously been well managed. The organization is beginning the process of revising its long-term care manual. Each fall, Saint John’s reviews policies & procedures to assure care/work are compliant with state guidelines. St. John’s on the Lake annual care survey window is between December – February. Thus, assuring organizational policies & procedures are current, and the policies & procedures are applied consistently per regulatory requirement are foci of this project.