Here is a detailed Table of Contents. Just click on the Tab to take you to the TOC of each category.
General Employment (29 Policies)
1A - Employment Standards
2A - Job Classification
3A - Position Descriptions
4A - Orientation of New Employees
5A - Standard Work Hours
6A - Employee Compensation
7A - Recruitment for Vacant Positions
8A - Employee Evaluations
9A - Competencies
10A – Lay-Offs
11A - Salary Information
12A - Grievance Procedures
13A – Probation
14A – Separation of Employment
15A – Temporary Privileges
16A – Credentialing
17A – Nepotism
19A – Tardiness
20A - Travel Expenses
21A - Personnel Records
23A – Disaster Privileges
24A – Students
25A – Basic Cardiac Life Support
26A – Office Environment Policy
27A – Time Reporting
28A – Reference Policy
29A – Signatory Authority
30A - Lockers
31A – Peer Review Policy
Employment Benefits (18 Policies)
1B – Jury Duty
2B – Bereavement Leave
3B – Vacation Leave
4B – Sick Leave
5B – Provider Recruitment Incentive
6B – Holiday Leave
8B – Unpaid Leave
9B – Pregnancy, Childbirth and Related Medical Conditions Leave
10B – Family Medical Leave Act
11B – Continuing Education
12B – Tuition Reimbursement
13B – Insurance
14B – Retirement Benefits
15B – Employee Health Care Benefit
16B – Volunteer Leave
17B – Break Time For Nursing Mothers
18B - Overtime
20B – Workers Compensation
Employee Conduct (19 Policies)
1C – Conduct of Employees
2C – Confidential Information
3C – Conflict of Interest
4C – Cell Phones and Electronic Devices
5C – Use of organization Computer Systems
6C – Tobacco and Smoking Related Products
7C – Drug-Free Workplace
8C – Garnishments, Attachments, and Judgments
9C – Employee Identification Badges
10C – Public/Media Information
12C – Solicitation of Goods and Services
13C – Dress Code
14C – Transportation of Patients
15C – Use of organization Vehicles
16C – Harassment
17C – Disciplinary Action
18C – Focused Review
19C – Impaired or Dysfunctional Provider
20C - Social Networking Policy
Safety Policies (5 Policies)
1D – Bomb Threat
2D – Inclement Weather
3D – Concealed Weapon
4D – Tornado Warning
5D – Fire Regulations
Clinical (30 Policies)
*All Clinical (30 files)
1.Abuse/Neglect Management
2.Acquisition of Supplies and Medications
3.Aerosol Treatment
4.Application of Ice Pack
5.Crash Cart
6.Ear Irrigation
7.EKG
8.Emergency Action
9.Eye Examination
10.Fingersticks
11.Hearing Screen
12.Immunizations – Administration of
12A. Immunizations – Nurse Visit Administration of
12B. Immunizations – Provider Visit Administration of
13.Mantoux Skin Test
14.Medication Administration - Intramuscular
15.Medication Administration – Oral
16.Medication Administration – Subcutaneous
17.Medication Administration – Z-Track
18.Nurse Visits
19.Oxygen Therapy
20.Pain Management
21.Pap Smears – Preparation of
22.STD Cultures – Preparing
23.Specimen Collection – Occult Blood
24.Specimen Collection – Throat
25.Specimen Collection – Urine
26.Time Out Procedures
27.Vital Signs – Orthostatic
28.Provider Ordered – Patient Obtained Medication
29.Critical Value Notifications
Environment of Care (36 Policies)
*All Environment of Care (36 files)
Hazard Materials and Waste Management
1.Hazard Surveillance / Risk Assessment
2.Hazardous Materials & Waste Management Program
3.Infectious Hazards / Universal Precautions Education
4.Infectious Waste, Segregation, and Collection of
5.Infectious Waste, Shipping of
6.Infectious Waste Spills: Clean-Up
7.Personal Protective Equipment
8.Hazard Communication Plan
Safety Management Policy
1.Safety Management Program
Performance Improvement (9 Policies)
*All Performance Improvement (9 files)
1. No Show Appointment Policy
1A. Risk Management Plan
2. Patient Discharge Policy
2A. Emergency Preparedness Plan
3. Patient Grievance Policy
4. Needs Assessment
5. Incidents Report
6. Suicidal/Homicidal Threats
7. Policy Review
Dental (16 Policies)
*All Dental (16 files)
1.Back-Up testing of Sterilizers
2.Butane Burner and Torch
3.Dental Laundry
4.Dental Radiology Safety
5.Dental Instrument Sterilization
6.Hazardous Material Spill clean-up
7.Mercury Spill Clean-Up
8.Permissible Duties of Dental Hygienists and Dental Assistants
9.Radiation Quality Controls, Frequencies, and Responsible party
10.Radiation Exposure Monitoring
11.Radiation Quality Assurance and Control
12.Radiation Quality Control Test
13.Safe Operating Procedures for Radiation
14.NOMAD Portable X-Ray Safe Operating Procedures
15.Safe Operating Procedures for Radiation - Gendex Orthoralix 8500 DDE – Panoramic
16.Sterilizer Spore Testing
Pharmacy (13 Policies, 1 additional file)
*All Pharmacy (14 Policies)
1. Pharmacy
2. Formulary
3. Medication Inventory
4. Medication Disposal
5. Patient Assistance Medication Pickup for Patients
6. Transcription for Medication Log out
7. Pharmaceutical Salesmen
8. Look Alike/Sound Like, High Alert & Hazardous Medication
9. Product Recall Notification
10. Vaccine Ordering, Storage & Handling
11. Medication handling during power outages
12. Vaccine related reactions - Reporting of
13. Vivitrol Program
Soundalike Listing
340b (6 Policies)
*All 340b Policies (6 files)
1 – 340B Compliance
2 – 340B Responsible Staff
3 – 340B Enrollment, Recertification and Change Requests
4 – 340B Procurement, Inventory Management and Dispensing
5 – 340B Monitoring and Reporting
6 – 340B Contract Pharmacy Compliance Elements
Behavior Health (8 Policies)
*All Behavior Files (8 files)
1 – Behavioral Health Utilization
2 – Continuity Of Care
3 – Screening and Assessment
4 – Care Plan
5 – Education
6 – Behavioral Health Records
7 – Abuse/Neglect Management
8 – Application for Emergency Admission (Pink Slip)
Outreach & Enrollment (4 Policies)
*All Outreach and Enrollment (4 files)
1 – Certified Application (CAC) Certification and Recertification
2 – Certified Designated Organization Renewal of CMS Agreement
3 – Certified Application Counselor Activities
4 – Certified Application Counselor (CAC) Training
Finance (44 Policies)
All Finance Polices (40 files)
General
1A - Fiscal Year Cycle
2A - External Reporting
3A - Internal Reporting, Monthly
4A - Monthly Bank Reconciliation
5A - Journal Entries
6A - Annual Audit
7A - Federal Draw Down
8A - Fixed Asset Inventory
9A - Capitalization/Depreciation
10A - Investment
11A - Electronic Funds Transfer (EFT)
12A - Bond Insurance
13A - Check Signatures
14A - Fiscal Record Retention
15A - Grant use of Funds
Payroll
1B - Payroll
2B - Payroll Overtime Payment
3B - Direct Deposit
4B - Payroll Statement Distribution
Accounts Payable
1C - Accounts Payable
2C - Expense Reimbursement
3C - Credit Cards
4C - Petty Cash
5C - Procurement
5C/2 - Procurement Federal Funds
6C - Purchase Orders
7C - Receipt of Deliveries
Accounts Receivable
1D – Counterfeit Notes
2D – Electronic Encounter
3D - Fee Schedule
4D - Account Adjustment
5D - Billing Cycles
6D - Collections
7D - Sliding Fee Scale
8D - Dental Service Treatment Estimates
9D - Cash Boxes
10D - A/R - Deposit of Receipts
11D - Refunding Credit Balances
12D - Returned Checks
13D - Medicare Credit Balance
14D - Credit/Debit Card Payment
15D - Check Payment
16D - Refusal to Pay
17D - Waiver of Fees
Information Technology - (11 Policies)
*Total Information Technology (IT) - (11 Files)
1 – Laptop Deployment
2 – Authenticate Electronic Personal Health Information / Record Revision
3 – Business Associates Agreements - Security Breaches
4 – System Unavailability Contingency Plan
5 – Emergency Access to EHR
6 – Information Technology (IT) Security
7 – Document Scanning/Indexing and Disposal
8 – Password Management
9 – Data Backups
10 – Social Networking
11 – Acceptable Use of IT Resources