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2012 PolicyandProcedure Manual ALPHA CENTER Policy and Procedure Manual Alpha Center 1212 S. College Ave. Phone 970.221.5121 • Fax 970.221.5084 Mission Statement: THE ALPHA CENTER IS A CHRISTIAN MEDICAL CLINIC THAT PROVIDES COUNSEL, EDUCATION AND SUPPORT TO INDIVIDUALS MAKING DECISIONS ABOUT SEXUALITY, RELATIONSHIP AND PREGNANCY ISSUES. ii Please date and sign below once you have completed reading the Policy and Procedure manual: Annual Policy and Procedure Review This Policies and Procedures Manual shall be reviewed, revised as necessary, and approved at least annually. Upon review and approval, the Medical Director, the President of the Board of Directors, the Clinic Director and the Clinic Manager shall initial and date below: Year 2012 2013 2014 2015 Initial Date Board Chairman ________ ________ Executive Director ________ ________ Medical Director ________ ________ Clinic Manager ________ ________ Board Chairman ________ ________ Executive Director ________ ________ Medical Director ________ ________ Clinic Manager ________ ________ Board Chairman ________ ________ Executive Director ________ ________ Medical Director ________ ________ Clinic Manager ________ ________ Board Chairman ________ ________ Executive Director ________ ________ Medical Director ________ ________ Clinic Manager ________ ________ Changing, Adding or Deleting Policies Policy: 1. In order to ensure the smooth flow of the organization’s procedures, only approved personnel, upon approval of the ED, may change, add or delete policies, which may be done between annual Policy and Procedure reviews. Procedure: 1. The ED, Medical Director, Clinic Manager and Client Services Director are the only authorized parties to change, add or delete Policies and Procedures. 2. All interested/affected users of the Policy should be contacted in a timely manner when policies are being changed, added or deleted. 3. Changed, added or deleted Policies must be approved by the ED prior to implementation. If the policy is medical or affects medical services, the Clinic Manager and Medical Director must also approve the policy. The ED approves non-medical policies. 4. A space shall be provided at the bottom of the written changed, added or deleted Policy for the date and for the initials of the ED, Nurse Manager and as the case may be, the Clinic Manager and Medical Director. 5. The approved written policy with initials will be placed in the policy book. Date: ________________________ Added_______ Changed_______ Deleted_______ Initials: ED_____________________ Clinic Manager__________________________ Medical Director_________________ Client Services Director___________________ Table of Contents Mission Statement: ii Policy: Assisting Minors Who Refuse Abortion 54 Annual Policy and Procedure Review ii Policy: Child Abuse / Sex Offences 55 COLORADO LICENSURE REQUIREMENTS 1 Abuse and Prevention Policy 56 NIFLA Legal Tips 65 Policy: 67 Colorado Department of Public Health and Environment contact information 2 Community Clinics and Emergency Center Standards 3 GENERAL INFORMATION 10 Agreement between Alpha Center and Life Choices of King County 11 Child Abuse Reporting Policy: Suicide Reporting /Assessing Risk Factors 68 Policy: Baby Supplies Receipt and Distribution 70 MEDICAL SERVICES 72 Policy: Pregnancy Testing 73 Policy: Hours of Operation, Opening/Closing Procedure 12 Policy: Attorney Inquiries 15 Policy: Medical Appointments without a physician on site 75 Policy: Subpoenas and Other Official Requests 16 Policy: Emergency Attention 76 Policy: Defamation 17 Policy: Standing Orders 77 Policy: Client Medical Record 78 CLIENT SERVICES 31 Policy: Scope of Services 32 Policy: Charting Guidelines defined. Policy: Telephone Guidelines 33 Policy: Client Medical Records Release 79 Policy: Client Follow-up 35 ULTRASOUND 82 Policy: Offsite Client Contact 37 Policy: Ultrasound Client Criteria 83 Policy: Admission to Clinic 38 QUALITY ASSURANCE 86 Policy: Freedom of Access 39 Policy: Quality Assurance 87 Policy: Confidentiality 40 Policy: Our Commitment of Care 88 Policy: Client Education 45 Policy: Value Statements 89 Policy: Birth Control 48 Policy: Management of Client Feedback 90 Policy: Media 49 Policy: 50 PERSONNEL 94 Policy: Adoption 51 Policy: Staffing 95 Policy: Minors 52 Policy: Personnel Training 98 Release for Publication Error! Bookmark not Policy: Registered Nurse Training for Pregnancy Options Counseling 99 Policy: Walk-Through Monthly Office Inspection 126 Policy: Conflict Resolution Policy: First Aid Kit 127 Policy: Exposure Control Plan Policy: Hazard Communication Program A. Container Labeling C. Employee Information and Training D. Hazardous Chemicals List G. Informing Contractors 128 129 129 129 130 131 Policy: Transporting Clients 134 Policy: Claims Management Procedures 135 100 Policy: Suspected misconduct, dishonesty, fraud, and whistle-blower protection 100 If any person knows of or has suspicion about misconduct, dishonesty, or fraud, the Executive Director should be contacted. If the alleged wrongdoing concerns the Executive Director, then the Board Chair or another officer should be notified. If the Executive Director, Board Chair, or officer receives information about misconduct, dishonesty, or fraud, they shall inform the Board which shall determine the appropriate procedure for investigating all credible allegations. At all times, the privacy and reputation of individuals involved will be respected. There will be no punishment or other retaliation for the reporting of conduct under this policy. The anonymity of the person reporting will be protected as requested unless this would impede the investigation. 100 Policy: Equipment Operation and Maintenance 136 INFECTION CONTROL 137 Policy: Universal Precautions Infection Control 138 Policy: Ultrasound Infection Control 142 107 APPENDIX 143 Policy: Medical Staff Peer Review 108 Pregnancy Test Release Form A and Medical Consent and Release 144 VOLUNTEERS 109 Client Initial Visit Form B 145 Policy: Volunteer Interview and Procedures 110 Client Contact Information Form C 146 Policy: Volunteer Job Qualifications and Descriptions Qualifications Responsibilities Client Pregnancy History Form D 147 111 112 112 Client Pregnancy Test Form E 148 Policy: Interns 113 Video Release Form F 149 Policy: Community Service Volunteers 114 Release for Publication Form G 150 Policy: Volunteer Evaluation 115 Evaluation Sheet Form H 151 Policy: Volunteer Supervision 116 Pregnancy Verification Form I 152 Policy: Post-Abortive Volunteers 117 Standing Orders Form J 153 Policy: Corrective and Disciplinary Measures 118 Client Medical Record Checklist Form K 154 Medical Records Release Form L 155 SAFETY 119 Statement of Policy on Adoption Form M 156 Policy: OSHA Compliance 120 Policy: Safety and Disaster Plan 121 Policy: Staff Health 104 Policy: Dress Code Ultrasound Consent, Waiver, and Release Form N 157 Ultrasound Referral Form O 158 Ultrasound Information and Appointment Sheet Form P 159 Designated Work-Related Medical Provider Form QA 186 Ultrasound Report Form Q 160 Consent for Release of Information Form RA 187 Ultrasound Exit Interview Form R 161 Material Assistance Donations Log Form SA 188 Feedback Form S 162 Pregnancy Retest Form TA 189 Feedback Log Form T 163 Suspected Child Abuse Reporting Form UA 190 Medical Personnel Record Checklist Form U 164 Material Assistance Intake and Concepts Shared Form VA 191 Staff Health Report Form V 165 Tuberculin Testing Form W 166 Hepatitis B Vaccine Information Form X 167 Volunteer Interest Form Y 168 Policies and Procedures in Case of Disaster Form Z 169 Spanish Material Assistance Intake Form WA 192 Progress Notes Form XA 193 RMFF Referral Form YA 194 Release for Ultrasound Models Form ZA Referral for Medical Evaluation Form CB 187 188 Volunteer Interest Letter Form AA 170 Telephone Log Form DB Client Referral Form FB 189 190 Volunteer Orientation Checklist Form BA 171 Annual PPE Hazardous Assessment Form FF 191 Bomb Threat Information Sheet Form CA 172 Annual Worksite Hzrds. Assessment Form FG 192 Walk-Through Monthly Inspection Form DA 173 Exposure Incident Report Form EA 174 Hazardous Material Masters List Form FA 175 Bloodborn Pathogens Training Record Form GA176 Statement of Commitment Form HA 177 Statement of Faith Form IA 178 Statement of Abstinence Form JA 179 Application for Employment Form KA 180 Tenured Employee Evaluation Form LA 181 Performance Evaluation Form MA 182 Confidentiality Information Agreement Form NA 183 Unique Aspects of Job/Environment Form OA 184 Safety Rules Form PA 185 P O L I C Y A N D P R O C E D U R E M A N U A L Chapter 1 Colorado Licensure Requirements 1 P O L I C Y A N D P R O C E D U R E M A N U A L Colorado Department of Public Health and Environment contact information Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, CO 80246-1530 HFD-7900 Contact: Cathy Davenport (303) 692-2908 Judy Hughes 2 P O L I C Y A N D P R O C E D U R E M A N U A L Community Clinics and Emergency Center Standards COMMUNITY CLINICS AND COMMUNITY CLINICS AND EMERGENCY CENTERS CHAPTER IX SECTION 1 DEFINITIONS 1.1 Community Clinic or Community Clinic and Emergency Center. A "community clinic" or a "community clinic and emergency center" is defined as a comprehensive community-based medical facility which includes general or primary care services, preventive health services, diagnostic or therapeutic outpatient services, appropriate inpatient services, and/or emergent care services. The emergency center (emergency services available 24 hours) portion of the license shall be an optional component, and a community clinic may be licensed as a "community clinic" or as a "community clinic and emergency center." A "community clinic" or a "community clinic and emergency center" includes accommodations for inpatient stays, unless otherwise exempted by statutory provisions or by a waiver of the requirement by the Department under section 10.1. A "community clinic" or a "community clinic and emergency center" may include general and primary care providers participating in the medically indigent program pursuant to article 15 of title 26. No waiver of inpatient accommodation requirements as required under section 10.1 of these regulations shall be necessary for medically indigent program providers who provide only primary care and other outpatient services during normal business hours. No waiver of inpatient accommodation requirements as required under section 10.1 of the regulations shall be necessary for a community clinic or a community clinic and emergency center located within a licensed hospital, but not licensed as part of the hospital, and has an admission or transfer agreement with that hospital. 1.2 Emergency or Emergent Care. Emergency or emergent care is defined as treatment for a medical condition manifesting itself by acute symptoms of a sufficiently severe nature that are life, limb, or disability threats requiring immediate attention, where any delay in treatment could be reasonably expected to place the health of the individual in serious jeopardy, or seriously impair bodily functions, or cause serious dysfunction of any bodily organ or part. 1.3 Inpatient Care. For the purposes in Chapter IX of these regulations, "inpatient care" shall be defined as extended care or stay in the facility beyond the primary care or general services normally rendered which would include an overnight stay or a continuous period of care exceeding twenty-four (24) hours, but not to exceed 72 hours. 1.4 Primary Care. Primary care is defined as a practice that deals with the individual rather than an organ system or an abnormal physiology and provides an array of services covering the preventive, diagnostic, and therapeutic needs of patients, including referral and coordination of care to the services. 1.5 Exclusions. The term community clinic or a community clinic and emergency center does not include the following: (a) A facility that is licensed as part of or a department of a general hospital and is not freestanding; (b) A facility which is used as an office for the private practice of a physician(s) except when: 1) it holds itself out to the public or other health care providers as a community clinic or a community clinic and emergency center or as a similar facility with a similar name or variation thereof which creates confusion in the mind of the public, indicating that it is capable of 3 P O L I C Y A N D P R O C E D U R E M A N U A L providing the same care as required by these regulations and or in fact provides the same level of care as required by these regulations, and in the case of an emergency center, of providing 24hour emergency care; 2) it is operated or used by a person or entity different than the physician(s). 3) patients are charged a fee for the use of the facility in addition to the physician(s) professional fee. SECTION 2 LICENSE 2.1 A community clinic or a community clinic and emergency center shall be licensed and meet all of the licensure requirements in Chapter II and the requirements of this Chapter IX of the Colorado Department of Public Health and Environment's Standards for Hospitals and Health Facilities. 2.2 A community clinic or a community clinic and emergency center shall be in compliance with all other applicable state, local, and federal laws. SECTION 3 ORGANIZATIONAL STRUCTURE 3.1 Governing Body. The community clinic or a community clinic and emergency center shall have a governing body which shall have responsibility for the oversight of the organization and the provider staff. The governing body shall meet as necessary. The governing body shall adopt the general by-laws or policies by which the community clinic or a community clinic and emergency center operates. These bylaws or policies shall be reviewed periodically and revised as needed. 3.2 Medical Director. The governing body of the community clinic or a community clinic and emergency center shall appoint a medical director for the facility. Such medical director shall be a physician, licensed under the laws of the state of Colorado, who is a member of the facility's staff. 3.3 Provider Staff. The community clinic or a community clinic and emergency center shall have an organized provider staff under the direction of the medical director that shall be responsible for the quality of medical care provided to patients in the facility. 3.4 Administrator. The governing body of the community clinic or a community clinic and emergency center shall appoint an administrator or a designated person who is principally responsible for directing the daily operation of the community clinic or a community clinic and emergency center. The administrator shall develop clear lines of authority and responsibility for the provider staff. The administrator, in conjunction with the provider staff, or a representative committee from the provider staff, shall develop policies and procedures for the operation of the facility. The policies and procedures shall be approved by the governing body and reviewed periodically and revised as needed. 3.5 Government Entities. A community clinic or a community clinic and emergency center wholly owned and operated by the state or any of its political subdivisions shall be governed, directed, administered, and staffed according to the statutory provisions establishing such facilities. 3.6 Corporate Health Care Entities or Health Care Networks. A community clinic or a community clinic and emergency center that is part of a larger, corporate health care system or health care network may fulfill the administrative record requirements, the policies and procedures requirements, and the medical records requirements of this Chapter IX through a central system common to the entire organization, providing that the intent of the requirements of this Chapter is met. 4 P O L I C Y A N D P R O C E D U R E M A N U A L SECTION 4 STAFFING 4.1 Provider Staff. There shall be adequate provider staff to meet the preventive, diagnostic, and therapeutic needs of the patient population being served. The provider staff shall participate in the quality management program; and, in coordination with the administrator, participate in the enforcement of policies and procedures or rules and regulations of the facility. If the facility is operating as an emergency center, at least one of the provider staff on duty at all times shall be qualified in basic cardiac life support and advanced cardiac life support. 4.2 Personnel. The administrator shall develop and maintain personnel policies and procedures. Personnel employed by the community clinic or a community clinic and emergency center shall have qualifications as met by education, training, and experience necessary to meet the medical needs of the patients. Personnel shall be oriented and trained upon employment and kept abreast of new health care services developments and new technology through in-services and other educational programs. SECTION 5 MEDICAL RECORDS 5.1 All community clinics or community clinic and emergency centers shall maintain a clinical medical record system as established by the facility's written patient care policies. A designated member of the staff shall be responsible for maintaining medical records and for ensuring that they are completely and accurately documented. Medical records shall be systematically organized and easily accessible. All necessary precautions shall be taken to protect the confidentiality of the information contained within. 5.2 An individual medical record for each patient that receives services from any community clinic or a community clinic and emergency center shall contain, but not necessarily be limited to, the following: (a) identification and social data, evidence of consent forms, relevant medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient per visit; (b) reports of physical examinations, diagnostic and laboratory test results, reports of x-rays, scans, and other radiological imaging studies, and consultative findings; (c) all physician's orders, reports of treatments and medications, and other information necessary to monitor the patient's progress; (d) signatures of the physician or other health care professionals making entries into the medical record. 5.2 Medical records for adults (persons 18 years of age or over) shall be retained for no less than 10 years after the last patient usage. Medical records for minors must be retained for the period of minority plus 10 years after the last patient usage. SECTION 6 SERVICE PROVISION 6.1 Care From Licensed Practitioner. The policies of the community clinic or community clinic and emergency center shall ensure that every patient is under the care of a physician or, if applicable, a physician assistant or advanced practice nurse with appropriate specialization and registered pursuant to 12-38-111.5. 6.2 Patient Care Policy. The facility shall have written patient care policies. The policies shall include but are not limited to the following: (a) a description of the services furnished directly and those furnished through agreements, arrangements with, or referrals to other facilities or other health care service providers; 5 P O L I C Y A N D P R O C E D U R E M A N U A L (b) protocols for the medical management of health problems, including the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for periodic review and evaluation of the services furnished by the facility; (1) protocols shall include: (A) a description of the scope of medical acts that may be undertaken by the physician assistant, or advanced practice nurse, or other provider staff under the supervision of a physician or other authorized licensed practitioner; and (B) protocols to be followed for acts of medical diagnosis and treatment that may be undertaken without direct, over the shoulder physician supervision. (2) Protocols are not intended to mandate the development of practice guidelines for physicians or other licensed provider staff practicing in the facility. 6.3 Outpatient Surgery. Outpatient surgical procedures commonly performed in a physician's office may be performed in any community clinic or a community clinic and emergency center if adequate staffing, equipment, and supplies are available. SECTION 7 EMERGENCY SERVICES PROVISIONS 7.1 Services and Equipment. Emergency centers shall provide at a minimum the following services and equipment, both adult and pediatric as applicable: (a) an emergency call system; (b) oxygen; (c) ventilation assistance equipment, including airways, manual breathing bag; (d) continuous electrocardiogram monitoring with cardiac defibrillator; (e) intravenous therapy supplies; (f) laryngoscope and endotracheal tubes; (g) suction equipment; (h) indwelling urinary catheters; and (i) drugs and other emergency medical equipment and supplies, including basic obstetric supplies, necessary for the level of services to stabilize the patient as specified by the provider staff and by the specific needs of the community being served. 7.2 Triage Protocols. A community clinic or a community clinic and emergency center shall have in place emergency medical protocols to provide triage and stabilization procedures to be initiated by onduty staff; and to provide air or ground transportation with pre-arranged destinations, including transfer agreements with a hospital(s). SECTION 8 ANCILLARY SERVICES 8.1 Obstetrics. A community clinic or a community clinic and emergency center may provide for routine pre-natal care and for necessary emergency obstetrical services according to emergency triage protocols of the facility. However, the facility shall not provide services for the routine delivery of newborn infants and care of obstetrical patients and newborn infants unless the facility can meet the requirements for a birthing center in Chapter XXII of the regulations. 8.2 Laboratory Services. Laboratory services essential to the treatment and diagnosis of the patient (both primary care and emergency patients) shall be available. Laboratory services shall be provided directly or by contract. Services provided directly shall be provided pursuant to the "Clinical Laboratory 6 P O L I C Y A N D P R O C E D U R E M A N U A L Improvement Amendments of 1988," and the corresponding regulations (42 USC 263a and 42 CFR 493). 8.3 Radiological Services. Radiological services essential to the treatment and diagnosis of the patient shall be available. Radiological services shall be provided directly or by contract or plan. X-rays, films, scans, and other imaging records shall be maintained by the facility for a period of five years, if services are provided directly. Services provided directly shall be provided pursuant to the regulations of the Department of Health pertaining to radiation control (6 CCR 1007-1). 8.4 Pharmacy. Pharmaceutical methods, procedures, and controls which ensure the appropriation, acquisition, storage, dispensing, administration, and control of pharmaceuticals shall be developed in accordance with applicable state and federal laws regulating the practice of pharmacy. SECTION 9 AVAILABILITY OF SERVICES 9.1 The Community Clinic. The community clinic shall maintain regular hours for services. The community clinic shall provide an emergency referral number and/or a procedure for the provision of medical services when the clinic is not open for regular service. 9.2 The Community Clinic and Emergency Center. The community clinic and emergency center shall maintain operations on a 24-hour basis, every day of the year. If a community clinic and emergency center chooses to temporarily interrupt operations or access to services for any part of the 24-hour period, a means of making services available within 30 minutes or sooner if medically necessary shall be instituted. Any seasonal interruption in services, such as seasonal closures, shall be reported to the Department prior to such closure, and all signage that would indicate that services are available shall be removed. Protocols shall be developed by the medical director to establish appropriate response times for on-call staff for differing emergent situations that would present themselves at the facility. Clear directions at the front and/or emergency entrance to the facility that can be easily understood by persons approaching the emergency center shall be posted in a conspicuous location with an appropriate communications device, such as a "hot phone" or "tip and ring phone", so that care can be summoned immediately and an appropriate response by the facility can be made. SECTION 10 INPATIENT SERVICES 10.1 Limited Stay. A community clinic or a community clinic and emergency center may provide inpatient services to ill or injured persons where a determination has been made that transportation to a hospital or other appropriate facility when a higher level of care is not immediately necessary provided that the needs of such patients can be met by the facility during a short stay not to exceed 72 hours. "Meeting the needs of patients" shall include appropriate provider staff consistent with the licensure requirements relating to such staff. (a) The Department may waive the requirement for inpatient services after a review of applicant materials for licensure provided that the facility demonstrates that it meets the definition of a facility under this Chapter IX of the regulations, with the exception of the inpatient component, and is not the private practice of an independent, licensed physician. (b) The 72-hour limit on inpatient stays shall not apply to the Department of Corrections providing medical services pursuant to article 1 of title 17. 10.2 Patient Care Unit. A community clinic or a community clinic and emergency center providing inpatient care shall establish and maintain a patient care unit. Each patient shall have a visible means of identification placed securely on his or her person until discharge. Each patient room shall have adequate 7 P O L I C Y A N D P R O C E D U R E M A N U A L space to meet the needs of the patient. In general, the standard shall be 100 square feet for each single patient room or 80 square feet per bed for multiple bedrooms and include sufficient illumination to meet patient needs for treatment. Each patient shall have direct access to a call system which signals the provider staff on duty. The facility shall provide patient bathing facilities for patients staying overnight. 10.3 Admissions. Any community clinic or a community clinic and emergency center providing inpatient services shall develop admissions policies and procedures, which include but shall not be limited to appropriateness of admissions, and the necessary staffing to provide those services. (a) Necessary staffing includes the licensed staff with the ability to meet the needs of the patient and the regulatory requirements imposed by other state laws on the use of such licensed staff. 10.4 Nutrition. Dietary services shall be provided in the following manner: (a) Dietary or nutrition consultation shall be provided by a qualified person for routine dietary needs and on call consultation available for special dietary needs. (b) All food shall be pre-packaged and require microwave heating only and disposable products for preparation and service shall be used unless the facility meets the requirements of the Rules and Regulations Governing the Sanitation of Food Service Establishments in the State of Colorado, Colorado Department of Health, 1990 or the intent of such regulations as applicable and appropriate. (c) A person shall be assigned the responsibility for food preparation and service and shall have no other assigned duties during such assignment. (d) The food service area shall be an area separate from the employee lounge or other areas used by facility personnel or the public. (e) Food shall, at all times, be prepared, stored, and served properly so as to prevent the development and spread of food borne disease. (f) Catering and alternative methods of meal provision shall be allowed if patient needs and the intent of this part of the regulations are met. (g) There shall be food service available to serve adequate meals to patients "required to stay" in any community clinic or a community clinic and emergency center for more than six hours, if necessary or consistent with medical treatment or evaluation needed. Being "required to stay" is defined as a condition which requires the patient to stay in the facility for extended treatment or until transportation to another facility can be arranged. It does not apply to outpatient visits that may require extensive waiting before receiving services if the patient is able to leave after services are rendered or is able to reschedule a visit if service cannot be provided in a timely manner. 10.5 Discharge Planning. For those community clinics or community clinic and emergency centers that offer inpatient care, documentation of discharge and follow-up shall be included in the patient record to ensure the provision of post-discharge care. SECTION 11 INFECTION CONTROL 11.1 All community clinics or community clinic and emergency centers shall develop a plan for infection control that is adequate to avoid the sources of and prevent the transmission of infections and communicable diseases. The facility shall develop a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel. Sterilization procedures shall be developed and implemented in necessary service areas. SECTION 12 LIABILITY 12.1 Community clinics or community clinic and emergency centers shall submit evidence to the Colorado Department of Public Health and Environment that they maintain at least $300,000 8 P O L I C Y A N D P R O C E D U R E M A N U A L professional liability insurance per incident and $900,000 annual aggregate per year in order to demonstrate compliance with the Health Care Availability Act of 1988. SECTION 13 PHYSICAL PLANT AND ENVIRONMENT 13.1 The community clinic or and the community clinic and emergency center shall be constructed and maintained to ensure access to all patients and to ensure the safety of patients. (a) Life Safety Code. All community clinics or community clinics and emergency centers shall comply with the Life Safety Code, National Fire Protection Association 101, 1991 for new and existing ambulatory health care facilities. A community clinic or a community clinic and emergency center that is currently licensed and was lawfully constructed and found to be in compliance at the time of initial licensure and during any subsequent surveys may continue to utilize existing, approved life safety systems provided that they present no hazard to the life, health, and safety of patients. The community clinic or the community clinic and emergency center shall, in the event of any renovation to the facility of 50 percent or greater of the total interior of the physical plant, after the effective date of these regulations, comply with the requirements of the Life Safety Code, National Fire Protection Association 101, 1991. (1) Other Building Requirements. The community clinic or the community clinic and emergency center shall also demonstrate compliance with all other building and fire safety requirements of local governments and other state agencies, including but not limited to structural, mechanical, plumbing, and electrical requirements. (b) Pest Control. Policies shall be developed and procedures implemented for the effective control of insects, rodents, and other pests. (c) Waste disposal. All wastes shall be disposed in compliance with local, state and federal laws. (d) Preventive Maintenance. A preventive maintenance program to ensure that all essential mechanical, electrical and patient care equipment is maintained in safe operating condition shall be provided. Emergency systems, and all essential equipment and supplies shall be inspected and maintained on a frequent or as needed basis. (e) Housekeeping. Housekeeping services to ensure that the premises are clean and orderly at all times shall be provided and maintained. Appropriate janitorial storage shall be maintained. (f) Laundry and Linens. Laundry and linen services shall be provided by in-house staff or by contract. Separate clean and soiled linen areas shall be provided and maintained. Health Facilities Division Colorado Department of Public Health & Environment 4300 Cherry Creek Drive South Denver, CO 80246-1530 Phone: (303) 692-2800 Fax: (303) 782-4883 http://www.state.co.us 9 P O L I C Y A N D P R O C E D U R E M A N U A L Chapter 2 General Information 10 P O L I C Y A N D P R O C E D U R E M A N U A L Agreement between Alpha Center and Life Choices of King County (This is a computer reproduction of the agreement that is found in the manual) This agreement is into this 14th day of September, 1999 between Life Choices of King County (Washington) and Alpha Center for Women, Fort Collins, Colorado. Life Choices of King County hereby grants permission to Alpha Center for Women to use it’s Policies and Procedures Manual. Alpha Center for Women may adopt the principles, procedures, and forms that are contained in this manual. Alpha Center for Women will not sell or give away any part of this manual to anyone outside of our agency and offices. Alpha Center for Women shall indemnify and hold harmless from any liabilities, which may arise from any use or application of information contained herein, or relate in any way whatsoever to this manual. Signed by Carrol Purdy on September 14, 1999 11 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Hours of Operation, Opening/Closing Procedure The Alpha Center shall be open as follows: Monday Tuesday Wednesday Thursday Friday 1000-1600 1000-1600 1000-1600 1000-1600 1000-1600 (Hours may change as budgeting limits require) Special consulting hours may be arranged by an options counselor, with the prior approval of the Center Director, on a case-by-case basis when necessary. A schedule of hours and days when the clinic is open shall be conspicuously posted for public view and information. Changes in such hours shall be posted in advance of the change. Procedure: 1) Entrance and exit doors are to be kept unlocked during hours of operation. 2) The first staff person to arrive at the clinic is to: a. Disarm the alarm system. b. Turn on the lights and check all rooms for security reasons. c. Observe examination room and bathroom for cleanliness and order. d. Unlock medical records area and file cabinet. e. Adjust thermostat for comfort level. 3) At the end of the workday, a staff member or volunteer shall: a. Lock medical records file cabinet after all medical records have been returned to the drawer. b. Lock the door to the medical records storage room. c. Lock rear door to clinic. d. Complete a security check of all rooms. e. Turn off the lights. f. Arm the alarm system. g. Lock all doors to the facility. 12 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Computer Protection All computers shall be equipped with appropriate firewalls and anti-virus software in order to insure the protection of computer data and for computer safety. Procedure: 1. Each computer utilized at the Clinic will have the appropriate firewall software installed before utilization. 2. Each computer utilized at the Clinic will have the appropriate anti-virus software installed before utilization. 3. The appropriate software should be purchased and installed by a reputable service provider. 13 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Financial Procedures Deposits 1) 2) 3) 4) 5) Office Manager opens and sorts mail All donations are given to the Executive Director Information is entered into computer system for donor records by Office Manager Donations are kept in safe until weekly deposit day Office Manager or executive director makes deposit a. Alphabetize checks b. Copy of each check and cash (copies are filed in a notebook by Office Manager) c. Deposit slip is filled out and copied d. Deposit taken to bank 6) Baby bottles are taken to the bank to have coin counted on an as needed basis Payables 1) Bills are given to and approved by Executive Director 2) Generally the bill is paid on the same day it is received; judgment made by Executive Director based on available funds and when the bill is due 3) Check signers: Executive Director, Office Manager, Director of Development, Board of Directors Chairman 4) All purchases for anything are approved by the Executive Director 5) Credit card is used for ease of purchasing supplies by phone and internet; statement is reviewed monthly by a board member (usually treasurer) if charges are over $1,000. Payroll 1) All payroll processes are done by outside firm 2) Checks are signed by Executive Director (except for those that are directly deposited to employee accounts) 3) All employees are hourly with the exception of the Executive Director. No hours over 40 are to be worked without the approval of the Executive Director. Petty Cash 1) Executive Director is the only one to have access to petty cash 2) Money in from: employee purchase of supplies, stamps, phone, etc… 3) Money out for: staff lunch, small dollar supplies, small dollar client assistance, etc… 4) Receipts filed with petty cash “tally” sheet Financial Reports and Records 1) Financial statements including an income statement and balance sheet are prepared monthly on a cash basis 2) Financial records are kept on file at the Center indefinitely 14 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Attorney Inquiries A volunteer/employee of Alpha Center shall refer all inquiries from an attorney’s office to the Executive Director. A volunteer/employee will not give information to an attorney or to anyone from an attorney’s office. Procedure: 1) If a call comes in from an attorney’s office, tell the caller that it is our policy to refer all attorney calls to the Executive Director. This includes all information regardless of how benign it seems, including our services, address, etc. 2) Do not feel intimidated by an attorney. You do not have to talk with him/her. 3) If an attorney or anyone from an attorney’s office becomes obnoxious, you may hang up on him/her. Notify the Executive Director if this happens. 15 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Subpoenas and Other Official Requests Upon receipt of a subpoena or other official request for client information, the Alpha Center will provide reasonable corporation of civil authorities while also taking all appropriate steps to protect the interests of the client and the Center. Any such subpoenas or requests will be handled in accordance with the following procedure: Procedure: 1) Any subpoena or official request for client information received by the Center or its staff will be promptly brought to the attention of the Executive Director. 2) The client whose information has been requested will be notified of the request as soon as reasonably possible. 3) The subpoena or request will be submitted to the Center’s attorney or in certain circumstances, the Executive Director for review to verify that the subpoena or request has been validly issued and to explore whether there are any proper grounds for the Center to oppose any such subpoena or request. 4) In absence of any opposition to the subpoena or request, the Executive Director will oversee the gathering of all documents and other information necessary to respond. Only documents and information that are specifically responsive to the subpoena or request will be gathered and produced. 16 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Defamation Alpha Center volunteers/employees shall not give any false written or verbal statement which exposes any person to public contempt or ridicule or causes another’s business to be injured. 17 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Whistleblowing The whistleblower policy is intended to provide a mechanism for the reporting of illegal activity while protecting the employees who make such reports from retaliation. Procedure: Code of Conduct – The Alpha Center requires directors, officers, employees and volunteers to observe high standards of business and personal ethics in the conduct of their duties and responsibilities. As representatives of the Center, we must practice honesty and integrity in fulfilling our responsibilities and comply with all applicable laws and regulations. It is the responsibility of all directors, officers, employees and volunteers to report legal violations or suspected legal violations in accordance with this Whistleblower Policy. No Retaliation – No director, officer, employee or volunteer who in good faith reports suspected illegal conduct shall suffer harassment, retaliation or adverse employment consequence. An employee who retaliates against someone who has reported a violation in good faith is subject to discipline up to and including termination of employment. Reporting Violations – A person’s concerns about possible illegal conduct should be reported to his or her supervisor. If, for any reason, a person finds it difficult to report his or her concerns to a supervisor, the person may report the concerns directly to the Executive Director. Supervisors and managers are required to report suspected violations of the Code of Conduct to the Chairman of Board, who has specific and exclusive responsibility to investigate all reported violations. Reportable Conduct – Examples of reportable conduct include: forgery or alteration of documents; unauthorized alteration or manipulation of computer files; fraudulent financial reporting; pursuit of a benefit or advantage in violation of the Conflict of Interest Policy; misappropriation or misuse of Alpha Center resources, funds, supplies or other assets; authorizing or receiving compensation for goods not received or services not performed; authorizing or receiving compensation for hours not worked. Compliance Officer – The Chairman of the Board of Directors is the Compliance Officer and is responsible for investigating and resolving all reported complaints and allegations concerning violations of the Code of Conduct and shall advise the Executive Director and Board of Directors accordingly. Acting in Good Faith – Anyone filing a complaint concerning a violation or suspected violation of the Code of Conduct must be acting in good faith and have reasonable grounds for believing the information disclosed indicates a violation of the Code. Any allegations that prove not to be substantiated and which prove to have been made maliciously or knowingly to be false will be viewed as a serious disciplinary offense. Handling of Reported Violations – The Chairman of the Board will notify the sender and acknowledge receipt of the reported violation or suspected violation within five business days. All reports will be promptly investigated and appropriate corrective action will be taken if warranted by the investigation. 18 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Conflict of Interest Article I – Purpose The purpose of the conflict of interest policy is to protect the Alpha Center’s (“Center”) interest when it is contemplating entering into a transaction or arrangement that might benefit the private interest of an officer or director of the Organization or might result in a possible excess benefit transaction. This policy is intended to supplement but not replace any applicable state and federal laws governing conflict of interest applicable to nonprofit and charitable organizations. Article II – Definitions 1. Interested Person - Any director, principal officer, or member of a committee with governing board delegated powers, who has a direct or indirect financial interest, as defined below, is an interested person. 2. Financial Interest – A person has a financial interest if the person has, directly or indirectly, through business, investment or family: a. An ownership or investment interest in any entity with which the Center has a transaction or arrangement. b. A compensation arrangement with the Center or with any entity or individual with which the Center has a transaction or arrangement, or c. A potential ownership or investment interest in, or compensation arrangement with any entity or individual with which the Center is negotiating a transaction or arrangement. Compensation includes direct and indirect remuneration as well as gifts or favors that are not insubstantial. A finance interest is not necessarily a conflict of interest. Under Article III, Section 2, a person who has a financial interest may have a conflict of interest only if the appropriate governing board or committee decides that a conflict of interest exists. Article III – Procedures 1. Duty to disclose – In connection with any actual or possible conflict of interest, an interested person must disclose the existence of the financial interest and be given the opportunity to disclose all material facts to the directors and members of committees with governing board delegated powers considering the proposed transaction or arrangement. 2. Determining Whether a Conflict of Interest Exists – After disclosure of the financial interest and all material facts, and after any discussion with the interested person, he/she shall leave the governing board or committee meeting while the determination of a conflict of interest is discussed and voted upon. The remaining board or committee members shall decide if a conflict of interest exists. 3. Procedures for Addressing the Conflict of Interest a. An interested person may make a presentation at the governing board or committee meeting, but after the presentation, he/she shall leave the meeting during the discussion of, and the vote on, the transaction or arrangement involving the possible conflict of interest. b. The chairperson of the governing board or committee shall, if appropriate, appoint a disinterested person or committee to investigate alternatives to the proposed transaction or arrangement. 19 P O L I C Y A N D P R O C E D U R E M A N U A L c. After exercising due diligence, the governing board or committee shall determine whether the Center can obtain with reasonable efforts a more advantageous transaction or arrangement from a person or entity that would not give rise to a conflict of interest. If a more advantageous transaction or arrangement is not reasonably possible under circumstances not producing a conflict of interest the governing board or committee shall determine by a majority vote of the disinterested directors whether the transaction or arrangement is in the Organization’s best interest, for its own benefit, and whether it is fair and reasonable. In conformity with the above determination it shall make its decision as to whether to enter into the transaction or arrangement. 4. Violations of the Conflict of Interest Policy a. If the governing board or committee has reasonable cause to believe a member has failed to disclose actual or possible conflicts of interest, it shall inform the member of the basis for such belief and afford the member an opportunity to explain the alleged failure to disclose. b. If after hearing the member’s response and after making further investigation as warranted by the circumstances, the governing board or committee determines the member has failed to disclose an actual or possible conflict of interest, it shall take appropriate disciplinary and corrective action. Article IV – Records of Proceedings The minutes of the governing board and all committees with board delegated powers shall contain: a. The names of the persons who disclosed or otherwise were found to have a financial interest in connection with an actual or possible conflict of interest, the nature of the financial interest, any action taken to determine whether a conflict of interest was present and the governing board’s or committee’s decision as to whether a conflict of interest in fact existed. b. The names of the persons who were present for discussions and votes relating to the transaction or arrangement, the content of the discussion, including any alternatives to the proposed transaction or arrangement, and a record of any votes taken in connection with the proceedings. Article V – Compensation a. A voting member of the governing board who receives compensation, directly or indirectly, from the Center for services is precluded from voting on matters pertaining to that member’s compensation. b. A voting member of any committee whose jurisdiction includes compensation matters and who receives compensation, directly or indirectly, from the Center for services is precluded from voting on matters pertaining to that member’s compensation. Article VI – Annual Statements Each board member, executive director, and member of a committee with governing board delegated powers shall annually sign a statement which affirms such person a. Has received a copy of the conflicts of interest policy, b. Has read and understands the policy, c. Has agreed to comply with the policy, and 20 P O L I C Y A N D P R O C E D U R E M A N U A L d. Understands the Center is charitable and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more of its tax-exempt purposes. Article VII – Periodic Reviews To ensure the Center operates in a manner consistent with charitable purposes and does not engage in activities that could jeopardize its tax-exempt status, periodic reviews shall be conducted. The periodic reviews shall, at a minimum, include the following subjects: a. Whether compensation arrangements and benefits are reasonable, based on competent survey information, and the result of arm’s length bargaining. b. Whether partnerships, joint ventures, and arrangements with management organizations conform to the Center’s written policies, are properly recorded, reflect reasonable investment or payments for goods and services, further charitable purposes and do not result in inurement, impermissible private benefit or in an excess benefit transaction. Article VIII – Use of outside Experts When conducting the periodic reviews as provided for in Article VII, the Center may, but need not, use outside advisors. If outside experts are used, their use shall not relieve the governing board of its responsibility for ensuring periodic reviews are conducted. 21 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Record Retention and Destruction Policy 1. 2. 3. 4. 5. 6. The Alpha Center shall keep records according to the Document Retention Chart in this policy (see attachment). This policy applies to the original hard copy only. Duplicate copies may be disposed of at any time at the discretion of management unless the original has been lost. Records should not be kept any longer than necessary whether in hard copy, microfilm, optical discs or computer database. The basic requirements that apply to all records apply to e-mail records as well. Emails are to be printed and the hardcopy stored in the relevant subject matter file as is any other hardcopy communication. The email record must include the sender and recipient as well as the date and time it was sent and/or received. It is Alpha Center policy to ensure the security and confidentiality of all records within our custody or control containing personal, confidential or proprietary information. Such records will not be destroyed earlier than the dates indicated in this policy. Such records will be shredded, erased or otherwise modified so as to make the records unreadable or otherwise modifying the protected information as to make it unreadable or undecipherable through any means. Record destruction may be accomplished directly by Center staff or other secure means. If the Alpha Center is aware of or suspects that it may be involved in a Federal investigation of any sort, all record destruction shall be postponed until the investigation is completed. Legal counsel shall be consulted for guidance in this regard. The Executive Director shall monitor compliance with this policy by conducting annual audits. In addition, this policy will be reviewed and updated on an annual basis to ensure that it accurately reflects the Alpha Center’s current document management practices. Records shall be maintained as follows: Document Retention Chart Type of Document Accounts payable/receivable ledgers and schedules Annual reports Audit reports Bank statements and reconciliations Bylaws Checks (cancelled) Client records – Adults Client records – Minors Contracts, mortgages, notes and leases (expired) Contracts (still in effect) Correspondence (general) 22 Minimum Requirement 7 Years Permanently Permanently 7 years Permanently 7 years 7 years 7 years after majority 7 years Permanently 3 years P O L I C Y A N D P R O C E D U R E M A N U A L Correspondence (legal and important matters) Donation records Deeds, mortgages, and bill of sale Depreciation schedules Duplicate deposit slips Electric fund transfer documents Employment applications Expense analyses/expense distribution schedules Financial statements – year old Grant Records Insurance policies (expired) Insurance records, current accident reports, claims, policies, etc. Internal audit reports Inventories of products, materials and supplies Invoices (to customers, from vendors) Job descriptions Medical records – Adults Medical records – Minors Minute books, bylaws and charter OSHA log Payroll records and summaries Personnel files (terminated employees) Retirement and pension records Tax exempt application and determination letter Tax returns and worksheets Timesheets Trademark registrations and copyrights Workman’s compensation documents Withholding tax statements 23 Permanently 7 years Permanently Permanently 3 years 7 years 3 years 7 years Permanently 7 years 3 years Permanently 3 years 7 years 7 years 3 years 7 years 7 years after majority Permanently 7 years 7 years 7 years Permanently Permanently Permanently 7 years Permanently 10 years 7 years P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Political Activity activity. The clinic is a non-profit organization and as such is limited from participating in political Procedure: 1. The Clinic and its staff may not endorse candidates for political office. 2. The Clinic may distribute voters guides as long as the guides are non-partisan and contain no editorial opinion that would imply approval or disapproval of candidates. 3. The Clinic will not give or sell its mailing list to political candidates or causes. 4. The Center may do some lobbying for legislation, but it cannot exceed 5% of its time, energy or resources. 24 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Donor Mailing Lists The Clinic shall protect its donor mailing list. Procedure: 1. Under no circumstances may the donor mailing list be given to anyone outside of those who may need it to do their work for the Clinic. 2. The donor mailing list shall be secured by password in the Clinic’s computer system. 3. Anyone requesting to be removed from the list shall be removed immediately. 25 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Insurance The Clinic shall ensure that it has adequate insurance coverage to protect itself and all its staff and volunteers from liability. Procedure: 1. The CEO shall be responsible for acquiring the insurance for the clinic, which shall include professional liability, general liability, workman’s compensation and any other insurance the Board directs him/her to obtain. 2. Insurance coverage shall be reviewed annually. 26 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Board Review of Form 990 The Board of Directors of the Alpha Center must review the annual Form 990 information tax return prior to filing. Procedure: A qualified and authorized person shall complete the annual Form 990 informational return under the direction of the Treasurer. The return shall be reviewed by the Executive Director and Treasurer and then presented to all board members either via e-mail or by paper copy prior to its filing with the IRS. At the next board meeting, the Treasurer may review the return with the Board. 27 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Public Disclosure of Corporate Documents The Alpha Center’s Form 1023 (Application for Tax-Exempt Status) and Forms 990 (Informational Tax Returns) must be made available for public inspection and copying upon request. Procedure: The Form 1023 application to the IRS and Form 990 for the previous three years shall be available for inspection by the public during normal office hours. The names and addresses of contributors on Schedule B shall be redacted in the form that is made available to the public. If someone from the public requests a copy of Form 990, they shall be referred to www.guidestar.com where the center’s Treasurer has confirmed it to be widely distributed. Otherwise, copies will be provided for a fee of $1.00 per page plus postage, if any. Other corporate documents, such as bylaws, minutes, financials and policies and procedures shall be maintained as internal documents and shall not be made available to the general public, unless for a business reason as determined by the Executive Director and approved by the Board of Directors. 28 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Regulatory Filings The Clinic shall assure that all regulatory filings are done timely and appropriately. Procedure: 1. The CEO is responsible to make sure that all regulatory filings are performed timely and appropriately. 2. Such filings include: tax returns, state reports, CLIA reports, OSHA reports, employment reports, charitable permits, business permits, etc. 29 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Advertising The Clinic shall always advertise truthfully and fairly the services it provides. Procedure: 1. The CEO must approve all advertising prior to being placed. 2. Advertising shall not occur under the headings “Abortion Services” or “Birth Control”. 30 P O L I C Y A N D P R O C E D U R E M A N U A L Chapter 3 Client Services 31 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Scope of Services Alpha Center shall provide to the public free unplanned pregnancy options-counseling, support, assistance, education, and post-abortion support. Medical services shall also be free and shall include: pregnancy testing, pregnancy verification, sexually transmitted disease testing and treatment, and ultrasound confirmation of viable pregnancy. Clients will be given referrals and resources as needed. Alpha Center does not discriminate against anyone on the basis of sex, race, color, ancestry, religious creed, national origin, physical disability (including HIV/AIDS) mental disability, medical condition, age or marital status. All donations received are used to minister to clients regardless of any decision regarding the pregnancy. Thus, any financial support received directly from a client in no way represents compensation for services rendered or decisions reached by the client. There is to be no preference given to any one on the basis of color, religion, age, marital status, or her decision regarding her pregnancy. Everyone is promised confidentiality except when required otherwise by law. These issues will be discussed with the Executive Director or designee and the client when appropriate. Alpha Center staff will provide each woman with support so she can make the best choice for herself and her unborn child. If requested, we will make services available to her partner/husband, and her parents. We will continue to network with other support service organizations in the community, as well as similar groups elsewhere in the country, in order to offer the best care to our clients. The client may terminate services at any time. The Center may terminate services at any time and provide the client with adequate referrals as needed. This policy shall be made available to patients upon request. 32 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Telephone Guidelines Staff and volunteers shall be committed to answering all phone calls in a professional manner and with integrity at all times. 1) Use your most professional voice. Answer, “Alpha Center, this is (your first name). May I help you?” 2) Be straightforward about the services offered by Alpha Center. Inform the caller that the clinic offers free pregnancy testing, information regarding pregnancy options, initial medical consultation, limited ultrasound services, sexually transmitted disease testing and limited treatment, and practical assistance. 3) If you sense that the caller is interested in an abortion, always tell him/her that Alpha Center does not perform or refer for abortions. 4) Answer questions in an honest and straightforward manner. If the answer to a question is unknown, offer to have someone from the clinic get back to them with the correct information. 5) If anyone calls with inquiries beyond those related to client services, offer to have a staff member return the call, giving the staff member a detailed message regarding the nature of the call. Do not promise a specific time or day when the call will be returned. 6) If a phone call comes in for a volunteer or staff member who is unavailable, take a message and get a phone number where the call may be returned. Never give out a volunteer or staff member’s phone number, address or last name without permission. Relay the message to the person right away, leaving a message on voicemail, or pass the message on to another individual that can try to reach them later. If you determine that there is a sense of urgency regarding the callers need, offer to call him/her back yourself if you cannot reach the individual. Do not offer to return calls from media, attorneys or their representatives, social workers, etc. 7) When leaving a message regarding a client on a volunteer/staff member’s answering machine, leave only the clients first name to protect her privacy. (Don’t leave her phone number on a machine.) Your message should follow this pattern: “A Volunteer/staff’s name, this is (your name) from Alpha Center. Your client, Susie, called at 6:00 p.m. and wants you to call her as soon as possible. Call the clinic if you need her phone number. Thanks.” 8) Write down ALL client-related messages, along with the date, time, and your initials. There should be no exceptions to this. Then, contact the appropriate person as soon as possible. 9) Do not give out medical advice unless you are a part of the Alpha Center medical team. Callers with concerns/questions not appropriate for our services should be encouraged to contact their primary care provider or other medical service, including callers with questions about medication use in pregnancy. For emergent medical needs, see the “Emergencies” policy. 10) If client calls about medication and pregnancy, refer the caller to the physician who prescribed the medication. If caller is unable to call that physician, tell her to call her primary physician, or, if she is unable to reach her primary physician, to call her pharmacist. 11) When making appointments, follow the “Ultrasound/Medical Exam Appointments” and/or “Medical Appointments without a Physician on Site” policies. 12) Do not breach client confidentiality except as required by law. See “Confidentiality” policy. 33 P O L I C Y A N D P R O C E D U R E M A N U A L 13) Be sensitive to those who seem emotionally distressed, and do not allow yourself to be drawn into an argument with callers. 14) If you get a call from a troubled individual who expresses the intent to harm him/herself or others, stay on the phone and follow the guidelines in the “Confidentiality”, “Suicide reporting/Assessing Risk Factors” and “Child Abuse Reporting” policies. 15) Always use the “hold button” anytime you set the phone down. 16) Accept all collect calls. 34 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Client Follow-up Clients will be required to sign a consent that states whether or not a representative from the clinic may contact them. Client follow-up is an essential component of the ministry of Alpha Center that could provide crucial opportunity for continued ministry. The RN is responsible for initiating follow-up with her clients. All follow-up should be documented in the client’s file. Client follow-up is to be made only if client has permitted follow –up by signing release on Client Intake Form. The Alpha Center staff nurse or medical personnel should make at least three attempts to contact client. If the test was positive, contact should be made within four to five weeks to follow up and to document that client has started prenatal care. If she is abortion-minded, follow up in 24-72 hours. If the client is still abortion-minded/undecided following ultrasound, the counselor should follow-up within 24-72 hours. These follow-up calls communicate that you care. They should never be invasive or pushy. Remember to always re-state that you support them and care about them. TELEPHONE FOLLOW-UP PROCEDURE: 1) Be very discreet and confidential when attempting to reach a client. 2) Identify yourself to the client by first name only and make no mention of how you know the client until you are sure that you are speaking to the client. 3) If another person answers the phone and asks who you are, you may give your first name, or opt to remain anonymous, explaining that you will call back another time. 4) NEVER identify the name of the Clinic to the family/roommates of the client.In order to be sensitive to the client's surroundings, ask her if it is a good time to talk when you reach her. 5) Be gentle, but direct. Do not be afraid to ask if she has reached a decision regarding the pregnancy. 6) Demonstrate that you care by asking the client relevant questions, such as "Have you started prenatal care yet?” "How did your parents respond when you told them you were pregnant?" or "How is school going?"). 7) Document follow-up calls in the client’s file, including attempts at contact and written correspondence. FOLLOW-UP APPOINTMENTS: Follow-up appointments should be purposeful. Make sure that the client knows the purpose of the appointment and the value of maintaining contact with Alpha Center. The registered nurse is not expected to be an expert in all areas, but can offer the client simple, common-sense instruction. When the registered nurse reaches her/his limit in a particular area, then a referral to an outside agency is appropriate. Possible follow-up topics include: a) Identity in Christ or Gift Wrapped by God Bible study b) Ultrasound c) Adoption Education (literature, referrals) d) Earn While You Learn Mentor programs 35 P O L I C Y A N D P R O C E D U R E M A N U A L CORRESPONDENCE WITH CLIENTS: Note cards and baby congratulation cards are available at the Alpha Center for you to use in client correspondence. 1. Include photo copy of correspondence; letter, note card or email and place in client’s file 36 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Offsite Client Contact All staff and volunteers who engage in offsite client interactions will conduct themselves in an appropriate manner and in accordance with all guidelines that would otherwise be applicable to onsite interactions with clients. 37 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Admission to Clinic Clients may be scheduled for clinic services by: a) Making a telephone appointment. Procedure: 1) When a client comes into the clinic, the individual will be greeted by the receptionist and signed in. 2) The client will meet with a registered nurse for assessment and the RN will fill out the appropriate form. (Pregnancy Test) a) For Pregnancy test clients, a pregnancy test will be completed by a registered nurse. 3) The client for STD testing will meet with a nurse for assessment and the nurse will follow appropriate procedures according to the STD policy and procedure manual. For Pregnancy Test Release Form A, Initial Visit Form B, Client Contact Form C, and Pregnancy Retest Form TA: see appendix 38 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Freedom of Access The Alpha Center holds the policy that any client is free to leave the center at any time. This policy is communicated to each client through all appropriate means; including proper furniture placement, media disclosures, and gracious and prompt cessation of her/his session upon verbal communication of a client’s will to leave the Center. 39 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Confidentiality A client’s confidentiality must be respected at all times, except as required by law. Commitment to confidentiality is highly valued and is promised to clients in advertising literature. Therefore, it is incumbent upon the staff to honor that commitment. Thus, no information will be given to any other individual, group or entity without the written consent of the client. 1) Disclosure of private information by and between Alpha Center volunteers and/or employees will occur only as necessary to carry out job functions. Communication of detailed information will be limited to those within the ministry who are directly involved with client services. Information concerning clients should never be revealed to anyone outside the ministry. 2) There are certain situations where concern for safety and welfare of individuals may over-ride the standard of confidentiality. This includes: A client who is homicidal; A client who is suicidal; A client who is being abusive or neglectful to a minor or dependent adult (developmentally or physically disabled or frail) A minor client or a dependent adult who is being abused or neglected A client involved in statutory rape In these particular cases, the staff will inform the client of the obligation of Alpha Center to notify their supervisor and the proper authorities. After the session, the staff will take the necessary steps to insure that the requirements for Alpha Center are met. (See “Suicide: Assessing Risk Factors”, “Suicide Reporting,” “Child Abuse Reporting,” and “Statutory Rape Reporting” in the Policy and Procedure Manual for warning signs and assessment questions for determining suicide/abuse/neglect.) 3) When information is sought by a source outside of Alpha Center, a “Release of Information” form must be signed by the client. This must be done prior to the disclosure of any information, including the fact that an individual is a client of Alpha Center. (In cases of emergency, after consultation with the supervisor, disclosure of the fact that an individual is not a client is permissible.) No confidential information will be released to anyone over the telephone, including the client. The correct response for an employee/volunteer is, "Due to confidentiality, I cannot verify that the client has ever been seen or treated at the Alpha Center, nor can I tell you that the requested records are on file." 4) In the event that a court order to release client information is received, the supervisor must be notified. 5) Staff will not initiate contact with a potential client at the request of a third party. 40 P O L I C Y A N D P R O C E D U R E M A N U A L 6) Registered nurses and staff will chart interactions related to the release of client information in the client’s medical record. For Confidentiality Information Agreement, Form NA: see appendix 41 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Disclaimer Form Every client will be required to sign a disclaimer form that clearly describes the scopes of services provided by the Clinic. Procedure: 1. Client will be provided description of Alpha Center service and disclaimer to sign. 2. The client will be instructed to read the form, describing the scopes of services of the Clinic. 3. The client will then be instructed to sign the disclaimer form, and to legibly print their name In the space provided on the form. 4. Upon entering the counseling room, the client will hand the form to the registered nurse. 5. The registered nurse will check the form for the appropriate client signature and then the registered nurse will also sign the form. 42 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Conflicts of Interest All registered nurses and other staff members who act as advisors will avoid any conflict of interest or appearance therof between her responsibility to promote the client’s best interests and her personal relationship with anyone else related to or affecting the client’s circumstances. Procedure: 1. If at any time during an RN’s or other staff member’s (“staff member”) support services to a client, the staff member realizes that she has a personal relationship with anyone else related to or affecting the client’s circumstances, the staff member will immediately end her counseling of or support services to the client, and explain to the client that such a personal relationship potentially presents a conflict of interest for the staff member to continue the client’s counseling service. 2. Any such substitution will be documented in the client’s Clinic records, including an explanation of the reasons for the substitution. 43 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Counseling Alpha Center medical staff and volunteer mentor’s are to provide medical services and education at the center facility and under the direction of the Executive Director. Pregnancy options education sessions are not to take place off the premises. Male staff and volunteers will not meet with female clients. 44 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Client Education Clients will be offered options education regarding pregnancy. Some topics discussed are parenting, adoption, abortion, nutrition, fetal development, prenatal care, sexually transmitted infections etc. This information is available through verbal explanations, literature, video, and visual aids. Procedure: 1) The educational needs of the client will be assessed by the nurse who are directly involved with the client. 2) Education may be given to the client in the areas of: Prevention: Abortion/adoption/parenting education, pregnancy and sexually transmitted infections, abstinence, medical or physical complications, community resources and referrals. Health Maintenance: Anti-smoking and substance abuse information, nutrition, exercise. Therapeutic: Prenatal care: The following topics are recommended. However, medical staff is not restricted to these topics if additional needs are identified. a) Verification of pregnancy test b) Get permission to contact by phone (explain why) c) Ultrasound procedure for abortion minded/vulnerable d) Pregnancy symptoms e) Signs and symptoms of a miscarriage f) Estimated due date g) Fetal development h) Good, healthy habits: nutrition, danger of smoking, drinking, drugs, Preventing Premature Birth and Low Birth Weight Babies” i) Pregnancy risk factors j) Pregnancy comfort measures k) Prenatal vitamins l) Referral sheet for Poudre Valley Prenatal, Salud Clinic, Woman Care 3) Educational information, such as handouts, brochures, videos, etc., will be approved by the medical director, prior to clinic personnel use. 4) All educational needs and offerings will be documented in the client's file. 45 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Post Abortion Counseling and Education Ministry - PACE Post Abortion Counseling and Education (PACE) is a ministry of the Alpha Center. The Alpha Center PACE Coordinator and facilitators function under the authority of the Alpha Center Executive Director and Alpha Center Board of Directors. Procedure: The Alpha Center provides a free confidential Bible study to men and women seeking support after making an abortion decision in their lives. Support groups are available in either an 11 week group (for men & women) or weekend retreat format, (for women only). The Biblically based support groups are led by facilitators trained under the direction of the PACE Coordinator, using “The Peer Counselor Training Manual” by Angie Cote’ and Teri Reisser. The Bible study workbook used is Linda Cochrane’s Forgiven and Set Free study for women or Healing a Father’s Heart for men. Men and women interested in participating in a PACE group complete a PACE Intake packet which includes: Client Personal Abortion & Mental Health History Questionnaire Contract and Disclaimer Pre-lesson for Bible study participant How Do I Know Where I need Healing? Consent to release and obtain information if client is under care of Licensed Therapist. The PACE Coordinator meets with each participant to review completed PACE Intake packet prior to group placement. Subsequent placement into an 11 week group or weekend retreat format is based upon evaluation of PACE intake packet and assessing need for professional counseling. Referral for professional counseling will be made, when needed to a licensed therapist who is familiar with the PACE program. Group assignment is fulfilled when client obtains signed consent from licensed therapist recommending participant for group placement. Consent to obtain and release information is signed by participant, PACE Coordinator /facilitator and licensed therapist. Policy and Procedures relating to: Offsite Participant Contact Confidentiality Disclaimer Form Participant Education Child Abuse / Sex Offences Abuse and Prevention Policy Suicide Reporting / Assessing Risk Factors (Items are addressed separately in Alpha Center Policy and Procedure Manual.) 46 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Referrals/Resource Manual The Clinic shall maintain a referral and resource manual for the benefit of its patients. This manual shall contain resources in the community for assistance in meeting typical patient needs. Procedure: 1. Each person who contacts the clinic, whether by phone call or in person, shall be assessed for their need for a referral(s) to another organization, agency or healthcare provider. 2. Client’s who are in need of insurance will be provided a Pregnancy Verification for positive pregnancy test and referrals to Larimer County Health Department, Poudre Valley Prenatal Services and or Salud Clinic. 3. Alpha Center staff are to become familiar with the resource and referral list. Only those referrals and resources that have been verified as active shall be included in the list . 47 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Birth Control Health issues relevant to various forms of birth control may be addressed with single and married individuals by medical staff or may be referred to a medical professional. Approved informational brochures and bulletins may be given. 1) When discussing the topic of birth control with singles, RN will emphasize the value of chastity. The Alpha Center will not refer single individuals for contraceptive services. 2) When a married client requests contraceptive services, that individual will be referred to a physician. 48 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Media All media requests will be referred to the Alpha Center Executive Director. Procedure: Explain to those with media inquiries that the Executive Director handles all media requests. If the Executive Director is not at Alpha Center, provide the caller with the Executive’s name and cell phone number. Always refrain from answering any questions from media representatives. If pressured to give your personal opinion on a matter, “independent of acting as a representative of Alpha Center” or “off the record,” please do not do so. 49 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Release for Publication Volunteers and staff are encouraged to take pictures of clients and their babies for Alpha Center publications. A signed photo release form must accompany photos and testimonies of the clients. A copy of the release form should be placed in the client’s file. The text of the release form will read as follows: Release for Publication: I hereby consent to the use of a photo of myself and/or my baby and the publication of my story by the Alpha Center of Fort Collins, Colorado. I hereby give permission for unlimited publication of the story of my pregnancy and how the center helped me. I agree to waive any and all rights, claims, and actions that I and/or my baby may have against The Alpha Center arising from the publication and use of my story and photographs. I hereby release The Alpha Center, and any of its associated or affiliated offices, their directors, officers, agents, employees, and volunteers from all claims of every kind on account of such use. Date: Signature: For Release for Publication Form G, see appendix 50 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Adoption Alpha Center recognizes the validity of adoption as a positive alternative to abortion, but may not present a bias toward adoption when compared to other life-affirming alternatives. Alpha Center will not initiate or facilitate adoptions. Adoption information and referrals will be provided. No outside adoption agency representative or adoption attorney shall be allowed to consult on site at the Center. PROCEDURE: 1) When appropriate, a discussion about adoption will be approached by the registered nurse or adoption specialist. 2) The RN/AS will communicate to clients that Alpha Center is not biased toward or against adoption, but presents it as one of their choices. 3) The RN/AS will offer adoption referrals when appropriate and will provide the client with three referrals. 4) All Clients who receive adoption information and or referrals will sign a Statement of Policy on Adoption. A copy will be given to them and a copy will be in their file (Form M). 5) It is never appropriate for the Alpha Center staff to offer to facilitate an adoption or to suggest personal friends or contacts as potential adoptive families. 51 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Minors In Colorado, a minor is anyone under age 18. Under current law, a minor client has been given the legal ability to seek birth control information, procedures and supplies without parental knowledge or consent. A minor client has also been given the ability to obtain an abortion without parental consent, though parental notification may be required. Therefore, a minor can receive initial testing and options education from Alpha Center without Alpha Center contacting his/her parents, if that is the minor’s wish and if Alpha Center is willing to provide services under that restriction. If the minor client decides to carry her pregnancy and maintains relationship with the AC, she should be encouraged to involve her parents in her circumstances as it is crucial to the minor to have parental support to make a viable plan that does not include abortion. If the minor is genuinely concerned that her parents would become abusive she should be advised to contact authorities. A parent may not force a minor to abort. In fact, a forced abortion would constitute child abuse. In the event that parents are forcing their minor to obtain an abortion, you should immediately: 1) contact legal counsel who should talk to the minor and plan a legal course of action. OR 2) call Child Protective Services, report the abusive treatment and urge them to intervene. See CHILD ABUSE POLICY for further information on reporting requirements in the event of abuse or neglect. In accordance with statute 25-4-402 Section 4 the Alpha Center may provide STD/STI testing and treatment to minors: 25-4-402. Venereal cases shall be reported – physician’s immunity. (1) Any physician, intern, or other person who makes a diagnosis in, prescribes for, or treats a case of venereal disease and any superintendant or manager of a state, county, or city hospital, dispensary, sanitarium or charitable or penal institution in which there is a case of venereal disease shall make a report of such case to the health authorities in accordance with the provisions of section 25-1122 (1). (2) (Deleted by amendment, L. 91, p. 945, & 4, effective may 6, 1991.) (3) Reports of venereal disease shall be made in accordance with the requirements set forth in section 25-1-122 (1). (4) Any physician, upon consultation by a minor as a patient and with the consent of such minor patient, may make a diagnostic examination for venereal disease and may prescribe for and treat such minor patient for venereal disease without the consent of or notification to the parent or guardian 52 P O L I C Y A N D P R O C E D U R E M A N U A L of such minor patient or to any other person having custody of or parental responsibilities with respect to such minor patient. In any such case, the physician shall incur no civil or criminal liability by reason of having made such diagnostic examination or rendered such treatment. But such immunity shall not apply to any negligent acts or omissions. Alpha Center staff and employees are not permitted to transport clients. 53 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Assisting Minors Who Refuse Abortion The goal for staff and volunteers at the Alpha Center is for parents and children to work together through the challenges presented in unplanned pregnancies whenever possible. In instances where a minor who is pregnant refuses an abortion that a parent desires, the client and her parent, when possible will be informed of the legal right of the pregnant woman to refuse an abortion. Steps will then be taken to address the barriers that the minor child and her family may face with practical solutions. No minor client may be placed in housing, or harbored in any way without parental consent. 54 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Child Abuse / Sex Offences It is a crime for a suspect to have consensual sex with the victim if: 1) The victim is under 15 years of age PLUS the suspect is at least 4 years older. 2) The victim is 15 or 16 years of age PLUS the suspect is at least 10 years older. 3) The victim is under 18 years of age PLUS the suspect is at least 4 years older PLUS the suspect is in a “position of trust” (school teacher, counselor, babysitter, parent, step-parent, etc…) If the sexual contact is by a blood relative or a step-parent, the suspect can be charged with incest regardless of the suspect’s or victim’s ages. Child abuse can be charged for abuse on a child 15 years of age or younger (a 16 or 17 year old cannot be the victim of child abuse, but we can look at assault charges). To report a sexual abuse, or if you have any questions, please call 24-hour confidential reporting line: (970) 221-6540, or 970-498-6990 If client is under 18 and statutory rape occurred during time that fits above description the report must still be made. Example: Girl is 15. Partner is 20. However, if you discover they were sexually active when she was 14 and he was 19, the report must be made. 55 P O L I C Y A N D P R O C E D U R E M A N U A L Abuse and Prevention Policy Policy Alpha Center affirms the following statement: “Human beings are made in the image of God; therefore all humankind has intrinsic value and significance from conception to natural death. We affirm the sacredness and dignity of all people: male and female, unborn, aged, physically challenged, mentally handicapped and any person who is devalued – “the least of these” – in our society.” For this reason it is our policy to be committed to providing a safe environment for all human beings and to declaring a zero tolerance for abuse, harassment or neglect of clients and their children by any employee or volunteer. Therefore, we have a spiritual, moral, and legal obligation to provide a safe environment for children, clients, staff and volunteers participating in Alpha Center programs. The declared purpose of this policy is to prevent abuse and harm to clients and their children who access our programs and services, and to protect our staff and volunteers from false or wrongful accusations. Definitions of Abuse Abuse that causes harm is the corrupt, improper, practice and maltreatment of human beings physically, emotionally, and sexually. Abuse can involve the misuse of power, which can take place when people take advantage of a position of authority they have over vulnerable people. Vulnerable people include adults or children with physical or mental disabilities. The definition of abuse should include the neglect of children, harassment, and improper touching of children. Incidence of Abuse in the United States The National Child Abuse and Neglect Data System (NCANDS) reported an estimated 1,400 child fatalities in 2002. This translates to a rate of 1.98 children per 100,000 children in the general population. NCANDS defines “child fatality” as the death of a child causes by an injury resulting from abuse or neglect, or where abuse or neglect were contributing factors. Many researchers and practioners believe child fatalities due to abuse and neglect are underreported. States’ definitions of key terms such as “child homicide”, “abuse”, and “neglect” vary (therefore, so do the numbers and types of child fatalities they report). In addition, some deaths officially labeled as accidents, child homicides, and/or Sudden Infant Death Syndrome (SIDS) might be attributed to child abuse or neglect if more comprehensive investigations were conducted or if there was more consensus in the coding of abuse on death certificates. Recent studies in Colorado and North Carolina have estimated as many as 50 to 60 percent of deaths resulting from abuse or neglect are not recorded (Crume, DiGuiseppi, Byers, Sirotnak, 56 P O L I C Y A N D P R O C E D U R E M A N U A L Garrett, 2002; Herman-Giddens, Brown, Verbiest, Carlson, Hooten, et al., 1999). These studies indicate that neglect is the most underrecorded form of fatal maltreatment. Child Abuse and Neglect Fatalities: Statistics and Interventions Author(s): National Clearinghouse on Child Abuse and Neglect Information. Year published: 2004 Statistics take from Child Maltreatment 2002 (U.S. Department of Heath and Human Services, 2004). Physical Abuse is using physical force or action that results, or could result in injury to a child or youth. It is more than reasonable discipline. Sometimes injury is caused by over discipline. Injuring a child or youth is not acceptable, regardless or differing cultural standards on discipline. Bruising, odd burns, jumpy behavior, may be indications that a child or youth is physically abused. Emotional Abuse is a pattern of hurting a child’s feelings to the point of damaging their selfrespect. It indicates verbal attacks on the child, insults, humiliation, or rejection. A child or youth who is emotionally harmed may demonstrate severe anxiety, depression and withdrawal, self destructive or aggressive behavior. Sexual Abuse occurs when someone uses a child or youth for sexual stimulation or gratification. Sexual activity between children or youth may also be sexual abuse if older or more powerful children or youth take sexual advantage of those younger or less powerful. The seven forms of sexual abuse include the following: 1. Sexual Activity Completed: Included oral, vaginal, or anal sexual activities. 2. Sexual Activity Completed: Included attempts to have oral, vaginal, or anal sexual activities. 3. Touching / Fondling Genitals: Sexual activity involved touching/fondling genitals. 4. Adult Exposing Genitals to Child: Sexual activity consisted of exposure to genitals. 5. Sexual Exploitation – Involved in Prostitution or Pornography: Included situation in which an adult exploited a child for the purposes of financial gain or other profit. 6. Sexual Harassment: Included proposition, encouragement, or suggestion of a sexual nature. 7. Voyeurism: Included activities in which a child was encouraged to exhibit him/herself for the sexual gratification of the alleged perpetrator. Physical signs may include: Laceration and bruises Nightmares Irritation, pain or injury to the genital area Difficulty with urination Discomfort when sitting Torn or bloody underclothing Diagnosis of a sexually transmitted disease Behavioral signs may include: Anxiety when approaching certain persons 57 P O L I C Y A N D P R O C E D U R E M A N U A L Nervous or hostile behavior towards adults Sexual self-consciousness “Acting-out” sexual behavior Withdrawal Neglect occurs when a child’s parents or other caregivers are not providing the requisites of a child’s emotional, psychological, and physical development. Unlike abuse, which is incident specific, neglect often involves chronic situations that are not as easily identified. All provincial and territorial child welfare statutes include neglect or some type of references to acts of omission as grounds for investigation, which include the following eight subtypes: 1. Failure to supervise or protect leading to physical harm 2. Failure to supervise or protect leading to sexual abuse. 3. Physical neglect of food, clothing, shelter. 4. Medical neglect. 5. Failure to provide treatment for mental and emotional or developmental problems. 6. Permitting maladaptive behavior. 7. Abandonment/ refusal of custody 8. Educational neglect. Procedure A) Abuse, is further defined in the following statements provided by the Children Family Services Act (“CFSA”) as well as proper for reporting process. 1. The child suffering physical harm, inflicted by the person having charge of the child or caused by or resulting from that person’s, i. ii. failure to adequately care for, provide for, supervise or protect the child, or pattern of neglect in caring for, providing for, supervising or protecting the child. 2. There is a risk that the child is likely to suffer physical harm inflicted by the person having charge of the child or caused by resulting from that person’s. i. ii. failure to adequately care for, provide for, supervise or protect the child, or pattern of neglect in caring for, providing for, supervising or protecting the child. 3. The child has been sexually molested or sexually exploitated, by the person having charge of the child or by another person where the person having charge of the 58 P O L I C Y A N D P R O C E D U R E M A N U A L child knows or should know of the possibility of sexual molestation or sexual exploitation, and fails to protect the child. 4. There is a risk that the child is likely to be sexually molested or sexually exploited as described in paragraph 3. 5. The child requires medical treatment to cure, prevent or alleviate physical harm or suffering and the child’s parent or the person having charge of the child does not provide, or refuses or is unavailable or unable to consent, the treatment. 6. The child has suffered emotional harm, demonstrated by serious, i. ii. iii. iv. v. anxiety depression, withdrawal, self-destructive or aggressive behavior, or delayed development, and there are reasonable grounds to believe that the emotional harm suffered by the child results from the actions, failure to act or pattern of neglect on the part of the child’s parent or the person having charge of the child. 7. The child has suffered emotional harm of the kind describes in subparagraph I, ii, iii, iv or v of paragraph 6 and the child’s parent or the person having charge of the child does not provide, or refuses or is unavailable or unable to consent to, services or treatment to remedy or alleviate the harm. 8. There is a risk that the child is likely to suffer emotional harm of the kind described in subparagraph i, ii, iii, iv, v of paragraph 6 resulting from the actions, failure to act or pattern of neglect on the part of the child’s parent or the personal having charge of the child. 9. There is a risk that the child is likely to suffer emotional harm of the kind described in subparagraph i, ii, iii, iv or v of paragraph 6 and that the child’s parent or the person having charge of the child does not provide, or refuses or is unavailable or unable to consent to, services or treatment to prevent the harm. 10. The child suffers from a mental, emotional or developmental condition that, if not remedied, could seriously impair the child’s development and the child’s parent or the person having charge of the child does not provide, or refuses or is unavailable or unable to consent to, treatment to remedy or alleviate the condition. 11. The child has been abandoned, the child’s parent has died or is unavailable to exercise his or her custodial rights over the child and has not made adequate provision for the child’s care and custody, or the child is in a residential placement 59 P O L I C Y A N D P R O C E D U R E M A N U A L and the parent refuses or is unable or unwilling to resume the child’s care and custody. 12. The child is less than 12 years old and has killed or seriously injured another person or caused serious damage to another person’s property, services or treatment are necessary to prevent a recurrence and the child’s parent or the person having charge of the child does not provide, or refuses or is unavailable or unable to consent to, those services or treatment. The child is less than 12 years old and has on more than one occasion injured another person or caused loss or damage to another person’s property, with the encouragement of the person having charge of the child or because that person’s failure or inability to supervise. B. Ongoing duty to report The duty to report is an ongoing obligation. If a person has made a previous report about a child, and has additional reasonable grounds to suspect that a child is or may be in need of protection , that person must make a further report to a child’s aid society. C. Persons must report directly First the person who has the reasonable grounds to suspect that a child is or may be in need of protection must make the report directly to a children’s aid society. The person must not rely on anyone else to report on his or her behalf. Second, proper notes should be kept and the Executive Director should be notified immediately. It is also requested that the persons who suspect child abuse not only report it to the proper authorities as stated above, but also they must fill out a “Suspected Child Abuse” report form. (see appendix) D. What are “reasonable grounds to suspect”? You do not need to be sure that child is or may be in need of protection to make a report to a children’s aid society. “Reasonable grounds” are what an average person, given his or her training, background and experience, exercising normal and honest judgment, would suspect. E. Special responsibilities of professionals and officials Professional persons and officials have the same duty as any member of the public to report a suspicion that a child is in need of protection. The Act recognizes, however, that persons working closely with children have a special awareness of the signs of child abuse and neglect, and a particular responsibility to report their suspicions, and so makes it an offence to fail to report. 60 P O L I C Y A N D P R O C E D U R E M A N U A L Any professional or official who fails to report a suspicion that a child is or may be in need of protection, where the information on which that suspicion is based was obtained in the course of his or her professional or official duties, is liable on conviction to pay a fine. Persons who perform professional or official duties with respect to children include the following: health care professionals, including physicians, nurses, dentists, pharmacists, and psychologists; teachers, and school principals; social workers and family counselors; priests, rabbis, and other members of the clergy; operators or employees of day nurseries; youth and recreation workers (not volunteers); peace officers and coroners; solicitors; service providers and employees of service providers; and any other person who performs professional or official duties with respect to a child. This list sets out examples only. If your work involves children but is not listed above, you may still be considered to be a professional for purposes of the duty to report. If you are not sure whether you may be considered to be a professional for purposes of the duty to report, you should contact your local children’s aid society, professional association or regulatory body. F. Limitations of Professional Confidentiality The professional’s duty to report overrides the provisions of any other provincial statute, specifically, those provisions that would otherwise prohibit disclosure by the professional or official. That is, the professional must report that a child is or may be in need of protection even when the information is supposed to be confidential or privileged. (The only exception for “privileged” information is in the relationship between a solicitor and a client.) Policy for Screening In keeping with the above-declared policy of providing a safe environment for all human beings and a zero tolerance for abuse, we further add that Alpha Center adheres to the following screening process for all staff and volunteers that are in medium to high-risk positions. Low Risk- Volunteers who fulfill roles such as fundraising, property maintenance, general membership and board participation. Medium Risk- Staff and volunteers who are never alone with vulnerable clients and their children but who may have contact by virtue of their position or responsibilities. 61 P O L I C Y A N D P R O C E D U R E M A N U A L High Risk- Staff and volunteers who have opportunity to be alone with clients and or their children and who hold a position of power or trust. Procedure For all volunteers and staff in medium to high risk roles the following screening process must be adhered to by all Alpha Center staff. 1.) Targeted recruitment of volunteers and staff which would be individuals who sign the Statement of Faith, the Statement of Commitment, the Care Commitment and Statement of Abstinence when appropriate. 2.) Applicants need to have made a personal confession of Christ as their Savior for no less than a year and a minimum of at lease six months attendance at their local church 3.) Staff and volunteer applications used at all times 4.) Background and reference checks- all applicants must provide references 5.) References must be checked by director or appropriate staff 6.) When checking references, watch for patterns that may suggest negative behaviors such as repeats movement from church to church etc. 7.) Criminal/Police record checks 8.) Personal interviews- with either Executive Director, Nurse Manager or in the case of hiring director, personal interview would be done Board Executive 9.) Volunteer and Staff training- 20-25 hours, minimum of 2-3 weeks orientation, continued evaluation process to ensure proper adherence to Alpha Center policy and procedures manual available and accessible on site. Policy Responding to Allegations of Abuse All allegations of abuse or complaints of abuse must be responded to immediately in an appropriate manner wither by the director or executive member of the board of directors. Procedure 1. Must complete an incident report form (see appendix) 2. Satisfy statutory reporting obligations of child protective agency 3. Express your organization’s concern for the complainant and assure them of your commitment to assist in investigation as well as conducting your own investigation. 4. Assure of confidentiality of the complainant 5. Suspend alleged perpetrator 6. Refrain from admitting liability 62 P O L I C Y A N D P R O C E D U R E M A N U A L 7. Contact the necessary experts or professional required for specific situation Additional Operational Procedures To ensure the safety of Alpha Center clients and their children the following is a list of operational procedures and specific guides recommended by Care Net. 1) The Executive Director should handle reports of alleged abuse on part of staff or volunteer or the Board of Directors in case of alleged abuse on part of the director with input from National office. 2) The advice of an expert should be obtained whenever necessary. 3) Alpha Center discourages out-of-program or off-premises contact between clients and their children unless accompanied by a colleague. (Use scripture reference where Jesus sent them out in two) 4) Alpha Center prohibits the use of corporal punishment. 5) Alpha Center advises that all staff and volunteers avoid activities that could easily lead to allegations of abuse or harassment such as photos of children without signed consent of parent, vehicle transportation of client and children, ongoing counsel with female staff or volunteer without other staff present in building and having an open door policy in place. 6) Keep documentation of all staff and volunteers on file indefinitely (at least five years). 7) Incident reports which must be completed for all cases of suspected child abuse. 8) Premises of operations should adhere to municipal building code of health and safety. 9) Premises should have appropriate design of washroom facility, lock closets, and rooms when not is use while serving clients and with children. 10) Premises should ensure adequate lighting on the exterior and interior of the building. 11) Proper ongoing formal abuse prevention training, this can happen during initial training period and should continue on a regular basis, by educating staff and workers to recognize and identify the signs and symptoms of abuse and molestation. Policy on Harassment Harassment is defined as follows; to worry, to impede, and to annoy persistently to the point of causing fatigue and exhaustion. It is the policy of Alpha Center that physical, sexual, or emotional harassment of any type will not be tolerated. Harassment from a staff or volunteer will result in dismissal; harassment by client perpetrated on staff or volunteer will be reported to proper authority or agency. Guidelines No Counseling will take place unless there are two persons on the premises at all times. 63 P O L I C Y A N D P R O C E D U R E M A N U A L There is no place for counselors to be counseling those of the opposite sex, except when male counterpart comes with the woman seeking support options counseling. Policies and Procedures adapted from the Christian Association of Pregnancy Support Services (CAPSS) 64 P O L I C Y A N D P R O C E D U R E M A N U A L NIFLA Legal Tips Vol. IX No. 7 July 2002 Mandatory reporting of Child Abuse and Neglect As has been reported in the national media, a recently completed research project uncovered the fact that Planned Parenthood and National Abortion Federation clinics throughout the country have not been complying with mandatory abuse reporting statues, exposing themselves to criminal and civil liability. This has sparked many Pregnancy Resource Centers/ Clinics to review their own child abuse reporting policies and procedures to make sure they are in compliance with state law. (this has been done) All 50 states have passed some form of a mandatory child abuse and neglect reporting law in order to qualify for funding under the federal law, Child Abuse Prevention and Treatment Act (CAPTA) 42 U.S.C. 5101, et seq.. All states require certain professionals and institutions to report suspected child abuse, including health care providers and facilities of all types, mental health care providers of all types, teachers and other school personnel, social workers, day care providers and law enforcement personnel. A number of states have broad statues requiring “any person” to report. (ours is not this broad, but we feel obligated to report) Pregnancy Resource “Clinics” are most likely considered mandatory reporters in your state. The average Pregnancy Resource “Center,” however, is most probably not a mandatory reporter because of the lack of professionals employed therein. Even if your attorney finds that in your state your Center is not a mandatory reporter, you may still want to adopt the policy that you will report suspicions of abuse. This is something you will need to decide with your local attorney. A good resource for understanding the laws in this area is The National Clearinghouse on Child Abuse and Neglect Information which is legislatively mandated to maintain information on line about reporting statutes. The NCCA site contains an extensive library of PDF documents summarizing and comparing state child abuse protection and reporting laws. The statues-at-a-glance reports, and has information on reporting, issues in all 50 states. The Clearinghouse keeps its statutory complications up to date and puts them in concise plain-language format. Check out their website at: http://www.calib.com/nccanch/pubs/index.cfm It is imperative that your Center review its policy and procedure in this regard and make sure it complies with state law. One resource might be to directly call the child abuse-reporting agency in your state, sometimes called Child Protective Services, and ask them if they have printed guidelines regarding the mandatory reporting laws. In the State of California, the Department of Social Services publishes guidelines for mandatory reporters, which is very helpful, and probably many other states offer the same thing. The other helpful service that your state’s Child Protective Services might provide, as they do in California, is that you can 65 P O L I C Y A N D P R O C E D U R E M A N U A L call their hotline number anonymously and give the facts of the situation you are dealing with and ask if it is reportable. One point of clarification that NIFLA wants to emphasize is that statutory rape is not always reportable as child abuse. Sometimes an act of sexual relations between two minors might qualify for one of them to be criminally prosecuted for statutory rape, but the same sexual relations would not be considered child abuse, most likely because the two involved were close enough in age. For example in Florida, statutory rape is specifically excluded from the child abuse reporting laws. NIFLA is going to be researching and preparing a brochure on the child abuse reporting laws in the 50 states. In the meantime, if you would like assistance in interpreting the law in your state, please do not hesitate to contact our General Counsel, Anne O’Connor at (732) 996-8079 or via email at [email protected]. The following is a sample Child Abuse Reporting Policy and Procedure based on the State of California’s law. You should not just copy it verbatim for your center, but rather you should have your local attorney review the laws in your state and make recommendations regarding your policy and procedure. POLICY: CHILD ABUSE REPORTING The Pregnancy Help Medical Clinic is obligated to report known or suspected cases of abuse (sexual, physical, and mental) and neglect of clients and those associated with clients. The Clinic Director or other authorized personnel shall determine the status of the incident and in compliance with state law will report the incident to the proper authorities within the prescribed time period. Child abuse may be any act of omission or commission that endangers or impairs a child’s physical or emotional health and development. Sexual abuse should be suspected if the following is observed: Venereal disease of the eyes, mouth, anus or genitals of a child. A pregnant girl under 18 who is evasive about her partner. Sexual activity with parent or family member. A minor under 14 reporting sexual activity. PROCEDURES: Staff and volunteers shall immediately report to the Clinic Director any suspicion or allegation of abuse or neglect of the patient or a sibling or a child of the patient, or other child or adult dependent person in the care of the patient. A report shall be made by the Director, or by the volunteer under the supervision of the Director. A report will not be made by the volunteer independent of supervision from the Director or designee. Reports shall be made by calling Child Protective Services. A written report shall be made on the reporting forms provided by Child Protective Services and mailed within the prescribed time period. A copy of the completed reporting form shall be placed in the patient’s file. 66 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Child Abuse Reporting The ALPHA CENTER is obligated to report known or suspected cases of child abuse (sexual, physical and mental) or neglect of clients or those persons who are associated with clients who are under the age of 18. The volunteer should consult with the Executive Director, who shall report the incident to the proper authorities in compliance with state law within the prescribed time period. Child abuse may be any act of omission or commission that endangers or impairs a child's physical or emotional health and development. Sexual abuse should be suspected if the following is observed: 1) Venereal disease of the eyes, mouth, anus or genitals of a child. 2) A pregnant girl under 18 who is evasive about her partner. 3) Sexual activity with parent or family member. 4) “A minor under 17 reporting sexual activity. It is a crime, for a male to have sex with a female who is not his wife, even if it is consensual, if the female is under age 15 and the male is at least four years older than her, or if the female is age 15 or 16 and the male is at least 10 years older than her. Incest is a crime against any minor under age 18. Consensual sex with a minor under age 18 by someone in a position of trust (adult family member, teacher, scout leader, etc.) is a crime, regardless of the age difference.” Procedures: 1) Staff and volunteers shall immediately report to the Executive Director any suspicion or allegation of abuse or neglect of the client, a sibling or child of the client, or any other child or adult dependent person in the care of the client. 2) A report shall be made by the Executive Director, or by the volunteer under the supervision of the Director. (A report will not be made by the volunteer independent of supervision from the Director.) Call Child Protective Services, 679-4490 to request a form. The written report shall be made on the form provided by Child Protective Services and mailed within the prescribed time period. 3) A copy of the completed reporting form shall be placed in the Client Medical Record. Note: There is no requirement to report any discovery of abuse or neglect that occurred during childhood, if it is discovered after the child has become an adult. (see exception in Child Abuse /Sex Offences Policy) However, if there is reasonable cause to believe other children, dependent adults (e.g. developmentally or physically disabled adults or frail elderly) may be at risk of abuse or neglect by the accused, the reporting requirements may apply. 67 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Suicide Reporting /Assessing Risk Factors Suicide Reporting Procedures: 1) All clients who mention the word suicide or indicate that they have had or are having any selfdestructive thoughts/intentions shall be referred to a professional counselor. A referral should be made regardless of how long ago the suicidal thought/action occurred. 2) The peer counselor should express concern: “I really care about you and don’t want you to do this.” If the caller does not appear to be in immediate danger, refer her/him to the Suicide Crisis Line or a professional. 3) If your contact with this person is over the phone and you suspect the caller has an imminent plan and the means to follow through with it, make every attempt to get the name, address, and phone number of where they are and have someone else call 911 immediately. If there is no one else available to assist you, stay on the line until the intensity subsides. Once this happens, make a verbal contract with the caller in which she/he agrees not to harm herself/himself until you call back. (SEE EXAMPLE) Then call 911 and give them the information. Call the caller back and stay on the phone until the authorities arrive. IMPORTANT: If the client is actively suicidal and has lethal means available, the volunteer must NOT hang up, even to call 911. Acute suicidality is a very intense emotional condition that the body cannot sustain for more than a few minutes (although it can return). The lay counselor should stay in constant contact with the client until the intensity can subside, rather than risk the few minutes of isolation while the client has lethal means in hand. In addition, the lay counselor should seek a reliable EXACT location, or a “No Harm” contract which she/he judges to be in good faith, prior to hanging up to seek help. 4) Consult with the Executive Director regarding a plan for the client. 5) Report the incident to the proper authorities if required The peer counselor shall document in the Client’s file all known or suspected cases of potential suicide, attempted suicide and all interaction including any contracts, verbal or written, and any referrals given. Assessing Suicide Risk Factors Warning Signs: 1) Verbal or written statements about her/his intention to die: “I’m going to kill myself”, “You won’t have to worry about me any longer”, “In case I don’t see you again, thanks for…”, “My family, everyone, so and so, the world would be better off if I weren’t around”, “I just can’t take it anymore”, “I just want to sleep and not wake up”. 2) Previous suicide attempt(s). 3) Exhibits or talks about feelings of worthlessness, helplessness and hopelessness. 68 P O L I C Y A N D P R O C E D U R E M A N U A L Questions to ask the person at risk: a) Have you thought about suicide? b) Have you thought about how you would do it? c) Do you have the means? (i.e. a gun, the pills, a rope) d) When do you plan to do it? e) Where do you plan to do it? f) What makes life not worth living? CONTRACTS: Whenever possible, engage the client/ caller in a contract. If your contact is in person, a written contract is preferable to a verbal one. (Remember a contract is not for the acutely suicidal. See above policy.) Sample Written Contract: I, (Client’s Name), promise that I will not hurt myself in the next (48 hours). I promise that I will call and talk with someone from the crisis line at (Roadhouse: 491-5744), (Suicide Resource Center: 635-9301), (Larimer County Center for Mental Health: 221-2114) if I feel like giving up. I will wait to hear from (Volunteer’s Name) within the next (12 hours) who will suggest a plan for help. Signed ________________________________________ Date __________________ Time _________________ Sample Verbal Contract: (for phone interactions, not for acute suicidality) “(Caller’s Name), I care about you and I want you to get some help. I want you to promise me that you will not hurt yourself in any way for at least (24 hours). Where is your (gun)? Point the barrel in a safe direction (away from you) and unload the bullets. Good. How are you doing now?” Stay with the client on the phone until the situation is diffused. Have her repeat her phone number and address for you. “Okay, I will call you back in a few minutes, stay by the phone. Do you promise not to hurt yourself? I want you to make a verbal contract with me that you call 911 if you feel like giving up before you hear back from me. Good. I will call you back in a few minutes.” 69 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Baby Supplies Receipt and Distribution Donations of appropriate baby supplies will be accepted and distributed to Alpha Center clients or to another distribution center. 1) All calls from individuals who want to donate items or who request baby supplies shall be directed to a knowledgeable staff member or volunteer. 2) Donations will be accepted according to criteria established by Alpha Center. 3) Eligibility of individuals requesting items will be screened according to criteria established by Alpha Center. 70 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Material Assistance Material assistance will be provided to current clients who have had a verification of pregnancy with the Alpha Center and have chosen to continue in relationship with the Alpha Center. Relationship accountability can be maintained by client participating in: Alpha Center Earn While You Learn mentor program Meeting with mentor or Alpha Center staff member for Biblical counseling Client must be searching for employment or training through resources provided Client must be seeking to complete education or GED Clients may receive two Wal-Mart gift cards to assist in purchasing diapers and formula. Assistance is provided once per month until the child is 2 years old. Client will be encouraged spiritually, offered prayer and when appropriate referred to church or Bible study. Client will also receive appropriate referrals to other community agencies depending on her needs. Client requesting financial assistance for rent, utilities, or emergency expenses will be evaluated by Nurse Manager and final decision will be made by the Executive Director. Money is never given directly to client but must be mailed directly to a company or landlord. The financial assistance is made once per year per client. Exceptions will be given individual consideration and final decision made by Executive Director. Clients must personally come in to the Alpha Center to receive assistance. Exceptions must be approved by the Nurse Manager or Executive Director. 71 P O L I C Y A N D P R O C E D U R E M A N U A L Chapter 4 Medical Services 72 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Pregnancy Testing Alpha Center offers a free pregnancy test to clients who request this service. Pregnancy testing appointments will be scheduled when registered nurses who can perform or oversee the testing are available on-site. PROCEDURE: 1) The client reads and signs the “Pregnancy Test Release” form. 2) The client provides a urine sample in a specimen cup. 3) The nurse performs the pregnancy test. 4) The nurse informs the client of the results. 5) If questioned regarding the accuracy of the test, read the statement that the manufacturer puts in the literature. Never say that the test is 100% accurate. 6) Regarding the test result, tell the client the following: a) We always recommend that the client see a physician at her earliest convenience regardless of the test results. If she does not have a physician, we can give her three medical referrals. b) If her test is negative, and she does not have her period within a week, we recommend that she return for a retest. c) If positive, the nurse will provide appropriate education. 7) Directly after the session, the test and urine sample should be disposed of properly. Gloves should always be worn during the disposal process. The pregnancy test should be completed in the bathroom. Urine should be flushed down the toilet. The specimen cup and gloves need to be disposed of in the designated container in the clinic. Disinfect the counter after each pregnancy test using gloves and proper disinfectant. PREGNANCY VERIFICATIONS: The Alpha Center shall provide verification of positive pregnancy tests results to any client who requests one. However a confirmation of pregnancy can only be given by a physician. 1) A nurse shall complete the “Pregnancy Test Verification” form. 2) The original will be given to the client and a copy will be placed in the client’s file. For Pregnancy Test Release Form A and Pregnancy Test Verification Form I, see appendix 73 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Ultrasound / Medical Exam Appointments The Alpha Center medical director has established the criteria for the performance of limited obstetrical ultrasound which adheres to the limited ultrasound guidelines prescribed by ACOG, the American College of Obstetricians, AIUM, the American Institute of Ultrasound in Medicine, and ACR, the American College of Radiology. The Alpha Center may provide first and second trimester limited obstetrical ultrasound exams to clients who are abortion-minded or abortion-vulnerable. The ultrasound is offered to confirm a viable intrauterine pregnancy and rule out a possible miscarriage. The ultrasound is performed by a licensed registered nurse with training and certification in limited obstetrical ultrasound. Procedure: 1) All ultrasound appointments must be made by a registered nurse trained in limited obstetrical ultrasound. 2) Exams/ultrasounds cannot determine viability earlier than 7 weeks from the first day of the client’s last menstrual period. This needs to be assessed when scheduling appointments. 3) Client’s requesting a pregnancy test for verification of pregnancy will be scheduled for a pregnancy test. 4) Following a positive pregnancy test, the abortion-minded/ abortion vulnerable client will be offered an ultrasound to confirm a viable intrauterine pregnancy and to rule a possible miscarriage. 5) Ultrasound consent and Medical History Intake will be reviewed with client and ultrasound consent signed by client prior to ultrasound. 6) If ultrasound findings are inconsistent with clients last menstrual period date, (LMP) Client will be: Referred to client’s personal private medical doctor or referred to Alpha Center medical director and medical staff at Rocky Mountain Family Physicians for follow up and evaluation of pregnancy. Client will be provided education on signs and symptoms of miscarriage and ectopic pregnancy. Signs and symptoms of miscarriage and ectopic pregnancy will be reviewed with client. 74 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Medical Appointments without a physician on site Any medical procedure requiring physician oversight will be done only if a verbal or standing order exists. Procedure: 1) When a standing or verbal order is carried out, the physician shall sign the client's Medical Record the next time he is in the clinic. 2) Standing orders will be signed by the Medical Director and will be filed in the "Standing Orders" file. 75 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Emergency Attention TELEPHONE CALLS: Referrals shall be given to people who call in with bleeding, cramping or any other medical problems that may warrant immediate medical care, as Alpha Center is not equipped to provide emergency care. 1) If a medical team member is on site, have that person assess the situation. 2) If there is no one on site to do an assessment, refer the client to: a) Her own health care provider OR b) The emergency room closest to her if she is not established with a health-care-provider OR c) Call 911 if she isn't able to do any of the above. 3) If a client should call for laminaria removal, the nurse will refer client to their own personal medical doctor or emergency room. IN THE CENTER: If a medical emergency should arise while a patient is on the premises, the following procedures should be followed: 1) Immediately notify a medical team member on the premises. 2) If no physician is available, contact the Medical Director or one of the physicians on the Emergency Consultation List. 3) If none of the above doctors are available, call Poudre Valley hospital (495-7000) or 911. 4) Documentation in the client's file shall include nursing assessment, vital signs, emergency treatment rendered and any pertinent findings. The nurse shall document the date and time the physician was notified and all attempts thereof. All information discussed will be documented as well as all instructions given to the client. EMERGENCY CONSULTATION LIST: The Clinic Manager will compile, update and maintain the following Emergency Consultation List. The list will be posted in a conspicuous location in the clinic. EMERGENCY CONSULTATION LIST: 1.) Dr. Jeff Kauffman, Alpha Center Medical Director, 484-0798 2.) Dr. Karen Hayes, OBGYN, 221-4977 3.) Rocky Mountain Family Physicians, 484-0798 76 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Standing Orders PREGNANCY TESTING: 1) All registered nurses are authorized to perform urine pregnancy tests on all clients presenting at the clinic for such testing. 2) These personnel are hereby authorized to inform the clients of their test results. 3) The client’s chart shall be documented accordingly. 4) A completed “Order for Urine Pregnancy Test” shall be filed in the client’s Medical Record. ULTRASOUND: 1) An ultrasound may be performed by a registered nurse or sonographer to confirm a viable intrauterine pregnancy. 2) A repeat ultrasound may be scheduled and performed if initial ultrasound findings are inconsistent with client’s LMP (last menstrual period) and yolk sac and intrauterine pregnancy is verified. 3) The ultrasound must be performed in compliance with the “Ultrasound Standards for Pregnancy” policy. 4) The ultrasound will be documented in ultrasound report and progress notes accordingly. 5) A completed “Order of Ultrasound” shall be filed in the client’s medical record. PRENATAL VITAMINS: 1) All medial staff and volunteers at Alpha Center may offer Prenatal Vitamins to pregnant clients. 2) Currently we are using PlusPharma or Major Prenatal Vitamin Brands 3) The patient’s chart shall be documented with brand name and amount given. 4) A completed “Order for Prenatal Vitamins” shall be filed in the client’s Medical Record. TREATMENT FOR NAUSEA OR VOMITING: 1) All nurses may suggest the use of the following for nausea or vomiting due to pregnancy: Unisom Sleeptabs: one every 6 hours as needed OR Vitamin B6 50 mg: one tab three times a day with meals 2) The patient’s chart shall be documented accordingly. 3) A completed “Order for Treatment for Nausea or Vomiting” shall be filed in the patient’s Medical Record. For Standing Orders Form J, see appendix 77 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Client Medical Record The Alpha Center shall maintain medical records in a manner consistent with standard medical practices. Procedure: 1) The client file shall contain the following documents: a) Case Intake Form – - completed by client on initial visit b) Medical Services Consent and Release Form – STD HIV antibody test consent form ( if applicable) Pregnancy test and consent form (if applicable) c) History and Physician Examination Record - completed by physician, if applicable d) Female / Male Health History & Sexual History Questionnaire e) Ultrasound Consent, Waiver and Release – if applicable f) Copies of written correspondence to the client g) Correspondence from the client h) Medical Consent Form (Inclusive of HIPPA Release & guidelines) i) Other documents as necessary 2) The client progress notes will be entered and maintained on the ekyros electronic progress note. The medical record shall include admission information consisting of name, address, telephone number, age, date of birth, consent for treatment, date service began and date terminated, date of last menstrual period, and the results of the pregnancy test. 3) The medical record shall contain documentation of pertinent observations and disclosures in relation to the client's needs and the care provided. Each encounter with the client by telephone or in person shall be documented. The ekyros electronic Concept Shared will be used to document all education provided, all resources referred, all literature given, and all videos presented. 4) Each entry in the medical record shall be dated and be authenticated with the signature and title of the person making the entry. 5) Information contained in the medical record is confidential and shall be disclosed only to authorized persons in accordance with federal, state and local laws. 6) Medical records shall be stored in a secured location to protect against loss, destruction or unauthorized use. This can be in the same location as the rest of the file. 7) The Clinic Manager shall periodically review medical records per clinic “Quality Assurance” Policy. 8) Medical records shall be retained for a period of seven years, except for minors whose records shall be kept at least one year after the minor has reached the age of 18, but in no case less than seven years. Since Alpha Center is a medical clinic, it is important to keep in mind that any charting could be subpoenaed as part of the client’s Medical Record. A Medical Record must be accurate because it is a legal document. In the case of a lawsuit, the Medical Record, not the care given, is on trial. The client’s care may have been excellent; however, if that care is not documented, it is seen by the courts as not having been done. 78 P O L I C Y A N D P R O C E D U R E M A N U A L CHARTING PROCEDURE: 1) Begin with the date and time. 2) Use black ink for all entries and use legible handwriting. 3) Record pertinent data, including verbal and non-verbal communication. 4) Always use positive, non-judgmental statements when describing your client. Be as objective and as affirming as possible. Consider how you would feel reading the same things about yourself that you write about your client. 5) Keep comments concise, but precise. You may abbreviate commonly used terms, e.g. “cl.” for “client”, “pg” for “pregnant”, etc. Omit “a”, “an”, “the”, etc., when not needed to clarify a statement, e.g. “Cl. viewed video ‘Your Crisis Pregnancy’.” 6) Avoid the over-use of pronouns. Misplaced or vague pronouns make the meaning unclear, e.g. “She went to see her lawyer. She said she would take it to court.” (Is she the client or the lawyer?) 7) Be careful to be an objective observer. You may use the terms “seems” or “appears” to describe an apparent emotional state, but it is better to chart what is observable. For example, “Cl. was tearful throughout the interview, did not make eye contact and responded only when spoken to.” 8) Conclusions may be made but they should be validated with available data, e.g. “Cl. appeared agitated, wringing hands, eyes darting, and she stated, “Are you finished yet?” 9) Include relevant client statements, e.g. “Cl. stated, ’I am afraid of what my parents will say’.” 10) If an opinion is given, it is important that it be stated as such. 11) Always document your interventions/suggestions, e.g. - “I encouraged cl. that we could talk to her parents together.” 12) If you make an error, draw a single line through the error, write the word “error” above it, and sign your initials. (Do not erase, apply correction fluid, or scratch out incorrect items.) 13) Don’t leave blank spaces in counseling or nurses’ notes. 14) Close with your signature and title, e.g. “RN”, “EMT”. WORDS TO AVOID: * Any words that would indicate a diagnosis, e.g. “Cl. is depressed” Correct charting would read: Cl. appears sad/cl. affect appears flat”. * Any word that would suggest a judgment or that a client should feel a certain way. e.g. “I asked her if she regretted having an abortion.” Correct charting would read: “Cl. was asked how she felt about her abortion.” * The word “is” especially without supporting data, e.g. “Cl. is apathetic to presentation of Gospel.” Correct charting would read, “Cl. appears apathetic to presentation of Gospel, yawns, sighs, looks away, states she is not interested in Gospel.” Policy: Client Medical Records Release It is the policy of the Alpha Center that appropriate procedures are in place to reasonably safeguard protected health information and sensitive information related to patient identity from any intentional or unintentional use or disclosure. Medical records will be made available to clients upon their request, either in person by appointment, or through a medical facility by fax. 79 P O L I C Y A N D P R O C E D U R E M A N U A L “Medical Records” includes the Ultrasound Worksheet, Medical Health History, Medical Exam, Verification of Pregnancy, Laboratory reports, Pap Smear reports and HIV results. Procedure: 1) The Nurse Manager or Clinic Manager will handle the release of requested records. 2) When a patient calls for an appointment, they will be asked to provide a valid Driver’s License or other photo ID. 3) When the patient arrives for the appointment, the patient will be asked to produce valid ID. A copy of the ID shall be placed in the patient’s chart on the left side. If the patient does not have photo ID, a photo shall be taken and placed in the patient’s chart with date and time. 4) When a patient calls to request copies of their medical record, they will be directed to a nurse. The nurse will make an appointment for them to come into the center and meet with a nurse. The patient must come into the center during regular business hours and show identification which will be compared to the copy in their file for verification. If the identification matches prior identification, then a copy of the medical records requested shall be provided upon signature by the patient on the medical record release form, which shall be placed in their medical record. 5) Staff should be alerted for the possibility of identity theft in the following situations. a. The photograph on a driver’s license or other photo ID submitted by the client does not resemble the client. b. The client presents a driver’s license or other identifying information that appears to be altered or forged. c. Information on one form of ID that the client submitted is inconsistent with information already in the office’s records. d. An address or telephone number is discovered to be incorrect, non-existent or fictitious. e. The client fails to provide identifying information, documents or to have their picture taken. f. The client’s signature does not match a signature in the client’s chart. 80 P O L I C Y A N D P R O C E D U R E M A N U A L 6) If the staff detects potentially fraudulent activity, it shall be reported to the Clinic Manager and Executive Director immediately. They will report to the appropriate authorities. 7) If client files are subpoenaed, the Executive Director should contact legal counsel for advice on how to proceed; there may be some privileges or circumstances that would prohibit complying with the subpoena. Date: ________________________ Added_______ Changed_______ Deleted_______ Initials: ED_____________________ Clinic Manager__________________________ Medical Director_________________ Client Services Director___________________ For Medical Records Release Form L, see appendix 81 P O L I C Y A N D P R O C E D U R E M A N U A L Chapter 5 Ultrasound 82 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Ultrasound Client Criteria The RN is responsible to elicit and detect information from the pregnant client regarding her abortionmindedness or abortion-vulnerability and her concerns about the pregnancy. The Alpha Center will provide ultrasound exams to abortion-minded or abortion-vulnerable women when they meet, in the counselor’s view, the following established criteria. ABORTION MINDED: The abortion-minded woman is one who has set the course for obtaining an abortion. Some examples of this behavior include: 1) Seeking information about how to obtain an abortion, including such questions as “How much does an abortion cost?” “Can you give me a referral for an abortion?” “Do you do abortions?” 2) She has an abortion scheduled, regardless of how tentative she sounds about it. 3) The abortion procedure has been initiated, as in the introduction of laminaria. ABORTION VULNERABLE: The abortion-vulnerable woman is one who, by continuing her pregnancy, encounters obstacles she may feel incapable of handling or unwilling to experience. Some examples of abortion-vulnerability include: 1) She has not eliminated the possibility of an abortion (She is undecided about this pregnancy). 2) She is being pressured by a parent, boyfriend or husband to have an abortion. 3) She has had an abortion previously. NON-ABORTION VULNERABLE: The above definitions of abortion-minded or abortion-vulnerable do not apply to this client. She has made a decision to “carry to term” and all 3 of the following criteria apply to her. She needs to be evaluated for needs concerning social support, medical information and referrals. 1) She does not believe that abortion is right. 2) All indications reveal a healthy pregnancy. 3) She has support from all significant influences in her life. 83 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Ultrasound Models for Training Alpha Center requires all Ultrasound model scans, shall be performed at the highest level of care. The Medical Director must approve the Clinic’s policy on training scans. In the event the medical professional sees something unusual during the scan or while reviewing the chart, the training model will be immediately notified to seek medical attention. Procedure: 1. As the models call in for appointments, they will be placed on a log with name and phone number. Each client will also be entered in Ekyros. 2. Each model should read, answer the questions and sign the consent and wavier prior to being scanned so that she understands fully that the purpose of the scan is not diagnostic but rather for training purposes only. 3. Each model will have the medical screen form filled out by a nurse. 4. Each model will have one training scan per pregnancy. 5. All training scans will be documented on the US report form. All their documentation will be clipped together and placed in a folder. The folder will be kept per year for 7 years. The folder will be marked as “US Training Folder” and kept in the Clinic Manager’s office. a. b. c. d. Consent Medical screening form US report form Evaluation form 6. All models will have a post evaluation form filled out. 7. All scans will be read and signed off by a MD. 8. If the Ultrasound findings are inconsistent with clients LMP, client will be referred for follow-up with PMD within 72 hours. 9. We will not utilize any model under 18. 84 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Ultrasound Standards for Pregnancy Medical personnel who meet the standards established by AIUM and ACOG will perform ultrasound exams at the Alpha Center. Standards: 1) Ultrasound technicians/sonographers will perform ultrasound exams within the scope of their licensing in the State of Colorado and will have a current license to practice. 2) Physicians will perform ultrasound exams only if they have completed training in ultrasound and are approved by the Medical Director and /or the Board of Directors to perform ultrasound exams. 3) Registered nurses may perform ultrasound exams if: a) they have completed an ultrasound course that follows AWHONN guidelines AND b) they have completed on-the-job training with a physician or sonographer AND c) they perform only LIMITED ultrasound exams AND d) prior to performing ultrasound exams, the nurse’s competency is evaluated by the Medical Director or designee and a letter of competency from the Medical Director is placed in the nurse's file. Procedure: 1) All ultrasound exams will be documented with ultrasound prints on an ultrasound worksheet and will be signed by the person who performs the ultrasound exam. 2) All ultrasound exams done in the Alpha Center will be reviewed and signed by a radiologist or an OB/GYN For Ultrasound Consent, Waiver, and Release Form N, see appendix 85 P O L I C Y A N D P R O C E D U R E M A N U A L Chapter 6 Quality Assurance 86 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Quality Assurance A quality assurance evaluation program shall be established. Volunteer nurses will comply with established Alpha Center quality assurance standards. Procedure: 1) Charting a) At the end of the physician examination, the Clinic Manager or a volunteer nurse will see that medical charts are complete and free of errors. b) A quarterly review of charts will be conducted by the Clinic Manager or a volunteer nurse. A minimum of eight random charts will be inspected for errors or deficiencies and volunteers will be instructed as needed if charting procedures are not being followed. 2) Evaluation of medical staff a) The Medical Director will periodically be asked for feedback regarding the nurse volunteer’s performance, and appropriate action to remedy adverse situations will be taken. b) Medical Staff shall receive an annual Peer Review (See Peer Review Policy). 3) Statement of Quality Assurance: a) For quality assurance, nurse volunteers will be observed annually. b) Charts will be reviewed quarterly by the Clinic Manager. Eight random charts will be inspected for errors. See “Client Medical Record Checklist” form. If charting procedures are not being followed, they will be reviewed with the volunteers individually or at volunteer meetings. c) Persons who cannot attend meetings are to make arrangements to secure the material covered (via cassette tape of meeting, handouts, or consultation with staff member). 4) Volunteer medical and nursing staff will be updated via mailings, handouts, an in-clinic communications notebook or periodic meetings. It is the responsibility of the volunteer to secure the information that is delivered through these mediums. For Client Medical Record Checklist Form K, see appendix 87 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Our Commitment of Care 1) Clients are served without regard to age, race, income, nationality, religious affiliation, disability, or other arbitrary circumstances. 2) Clients are treated with kindness, compassion, and in a caring manner. 3) Clients always receive honest and open answers. 4) Client pregnancy tests are distributed and administered in accordance with all applicable laws. 5) Client information is held in strict and absolute confidence. Client information is only disclosed as required by law and when necessary to protect the client or others against imminent harm. 6) Clients receive accurate information about pregnancy, fetal development, lifestyle issues, and related concerns. 7) We do not offer, recommend or refer for abortions or abortifacients, but we are committed to offering accurate information about abortion procedures and risks. 8) All of our advertising and communications are truthful and honest and accurately describe the services we offer. 9) All of our staff and volunteers receive proper training to uphold these standards. 88 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Value Statements 1) LOVE- We are committed to serving people on the basis of God’s unconditional love expressed to us and through us. 2) GOD’S WORD- We will operate in accordance with God’s word. It is truth; it directs our lives and is the best counsel we can give our clients. 3) PEOPLE- We will show each client respect, understanding that their life has value. 4) SERVANT LEADERSHIP- We will serve our clients understanding that Christ has called and equipped us. 5) PURITY- Purity will be our standard as we set examples for our clients by the way we live. 6) GRACE- We have been given grace by God and desire to embrace people with that same gracious attitude. 7) EXCELLENCE- All we do will be done with excellence because God is honored when we give our best. 8) GOD SUSTAINED MINISTRY- We trust God to sustain and guide this ministry. 9) CONFIDENTIALITY- We are committed to honoring our clients’ need for confidentiality. 89 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Management of Client Feedback Rationale: Alpha Center implements a procedure that allows a client to file compliments, complaints, or grievances (hereafter called “feedback”) regarding the services they receive. If complaints regarding medical care are received, client will be advised of their right to appeal directly to Colorado Department of Public Health and Environment (CDPHE.) Note: These procedures apply only to compliments, complaints, or grievances of a programmatic nature, not an alleged breach of confidentiality. Any allegation of a breach of confidentiality will be handled according to the suspected breach policy of the Disease Control and Environmental Epidemiology Division at CDPHE. Procedure: If the feedback is received via telephone at Alpha Center Telephone calls regarding citizen/organizational feedback will be directed to the Executive Director or the Clinic Manager. If for any reason one of the above individuals is not immediately available, the caller will be given the option of a return call by the first available person or given the option to call back. 1) The Executive Director or Clinic Manager should: a) Determine the general nature of the feedback. If another person may more directly address the subject of the call, the call should be transferred to the appropriate area. If the caller prefers not to transfer, the Executive Director or Clinic Manager should take all appropriate information. Information should be as detailed as possible and documented on a Feedback form (forms) within 24 hours of receiving the initial call. This would include, but not be limited to, the caller’s/client’s name, the name of the staff member, and a synopsis of the specific situation. The caller should also be given the option of a return call (within 48 hours) by another staff member in order to assure the caller that some type of action has been initiated. b) Identify the type of remedy the caller feels would be appropriate. When the caller identifies a remedy that the staff member feels may be unreasonable, the caller should be assured that the matter will be addressed, but that the caller’s remedy may not be possible. c) Ask the caller if he or she requires a response, either in writing or by telephone. If so, the caller must leave information that will allow the Executive Director or Clinic Manager make contact for further information or disposition (name, address, phone number, etc.). If the feedback is from an individual who wishes to remain anonymous, explain that anonymity may limit the efforts the program can make toward resolution. If the caller is calling on behalf of another individual, every attempt should be made to talk to the individual who was involved in the situation that resulted in the feedback. Due to confidentiality concerns, the limited amount of discussion that may be carried on with the third party may hinder/preclude a complete investigation. The time required for response will be largely determined by the nature of the call. The caller should be made aware of the estimate for completion of the action and when follow-up with the caller, if required, will occur (usually within 24-48 hours of the call). 90 P O L I C Y A N D P R O C E D U R E M A N U A L d) Inform (in person or via voice mail) the relevant staff person that feedback has been received immediately after taking a call. e) Record pertinent facts of the call in the Feedback Log (Form T) within 24 hours. 2) The person taking the initial call may be able to provide direct feedback and a solution within his/her scope of authority. If the person taking the call cannot satisfactorily provide a solution, the feedback will be forwarded to the next higher level. All calls will be forwarded to a higher level any time a caller requests. 3) The disposition of a feedback incident should be documented on the original Feedback Form files in the logbook in a secured location at Alpha Center with limited access. The relevant staff person will review and sign off on all dispositions of complaint or grievance calls for consistency with Alpha Center’s Policy and Procedures. The Clinic Manager will inform the Executive Director of each complaint and the actions taken to resolve them. Procedure: If the feedback is received via written correspondence All correspondence regarding complaints or concerns are reviewed by the Executive Director or Clinic Manager, who determines the appropriate person to draft a response. 1) When legal issues are involved, a copy of the correspondence will be faxed to Alpha Center’s legal council for review prior to the mailing of a response. 2) Depending upon the person to whom the letter was first addressed, the written response will be signed by the Executive Director, Clinic Manager, or a physician. The response is typically provided within 10 days. Other staff members will be to be notified of the concern/complaint and its resolution as needed. 3) With approval from the Executive Director when feedback is received in writing the Clinic Manager will complete the Feedback Form, record the incident in the Feedback Log, and complete steps b-e described above in regard to feedback via telephone. Procedure Note: For both types of feedback Completed Feedback Forms and the Feedback Log will be kept in a secured location at Alpha Center with limited access. The following will be recorded on each Feedback Form: 1) Date of the feedback incident. 2) Name, address, and telephone number of the individual making the call or signing the letter. 3) Name of the individual(s) handling the feedback. 4) Brief description of the feedback. 5) Brief description of the disposition. Include date forwarded to another individual and date that information is received back from them. 6) Date of the follow-up call or letter. In the case of a call, record the initial caller’s responses. Information about an Alpha Center staff or volunteer who is the subject of a complaint/concern call should be recorded on a Feedback Form and not on the log. 91 P O L I C Y A N D P R O C E D U R E M A N U A L All Feedback that meets the criteria above should be addressed. Complaints concerning policy will be addressed directly by the Executive Director or Clinic Manager. Any personnel actions that might result will follow the guidelines in the Employee Handbook or the Policy and Procedure manual. For Feedback Form S and Feedback Log Form T, see appendix 92 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Chart Review The Clinic Manager or designee shall review all client charts, intake forms and advocates notes within 24 hours of the client’s visit to the Clinic. Procedure: 1. Each intake, form and note for every client will be filed in the appropriate file chart. 2. At the end of every day, these forms, charts and notes will be reviewed by either the Clinic Manager or designee using the Quality Assurance forms (in Clinic Manual) as guidelines for review. 3. Each form, chart and note will be reviewed to assure the proper procedure was followed, the appropriate information recorded, the appropriate signatures obtained and any incidents of abuse or suicide reported. 4. Any incidents of abuse or suicide must be reported to the proper authorities. 5. Any errors will be noted and shall be reviewed with the appropriate Client Advocate to assure understanding or the proper procedures. 93 P O L I C Y A N D P R O C E D U R E M A N U A L Chapter 7 Personnel 94 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Staffing The Clinic shall be staffed in such a manner as to provide the best service possible to our clients. Procedure: 1) Two or more persons shall staff the Center during hours of normal operation. 2) There shall be a licensed Nurse on duty whenever nursing services are offered. 3) The Executive Director and Clinic Manager shall arrange their hours so as to be available to complete their related duties and supervisory needs. 4) Staffing needs will be assessed on a month-to-month basis. 95 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Personnel Manual The Clinic shall maintain a personnel manual for its employees. Procedure: 1. The CEO shall prepare a personnel manual that should include at least the following policies and procedures: Job descriptions Staffing chart Exempt and nonexempt staff Overtime/ comp time Performance reviews Employee resignation, termination Leave of absence Bereavement leave Jury duty Spiritual retreat days Job related education Personnel files Drug and alcohol abuse Conflict resolution procedure Holidays Vacations Sick leave 2. The Personnel Manual shall be approved and then reviewed bi-annually by a committee of the Board. 96 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Personnel Records The Center shall maintain current and accurate personnel records for all employees working at this facility or any satellite offices. Procedure: 1) A personnel record is started when a person is placed in a paid position at the Center. 2) The personnel record should contain the following information as included in the Medical Personnel Record Checklist. (Form U) 3) These records shall be maintained for three years following termination of employment. 4) These records should be maintained in a confidential manner and shall be made available to representatives of the appropriate governing authority upon request to ensure compliance with applicable rules and regulations. 5) The Center's Personnel Handbook shall apply to all compensated employees. For Medical Personnel Record Checklist Form U, see appendix 97 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Personnel Training Alpha Center personnel shall be trained, professional and qualified in order to provide the best possible service to our clients. Procedure: 1) The Clinic shall recruit qualified personnel (employees and volunteers) and provide initial orientation and training. Continuing in-service training programs shall be provided as needed. Supervision by designated managers is designed to improve client services and staff efficiency. 2) All personnel involved in Clinic operations must read this Policies and Procedures Manual. 3) All personnel shall be familiar with the infection control and emergency procedures as detailed in the Policies and Procedures Manual. 4) A copy of the appropriate job description shall be provided to each person employed or volunteering to work in the Clinic. 5) All personnel shall attend staff meetings and training sessions throughout the year. 6) All personnel shall be reviewed regularly on performance standards by appropriate supervisor. For Application for Employment Form KA, Tenured Employee Evaluation Form LA, Performance Evaluation Form MA, Confidentiality Information Agreement Form NA, Unique Aspects of Job/Environment Form OA, Safety Rules Form PA, and Designated Work-Related Medical Provider Form QA, see appendix 98 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Registered Nurse Training for Pregnancy Options Counseling Alpha CenterRegistered Nurse performing options education for pregnancy test client shall be: trained, professional and qualified in order to provide the best possible service to clients. Procedure: 1) Alpha Center shall recruit qualified licensed medical personnel to provide options education to abortion minded and vulnerable clients. 2) Initial orientation, training, continuing in-service, and education shall be provided as needed. 3) Supervision shall be designated to Nurse Manager. 4) Personnel to review CARENET “Serving with Care & Integrity Manual” and/or“Intimacy Before Impact Training Manual.”. 4) Personnel to observe 3-5 abortion-minded clients in options counseling with Nurse Manager or current staff nurse. 5) Personnel to be orientated to Alpha Center approved resources, referral lists and brochures. 6) Personnel to be trained on CARENET abortion-minded and abortion-vulnerable criteria for ultrasound referral and scheduling. 7) Personnel will be orientated to proper eKyros data entry and client record documentation. 8) Personnel will be orientated to legal issues regarding options education relating to adoption, abortion, and medical information. 9) Personnel must read Policy and Procedure manual yearly. 10) Personnel shall be familiar with infection control and emergency procedures as detailed in the Policy and Procedure Manual. 99 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Conflict Resolution Volunteers and staff shall make every effort to resolve issues of conflict by directly approaching the one with whom the conflict exists. The parties involved shall prayerfully consider what personal responsibility needs to be claimed and how resolution of the conflict can best be made. A formal grievance may be filed if reasonable efforts to resolve the conflict are unsuccessful. The individual should inform the other party of his/her intent to file a formal grievance. Procedure: 1) If the parties agree that they would like help in conflict resolution, it shall be their responsibility to contact the appropriate supervisor. 2) If the grievance is against the individual’s supervisor, a three-way meeting with the supervisor’s superior may be requested. 3) Conflict of a serious nature should be addressed immediately with the individual’s immediate supervisor. “Serious” means any situation where it is believed that a client, the ministry or any Alpha Center volunteers or staff may be in jeopardy. 4) The individual shall make a written letter of grievance and make a copy for his/her own file. The original should be mailed/given to the appropriate supervisor. 5) The letter will be reviewed and a written response given within two weeks of its receipt. A meeting may be requested by the supervisor so that the complaint may be reviewed with the concerned parties. 6) The supervisor will make a determination as to the legitimacy of the grievance, and recommend a course of action with which all parties will be expected to comply. 7) All parties will receive a written report from the supervisor, which includes the charges made, the investigative findings and the recommended course of action. Policy: Suspected misconduct, dishonesty, fraud, and whistle-blower protection If any person knows of or has suspicion about misconduct, dishonesty, or fraud, the Executive Director should be contacted. If the alleged wrongdoing concerns the Executive Director, then the Board Chair or another officer should be notified. If the Executive Director, Board Chair, or officer receives information about misconduct, dishonesty, or fraud, they shall inform the Board which shall determine the appropriate procedure for investigating all credible allegations. At all times, the privacy and reputation of individuals involved will be respected. There will be no punishment or other retaliation for the reporting of conduct under this policy. The anonymity of the person reporting will be protected as requested unless this would impede the investigation. 100 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Avoiding Tort Claims All staff and volunteers shall be trained to avoid any situation that could give rise to a tort claim. Procedure: 1. The training given by the Clinic shall include how to avoid claims of battery, assault, intentional or negligent infliction of emotional distress, false imprisonment, deceit or fraud, defamation, and invasion of privacy. 2. Recurrent training shall occur at least annually. 101 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Identifying Fake Clients Understanding that NARAL and others would rather see our Clinic out of business, we must be on alert for any fake clients presenting at the Clinic. Procedure: 1. All volunteers and staff will be trained in identifying fake clients. 2. Appropriate measures will be taken with these clients. 3. The CEO will be informed immediately of any fake clients. 102 P O L I C Y 4. A N D P R O C E D U R E M A N U A L Policy: Volunteer and Donor Relationships Contacting volunteers and or donors for the purpose of pursuing personal business other than that pertaining to the Alpha Center is strictly prohibited. 103 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Staff Health In order to ensure a healthy work environment, all staff (employees and volunteers) who work at Alpha Center shall be free of fever, tuberculosis, contagious sore throats, contagious rashes or other conditions which may pose a risk to a pregnant client. In addition, all Alpha Center staff (employees and volunteers) that has contact with clients shall have a physical exam every five years. A qualified professional should examine the staff person and complete the “Staff Health Report”. If the staff member may be exposed to blood or other potential infectious materials, he/she must be offered a Hepatitis B vaccination. (See “Hepatitis B” Policy). Procedure: 1) If a staff person believes that she/he may have a contagious condition, she should contact the Nurse on duty. If it is decided that the condition may pose a risk to a client, he/she will be asked to remain home and/or to seek medical care. 2) Vaccination status of staff will be kept on file at the medical clinic, if needed. 3) The Alpha Center shall host a "physical day" when staff can be seen by a physician and have their ‘Staff Health Report Form’ completed. The physical shall include a TB test and medical history. 4) The physician will complete the “Staff Health Report” and indicate that the person is able to perform assigned duties and that a health condition that would create a hazard for the staff, clients and visitors does not exist. 5) Staff who cannot participate in the "physical day" or who are hired in between dates set for the "physical day" shall obtain a physical on their own and return their completed “Staff Health Report” to the Executive Director. 6) All health records shall be maintained in the employee’s personnel file which is considered confidential information. This will include all “Staff Health Report”, vaccination status, refusal of testing/treatment, recent negative TB test and emergency phone numbers. 7) Staff who may be exposed to blood or other potentially infectious materials shall be offered a Hepatitis B vaccine pursuant to the “Hepatitis B” Policy. For Staff Health Report Form V and Tuberculin Testing Form W, see appendix 104 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: TB Skin Testing for Alpha Center Employees Purpose: To provide annual screen of Clinical Staff. Managed by Clinic Manager/Medical Director 1. TB test will be offered annually to Clinical staff employee. Usually in April. 2. Clinical Staff employee will fill out Alpha center TB screening form before PPD administration. The form will be reviewed by Clinic Manager. PPD will be initiated on Clinical staff employee who meets the criteria. a. Do not administer if Clinical staff employee has had a positive test in the past or has had BCG. b. Do not administer if Clinical staff employee is pregnant/nursing. c. Do not administer to Clinical staff employee who have erythema nordosum, measles, mumps, shingles, chicken pox, recent vaccine or allergy to thimerosal. d. Do not administer TB test if Clinical staff employee has had a live vaccine within 3 weeks. e. Do not administer TB test if Clinical staff employee is on steroids. 3. If TB test is a new positive, Clinical staff employee will follow-up with their PMD or Larimer County Health Department. 4. Employee will not be able to return to work until cleared by MD and have written documentation. 105 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Hepatitis B Vaccine Alpha Center wishes to comply with OSHA regulations that require that all employers offer and/or provide the Hepatitis B vaccine to all employees who may be at risk of acquiring the Hepatitis B virus (HBV) infection. The Hepatitis B vaccine series shall be offered to all volunteers/employees who have contact with patients in the Alpha Center and who may be exposed to blood or other potentially infectious materials. Alpha Center shall offer the Hepatitis B vaccine at no charge to the volunteers/ employees. Procedure: 1) The Clinic Manager shall identify employees/volunteers who may be at risk of acquiring the Hepatitis B virus infection. 2) The employer or other health care provider will offer the vaccine to these volunteers/employees. 3) The volunteer/employee shall fill out the “Hepatitis B Vaccine Information Form” indicating his/her wishes regarding the vaccine. The completed form shall be placed in the personnel file. 4) The volunteer/employee who would like to receive the Hepatitis B vaccine will be referred (Larimer County Health Department, $45 per shot times 3 doses) for administration of the vaccine. Proof of the vaccine administration will be submitted and placed in personnel file. 5) The volunteer/employee who declines Hepatitis B vaccination will be instructed that he/she may receive the Hepatitis B vaccine in the future at no cost to him/her if he she so desires. For Hepatitis B Vaccine Information Form X, see appendix 106 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Dress Code Staff attire shall reflect the professionalism and high standards of Alpha Center. Employees and volunteers will be expected to dress appropriately within the requirements listed below during clinic hours or when conducting any Alpha Center business in a public setting. Dress Code/ Personal Appearance: Please understand that you are expected to dress and groom yourself in accordance with accepted social and business standards, particularly if your job involves dealing with clients or donors in person. Since you are talking to clients and visitors about living a chaste lifestyle, your apparel must be modest to reflect your speech. Sun dresses/blouses that reveal “too much” (no tummy showing, no cleavage, etc.); men’s undershirts and boxer shorts; thin-strapped tank tops with showing bra straps, are all not appropriate dress. Dresses should be no shorter than four inches above your knees. Shorts may be worn from time to time, especially at events such as the Walk-for-Life, if they are dressy, without holes or tears. Shorts should be no shorter than four inches above your knees. Jeans may be worn if they are dressy without tears or holes. Please be aware that low-cut jeans can show more than you think when bending or leaning over. A neat, tasteful appearance contributes to the positive impression you make on our clients, visitors and donors. You are expected to be suitably attired and groomed during working hours or when representing the Alpha Center. Personal appearance should be a matter of concern for each employee. The Executive Director reserves the right to evaluate the propriety of employee’s dress and appearance. If the Executive Director feels your attire is out of place, you may be asked to leave your workplace until you are properly attired. You will not be paid for the time you are off the job for this purpose. The Executive Director has the sole authorization to determine an appropriate dress code, and anyone who violates this standard will be subject to appropriate disciplinary action. 107 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Medical Staff Peer Review All medical staff shall be given an annual peer review to insure quality job performance. Procedure: 1) At the end of a year of volunteer service, the Clinic Manager will arrange for all medical practitioners to be reviewed. 2) The Medical Director will audit five patient charts of the medical staff member under review. 3) A meeting will be scheduled between the Medical Director, Clinic Manager and the volunteer after review process is completed if there is a concern of quality. 4) If there is any disagreement regarding the review recommendations, a meeting will be scheduled with the Executive Director. 5) Medical Review Sheets will be placed in each individual's personnel file. For Medical Staff Peer Review Form LB, see Appendix 108 P O L I C Y A N D P R O C E D U R E M A N U A L Chapter 8 Volunteers 109 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Volunteer Interview and Procedures Prospective volunteer candidates are sent a volunteer interest application. Upon completing and returning the volunteer interest application, the person in charge of the area of interest contacts prospective candidates and schedules an interview to discuss candidate’s interest and understanding of the Alpha Center. Procedure: 1) Volunteer interest application is mailed to each interested candidate. 2) Upon receiving completed volunteer interest application, the person in charge of the area of interest indicated contacts candidate and schedules an interview. The interview will be composed of the following elements: a) Knowledge of the Alpha Center b) Interest in serving in this ministry c) General overview of the Alpha Center organization and structure d) Description of volunteer positions, qualification and training e) Review commitment requirements f) Evaluation and assessment of prospective volunteer’s spirituality maturity and Commitment g) Encouragement of candidate to pray about commitment 3) If decision is made to continue pursuit of volunteer position the following steps will be taken: a) Call candidate’s references b) Schedule candidate for next available training c) Begin orientation process 4) Volunteer supervision and evaluation a) Volunteer placed with appropriate department b) Supervision given by appropriate staff member c) Evaluation by appropriate staff member at six months and one year, thereafter on an annual basis 110 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Volunteer Job Qualifications and Descriptions For mentors and administrative volunteers. Qualifications: 1) Must have a commitment to Jesus Christ as Lord and Savior 2) Must affirm a complete pro-life stance 3) Must be able to sign the Alpha Center Statements of Faith, Commitment and Abstinence (if single) 4) Must be in full agreement with the Alpha Center Mission Statement 5) Must be dependable, stable, and capable of following through on commitments 6) Must have a sincere desire to reach out with the love of Jesus to people in difficult situations. 7) Volunteers for pregnancy test counseling must hold a medical license (R.N., LVN, etc.) 8) Have a current and active Colorado state medical licensure. Counselor Job Responsibilities and Time Commitment: 1) To pray before each shift to allow the Holy Spirit to be in control. “Not by might, nor by power, but by my Spirit, says the Lord of Host.” Zechariah 4:6 2) To attend counselor training sessions to keep up-to-date on statistics and information relating to pregnancy resource centers 3) A commitment of two years of service, to begin at completion of training 4) To provide crisis intervention for each client in an atmosphere of warmth and compassion through listening and other helping skills 5) To provide accurate information and education on abortion 6) To provide information on parenting and adoption 7) To be responsible to review and follow all Alpha Center policies and procedures 8) To offer appropriate material resources and referrals relating to a client’s situation 9) To look for teachable moments with a client in order to share the love of Jesus and His plan of salvation 10) To be responsible to follow up with clients appropriately according to the policies and guidelines of the Center 11) To become familiar with the Alpha Center support systems 12) To be responsible for accurate charting on client contacts 13) Be willing to attend Alpha Center fundraising events, annual walk, and banquet 111 P O L I C Y A N D P R O C E D U R E M A N U A L STD Clinic Volunteers: Qualifications 1. Be a committed Christian who demonstrates a personal relationship with Jesus Christ as Savior and Lord. 2. Exhibit strong commitment and dedication to the sanctity of all human life. 3. Exhibit strong commitment and dedication to sexual purity. 4. Agree with and be willing to uphold the Statement of Faith, core values and policies of the Center. 5. Have a bachelor or master’s degree in nursing or equivalent experience. 6. Exhibit strong interpersonal and administrative skills. Responsibilities 1. The Volunteer Nurse provides support and care to the clients and maintains professional standards of care, following the ANA Code of Ethics 2. Under the general supervision of the Clinic Manager, the volunteer nurse is responsible for a wide variety of clinic functions, planning and performing direct and indirect nursing interventions, and is responsible for organizing, planning, assessing and performing the medical services provided by the Alpha Center 3. The Nurse also works in conjunction with physicians, nurses and lay counselors to assure that patients are receiving the best medical, nursing, and psychosocial care possible. 4. Checks equipment and supplies for the medical clinic and reports to Clinic Manager any needs. 5. Maintains a working knowledge of nursing methods, principles and practices in relation to the prevention and treatment of disease, safety and infection control, clinical systems, supplies and equipment 6. Assures compliance with infection control guidelines 7. Organizes, directs, supervises and evaluates professional and ancillary personnel in the absence of the Clinic Manager 8. Helps to oversee nursing services in clinic in the absence of the Clinic Manager. 9. Provides nursing care: assesses patient needs and makes nursing judgments that reflect safe nursing practices 10. Maintains accurate records, oversees care-plans and follow up on physician’s orders and standardized procedures 112 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Interns From time to time students may want to do an internship with us to receive college credit for their volunteer work. It is imperative that the intern is a good fit for the needs of the Alpha Center, as well as the student’s internship requirements. The following steps must be taken when determining if an internship is workable: 1) The intern must first be interviewed by an appropriate staff member to determine the qualifications of the intern as well as the best placement. 2) The intern must have the following qualifications: a) Must be able to sign the Alpha Center Statements of Faith b) Must be pro-life c) Must fill out a Volunteer Interest Form 3) After it is determined that the intern is qualified, and it is determined by the appropriate staff member that he/she will be a good fit in a particular department, the intern will then be interviewed by the department director. 4) The department director has to determine if there is enough work for the intern to do to fulfill the internship requirements. The department director and the intern must write a working agreement, explaining how the intern will fulfill the internship while working for the Alpha Center. The department director is the supervisor of the intern. The intern must report to the department director, and the department director must discipline the intern when necessary. The intern must understand that the Alpha Center holds the right to terminate the working agreement at any time and for any reason. 113 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Community Service Volunteers Those who wish to volunteer for the Alpha Center to fulfill community service requirements are viewed by the Alpha Center as people who need ministry. It is assumed that many who need to volunteer for community service will not be Christian, or pro-life. The following are steps that must be taken when determining if a Community Service Volunteer is permissible: 1) Community Service Volunteers will be interviewed by the Office Manager and a Volunteer Interest Form must be filled out. 2) The volunteer coordinator will determine the best placement for the volunteer. Community Service Volunteers may NOT be placed in any positions of authority or leadership. A position will not be created for the purpose of the volunteer. The needs and reputation of the Center must be the first priority. Community Service volunteers are only allowed to do tasks such as cleaning, auxiliary work and help with mailings. The Office Manager is the supervisor of the Community Service Volunteer. When necessary, the Volunteer Coordinator will discipline the Community Service Volunteer. 114 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Volunteer Evaluation Alpha Center shall evaluate each volunteer who has direct contact with clients after six months and after one year of service. Thereafter, volunteers shall be evaluated annually. This evaluation may include an interview with the supervisor and /or observation of a client session. This will be documented in the volunteers file. Procedure: 1) The supervisor or designee observes the volunteer in a client session. The observer will evaluate the consistency and quality of the volunteer’s client follow-up. 2) At the completion of one year of service, if the performance appraisal of the volunteer by the supervisor is satisfactory the volunteer then may commit to continued service. 3) If there are areas of weakness that need to be strengthened, a period of retraining for these areas will be implemented. 4) Following the retraining, the supervisor will determine whether performance expectations match clinic policies and procedures. If so, the volunteer will be asked to continue to serve. 5) If the standard of work or the result of the retraining period falls below expected levels, the supervisor, after a meeting with the volunteer, will remove her/him from service. 115 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Volunteer Supervision Questions or concerns related to any aspect of the volunteer’s work with Alpha Center shall be directed to his/her immediate supervisor. Procedure: 1) The volunteer will be given the name of his/her supervisor upon commencement of service with Alpha Center. 2) The volunteer shall attempt to reach his/her supervisor as soon as possible when a question or concern arises for which consultation is needed. 3) In emergent situations (see “Confidentiality” policy for examples of emergent situations) the volunteer shall call his/her supervisor immediately regardless of the time of day or night. If the volunteer is in doubt about whether or not the situation is urgent/ s/he shall call his/her supervisor for consultation. 4) In cases where the situation requires attention before the immediate supervisor can be reached, the volunteer shall attempt to reach the Executive Director on the cell phone. It is the responsibility of each volunteer to keep this number readily available. If both the immediate supervisor and the Executive Director are unavailable, the volunteer shall attempt to reach the Medical Director. If all are unavailable, the volunteer shall attempt to call the Board Chairman. 5) In non-emergent situations, the volunteer will wait until his/her supervisor is available to address the concerns. 6) The volunteer shall refrain from seeking advice from other staff who do not supervise him/her directly. 7) The volunteer shall document what supervision is received if given by someone other than the immediate supervisor. 116 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Post-Abortive Volunteers To ensure that emotional healing has taken place on the part of the post-abortive volunteer, new client services volunteers who are post-abortive must participate in PACE Bible study prior to working with clients. Volunteers who are currently working in the ministry and who are post-abortive will be asked by their director to attend Christian post-abortive counseling within a reasonable period of time. The definition of a “reasonable period” shall be determined at the discretion of the director. 117 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Corrective and Disciplinary Measures Corrective and/or disciplinary measures shall be initiated for the volunteer who does not meet the criteria of his/her job description and/or does not follow the policies and procedures of Alpha Center. Procedure: 1) A notation will be made in a volunteer’s file upon receipt of a grievance toward the volunteer, a confirmed violation of policies and procedures, or following a substandard performance review. 2) A supervisor will meet with the volunteer to address the issues in question. 3) A two-month probationary period may be instituted at the discretion of the supervisor for a violation of policies and procedures and/or for a failure to observe the requirements of the job description. The probation period will include a review of appropriate policies and procedures and/or job description as well as corrective measures as determined by the supervisor. During a probationary period, the volunteer may be relieved of duties which involve client contact. 4) At the end of the probationary period, the volunteer will meet with his/her supervisor to evaluate progress. 5) Reinstatement of client contact duties may occur at the discretion of the director when the volunteer has satisfactorily completed corrective and/or probationary measures. 6) A volunteer will be removed from service if her supervisor determines that her actions are detrimental to the clients or the work of Alpha Center. 118 P O L I C Y A N D P R O C E D U R E M A N U A L Chapter 9 Safety 119 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: OSHA Compliance Employees and volunteers of Alpha Center Medical Clinic will be trained in OSHA policies prior to working in the clinic and will be given ongoing training opportunities. Procedure: 1) Prior to working in the Alpha Center Medical Clinic, each staff member/volunteer shall be trained in all OSHA policies including Safety and Disaster, Identification of Hazardous Materials and Waste, Universal Precautions Infection Control, TB Infection Control, Blood Borne Pathogens Exposure Plan, and Hepatitis B Vaccination. 2) Ongoing training will be provided as needed during safety meetings. The Clinic Manager shall address all concerns regarding OSHA compliance in the staff meetings and/or with individuals who fail to comply with policies. 3) All OSHA policies shall be found in the OSHA binder that is available to all in the Clinic Manager’s office. 120 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Safety and Disaster Plan Staff/volunteers of the Alpha Center will be knowledgeable in and follow this Safety and Disaster guideline. It is the policy of this office that this building environment is as safe as possible for all persons who enter. Every reasonable effort will be made in accident prevention, fire protection, earthquake preparedness, tornado preparedness, and health preservation. This office will maintain a safe and healthful work place, and it will provide safe working equipment. In the case of injury, first aid and medical services will be immediately available. This policy will commit this office to compliance with the requirements of all the relevant regulations and to establishing and maintaining a place of employment that is as free as possible of recognized hazards that could harm persons or property. Procedure: A. General Information 1) Proper procedures and receptacles will be used for disposal of contaminated waste and supplies. 2) Chairs, wastebaskets, cords and other articles will not be left in aisles or walkways where they might be a hazard. 3) Desk, file and cabinet drawers/doors will not be left open while unattended. 4) A clean and clutter free work place shall be maintained. 5) Gloves should be worn whenever there is a chance of contact with bodily fluids or hazardous substances. 6) Safety glasses or a protective eye shield should be worn whenever there is a chance of contact with body fluids or hazardous substances. 7) Use good judgment when working around equipment and instruments. 8) Report all safety hazards to the Clinic Manager or Executive Director. 9) Do not attempt to perform unfamiliar work unless you are assigned to do so and instructed properly. 10) Report all electrical and equipment failure to the Clinic Manager, Director of Operations or Executive Director. Do not attempt to make repairs yourself. 11) Product guidelines must be followed when cleaning equipment. 12) It is recommended that each at risk staff/volunteer should be vaccinated with the Hepatitis B vaccination. 13) Consult the Clinic Manager, Director of Operations or Executive Director for additional safety information. 121 P O L I C Y A N D P R O C E D U R E M A N U A L B. Responsibility 1) To coordinate the safety program, the Clinic Manager will act as Safety Director. The overall effectiveness of the safety program is her responsibility. Her duties include the review and analysis of accident information, quarterly inspection reports and the communication of pertinent information to all staff/volunteers, and reviewing all accident investigations and safety inspection reports. She is also responsible for passing safety information along to all staff/volunteers, and for maintaining an accident/illness log to help in identifying accident/illness trends and problem areas so that additional safety efforts can be directed as needed. 2) Regular "walk through" inspections will be conducted by the Clinic Manager. A written report, “Walk Through Inspection Form” will be completed and filed appropriately. The written report will be reviewed quarterly at staff meetings. 3) Executive Director, Director of Operations or designee duties shall include: a) Fully comply with all applicable Safety and Health laws, rules and regulations, etc. b) Conduct regular written Safety and Health Inspections of all premises to identify and eliminate any unsafe and unhealthy working conditions and/or practice (or delegate) c) Investigate promptly and thoroughly (within 36 hours) every accident to determine cause and appropriate corrective action to prevent reoccurrence. d) Provide continuing Safety Training and education for all personnel, permanent and/or temporary (or delegate) e) Enforce all Safety Standards. 4) Clinic Manager duties shall include: a) Develop proper attitudes toward safety and health personally and in all employees by being a good example. b) Ensure that all jobs are performed with the utmost regard for the safety and well being of all. c) Be responsible for proper and thorough documentation of matters relating to safety and health. d) Attend all volunteer and staff meetings that deal with safety. e) Keep a first aid box available and maintain contents according to regulations. 5) Staff and Volunteers are responsible for: a) Their own safety and that of their co-workers in the performance of their jobs. b) Being compliant with all applicable rules, regulations and safety standards. c) Reporting in writing all unsafe conditions, equipment, or accidents immediately to the Clinic Manager, Director of Operations or Executive Director. 122 P O L I C Y A N D P R O C E D U R E M A N U A L C. Personal Safety 1) Do not attempt to lift objects that weigh more than 25 pounds or that are large or bulky without assistance. Use good body mechanics that protect the spine by using thigh muscles when lifting objects and bringing objects close to you before attempting to lift them. Do not bend at the waist or twist when lifting objects. 2) Do not use an extended reach to move or lift objects that are overhead. Instead, use a step ladder so that the object is visible at or near eye level prior to moving the object. 3) Clean up any spills as soon as detected and mark the area with a caution sign if the floor or carpet remains wet or soiled so that others are not in danger of falling or slipping. 4) Wear personal protective clothing when doing direct patient care. Observe and perform rules according to the “Universal Precautions Infection Control” policy. 5) Ask for help from the Executive Director, Director of Operations or Clinic Manager if you are not familiar with a procedure or how to perform it. 6) Continue to update your knowledge of the use, storage, and handling of hazardous/toxic substances. Updates will be given at quarterly staff meetings and as needed. 7) Report all injuries or accidents immediately to the Clinic Manager. D. Emergency Equipment The building shall have the following emergency equipment and supplies available: 1) One fire extinguisher on each floor. 2) Two flashlights with extra batteries 3) One first aid kit, in the kitchen, in the drawer to the far right of the sink. 4) Two quarts of bottled water 5) Weather Radio in file room E. Fire Evacuation Plan 1) Remove clients from affected area. 2) Have someone dial 911 and provide them with all the information they seek. 3) Close all doors in the building, so that people are contained away from the fire. 4) Attempt to extinguish the fire using the ABC category fire extinguisher located by the back door in the kitchen on the first floor, by the stairs on the second floor and by the bathroom in the clinic. 5) Evacuate the building if attempts to extinguish the fire are not quickly successful. 6) Take attendance once outside to be certain all persons who were at the Clinic have been safely evacuated. F. Earthquake Preparedness During an actual earthquake, the staff and clients are to get under safe tables, desks or doorjambs and wait until all motion has stopped. Try to keep away from shelves, pictures, and glass such as windows, mirrors, etc. The Executive Director or designee shall determine when it is safe to leave the building. Following an earthquake, assume that there will be no electricity or water available for at least 3 days. The Executive Director will make sure that the gas has been turned off. 123 P O L I C Y A N D P R O C E D U R E M A N U A L G. Tornado Preparedness When a Tornado Warning is issued, it means a tornado has been sighted or is imminent. Take shelter immediately. The Alpha Center has a shelter in our file room in the basement clinic. There will be water and juice in the small refrigerator. There is a weather radio in the room. Flashlights can be found in each clinic room and the nursing station. All persons in the building at the time of the Tornado Warning are to go directly to the shelter. The Executive Director will make sure all persons are accounted for. Once the Tornado Warning has been cleared by the weather radio, then the person can be released. H. Bomb Threat or Terrorist Activities To handle threats that come over the telephone, stay on the line and have another staff/volunteer dial 911 on another phone line. Stay calm and do not use retaliation language. Try to keep the caller on the phone and secure information from them. Ask questions like, "When will the bomb go off?", “Where is the bomb located?", “What kind of a bomb is it?", “Why has the bomb been planted?” etc. Try to remember as much as you can about what the person is saying, background noises, etc. There is a form, “Bomb Threat Data” which should be used to help you remember/record the call. Keeping the person(s) on the line as long as possible will help the Police attempt to trace the call. Other staff/volunteers/clients (those not on the phone with the caller and 911) should evacuate the building, gather in the back parking lot and await further instruction from the Police or Fire Departments. H. Violence in the Workplace Develop a “danger plan” with co-workers, including a danger signal. If you notice a potentially dangerous situation, and can do so without alerting the threatening party, call 911 and get out of harm’s way. To handle any threat to personal safety by another person or persons, try to stay calm and do not use retaliation language. Other staff/volunteers should evacuate Center. The Alpha center danger signal is “get me the Alpha Center chart!” There are two panic buttons in the building that go directly to the police department. One is under the office manager’s desk and the other is in the clinic by the sink in the nurse’s station. You must hold the button down for more than 3 seconds for it to activate. Our safe room is in the CSU office. The door can be locked from the inside with an escape door out to the back parking lot. Once a threat has been identified, us our security pads to call the local police department. Code is 2 5 8 0 I. Reports If any of the above events occur, they should be written up as unusual occurrences and documented in the appropriate Clinic files. 124 P O L I C Y A N D P R O C E D U R E M A N U A L For Bomb Threat Information Sheet Form CA, see appendix 125 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Walk-Through Monthly Office Inspection The Executive Director or designee shall perform office inspection monthly. Procedure: 1) The Clinic Manager, Safety Officer shall complete a Walk-Through Office Inspection every month. 2) All items on the “Monthly Walk-Through Inspection” form shall be considered on the Walk-Through. 3) Visual inspection of portable fire extinguishers: Check for proper charge. Make sure pin is in place. Make sure hose and connection are not worn or damaged. Initial and date tags on portable fire extinguishers. 4) The “Monthly Walk-Through Inspection” form shall be completed and filed. The form is kept on the Clinic Manager’s file on the AC server. It is kept by the year. 5) Any necessary repairs and improvements shall be overseen by the Executive Director to insure their completion. For Walk-Through Monthly Inspection Form DA, see appendix 126 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: First Aid Kit It is the responsibility of the Clinic Manager to maintain the first aid kit. Procedure: Every month the Clinic Manager will check the first aid kit's contents against the supply list. When one half of any one product is gone, the Nurse will write a request for the item to be re-ordered and give it to the Executive Director or Director of Operations who will have the order placed. General Use Home/Auto/Office Kit 1 20 2 1 1 1 1 1 1 2 1 Box Sheer Bandages, 3/4" x 3" Flexible Fabric Bandages, 1" x 3" Oval eye Pads Hypo-Allergenic First Aid Tape, 1/2" x 180" (5 yds.) in dispenser Elastic Bandage, 2" First Aid Cream, .8 oz. tube Tweezers First Aid Guide Contents Card Disposable Gloves Tube burn cream 127 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Exposure Control Plan All employees/volunteers of The Alpha Center shall be given instructions and procedures to control infectious disease hazards which might result from exposure to body fluids. (See “Universal Precautions Infection Control” Policy.) Procedure: 1) The Clinic Manager shall identify all staff who may be potentially exposed and ensure their training in Universal Precautions Infection Controls. Such staff will include physicians, nurses and other medical staff. Training shall include an explanation of: a) Applicable regulatory text, a copy of which will be provided b) Epidemiology and symptoms of bloodborne pathogens c) Modes of transmission of bloodborne pathogens d) Employer's written exposure control plan e) Methods to control transmission of HBV and HIV f) How to recognize occupational hazards g) Information on free HBV vaccine and its benefits, risks, etc. h) Emergency procedures for and reporting of exposure incidents i) How to use personal protective equipment j) The use of labels for hazardous materials 2) Every direct contact with body fluids will be handled as if it was infectious, and every employee exposed to direct contact with body fluids will be protected as though such body fluids were HBV or HIV infected. If an exposure incident occurs, it will be addressed and reported immediately to the Clinic Manager or Executive Director. She will give instructions for obtaining a confidential post-exposure follow-up. 3) If an employee refuses evaluation, s/he will sign an Informed Refusal Form. 4) The evaluation and follow-up will be offered free of charge to the employee and will include evaluation, counseling and post-exposure prophylaxis if indicated. 5) Employees will be made aware of this plan initially during Bloodborne Pathogen Training and periodically at monthly Safety Meetings. For Exposure Incident Report Form EA, see appendix 128 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Hazard Communication Program The management staff of The Alpha Center is committed to the prevention of incidents or happenings that result in injury and/or illness and to comply with all applicable federal and state health and safety rules. We require that management spare no effort in providing a safe and healthful work environment for all employees, that all levels of supervision be accountable for the health and safety of those employees under their direction, and through this written hazard communication program share assigned responsibility. In order to comply with Occupational Health and Safety Administration 1910.1200, the following written hazard communication program has been established for The Alpha Center. All company divisions and sections are included in this program. The written program will be available in the Policy and Procedure Manual for review by any interested employee. Procedure: A. Container Labeling The Clinic Manager will verify that all containers received for use will clearly list contents on the label, note the appropriate hazard warning, and list the manufacturer’s name and address. It is the policy of this company that no container will be released for use until the above data are verified. The Clinic Manager will ensure that all secondary containers are labeled with either an extra copy of the original manufacturer’s label or with the “central stores” generic labels that have appropriate identification and hazard warnings. B. Material Safety Data Sheets Copies of MSDSs for all hazardous chemicals to which employees of this company may be exposed will be kept in the Clinic Manager’s office, MSDSs will be arranged in a binder, marked MSDS. If MSDSs are not available or new chemicals in use do not have an MSDS, immediately contact the Clinic Manager. Prior to a new hazardous chemical being introduced into any section of this company, each employee of that section will be given information as outlined above. The Clinic Manager is responsible for ensuring that MSDSs for new chemicals are available. C. Employee Information and Training Prior to starting work and annually, each employee will attend a health and safety informational/training meeting with the Clinic Manager. 129 P O L I C Y A N D P R O C E D U R E M A N U A L An overview of the requirements contained in 29 CFR 1910.1200 and 1926.59 – Hazard Communication Standard. Chemicals present in their workplace operations. Location and availability of our written hazard program. Physical hazards and health effects of the hazardous chemicals. Methods and observation techniques used to determine the presence or release of hazardous chemicals in the work area. How to reduce or prevent exposure to these hazardous chemicals through use of control/work practices and personal protective equipment. Steps the company has taken to reduce or prevent exposure to these chemicals. Safety emergency procedures to follow if the employee is exposed to these chemicals. How to read labels and review MSDSs to obtain appropriate hazard information. After attending training, each employee will sign a form to verify that he or she attended the training, received our written materials, and understood this company’s policies on Hazard Communication. Form FC D. Hazardous Chemicals List The following is a list of all known hazardous chemicals used by The Alpha Center employees. More information on each chemical noted is available by reviewing MSDSs located in the Clinic Manager’s office. The list of Hazardous chemical is in the MSDS book. See Alpha Center Form FA (NOTE: The hazard-communication standard requires a list of all hazardous chemicals; however, identifying locations and processes may help you carry out the program. E. Hazardous Non-Routine Tasks Periodically, employees must perform hazardous non-routine tasks. Before starting work on such projects, each affected employee will be given information by the Clinic Manager about hazardous chemicals to which he or she may be exposed during such activity. This information will include: Specific chemical hazards. Protective/safety measures employees can take. Measures the company has taken to reduce the hazards, including ventilation, respirators, presence of another employee, and emergency procedures. Examples of non-routine tasks performed by employees of this company: 130 P O L I C Y A N D P R O C E D U R E M A N U A L F. An annual worksite hazardous assessment will be completed, form FG. Form will be placed in binder in Nurse’s office and kept for seven years. G. Informing Contractors It is the responsibility of the Clinic Manager or Executive Director to provide contractors with the following information: Hazardous chemicals to which they may be exposed while on the job site and the procedure for obtaining MSDSs. Precautions employees may take to lessen the possibility of exposure by using appropriate protective measures and an explanation of the labeling system used. Also, it is the responsibility of the Clinic Manager or Executive Director to identify and obtain MSDSs for the chemicals the contractor is bringing into the workplace. H. Exemptions Exempt chemicals are those used as “consumer product” by the Consumer Safety Act. These chemicals are used in the work place for the purpose intended by the chemical manufacturer. OSHA considers office chemicals such as Wite out, cleaning chemicals and copier chemicals to be exempt under the provisions of the rule as consumer products. Consumer products, which are hazardous chemicals as defined by the HCS, fall under the provisions of the standard only when they are used with greater frequency or duration than a normal consumer, or for “uses not intended by the manufacturer.” 131 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Personal Protective Equipment Program It is the policy of The Alpha Center to identify and control (or eliminate) hazards in our workplace. When this is not feasible, Personal Protective Equipment, PPE, will be provided to employees. Employees are expected to wear the PPE required for their job and keep it in good condition. Employees must report damaged or inadequate PPE to their supervisor immediately so that it can be replaced. The Clinic Manager and all employees are required to set a good example by wearing the PPE required in their Department. Employees will work with Clinic Manager to purchase comfortable PPE that fits. Our Executive Director will encourage employees to look out for themselves and their co-workers. This program applies to all employees who are exposed to physical and/or chemical hazards in our workplace. The following areas are included: Clinic area First floor Bathroom-Pregnancy Testing area Procedure: A. PPE Rules are posted in the Clinic Manager Office. B. Each individual employee is responsible for notifying the Clinic Manager when equipment, chemicals, or procedures change in their department so that the Hazard Assessment, and PPE Rules, can be updated. C. All employees will receive training on the PPE used in their area when they are hired. Retraining will be given when: PPE is not worn according to our rules, When a task, equipment, or procedure changes in their department, and When an accident or near-miss indicates a need. Annually D. Enforcement is necessary to make sure workers do their part in protecting their own safety. The Clinic Manager will enforce proper use of PPE in their department. Enforcement of safety rules shall be fair and uniform. Failure to comply with our PPE rules will result in disciplinary action (up to and including termination). E. An annual hazardous assessment for PPE will be done, see form FF. Once filled out, form will be placed in binder in Nurse’s office and all nursing staff will be included in assessment. Copies will be kept for seven years. 132 P O L I C Y A N D P R O C E D U R E M A N U A L F. Volunteers are expected to follow our PPE rules. PPE can be obtained for them in the clinic. Contractors will follow our PPE rules. When Supervisors hire a contractor they will inform them what PPE is required so they can bring it with them. Alternatively, the supervisor will provide the PPE we require to the contractor. 133 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Transporting Clients Because of insurance liabilities, no staff member or volunteer will be allowed to transport clients. 134 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Claims Management Procedures 1) An injured employee must immediately notify his/her supervisor. When an on-the-job accident or injury occurs, the most important consideration is the injured employee. In a life threatening or severe emergency, take the employee to the nearest medical facility immediately or call 911 for assistance. For non-emergency injuries, take the employee to Dr. _____, the designated medical provider. (The employee may be held personally responsible for payment of any medical bills if an unauthorized medical facility is used.) 2) After the injured employee has been given medical attention, the next step is to contact the Alpha Center’s workers' compensation insurance carrier. If an employee is injured on the job, the Alpha Center’s workers’ compensation insurance will provide for payment of medical expenses and weekly compensation payment, if applicable. Alpha Center’s workers’ compensation insurance carrier is COLORADO COMPENSATION INSURANCE. Our policy number is 3271487. Ms. VIRGINIA HERRERA, at 1-303-782-4072, is the claims adjuster who handles our account. Contact Ms. Herrera and explain the circumstances of the accident, give the probable amount of time, if any, the employee may be off work, the preliminary medical prognosis and mention that the appropriate FIRST REPORT OF INJURY is being completed. 3) After the insurance carrier has been contacted, investigate the cause of the accident. Accident investigation is an indispensable factor in loss control. Some of the basic things to cover in the investigation are: a) Was the accident the result of third party negligence? b) Did the accident indeed happen on the job? c) All witnesses should be interviewed and written statements taken d) What could have been done to prevent this accident? e) Was a posted safety rule knowingly violated? 4) Injured employees will be contacted at least on a weekly basis. Modified duty will be implemented whenever possible. 5) A quarterly policy review will be held with Ms. Herrera. This review will look at such things as reserves; rate calculation, discounts and loss prevention/loss control implementation and training. 135 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Equipment Operation and Maintenance The Clinic shall maintain the equipment necessary to meet its scope of services. Procedure: 1) The Clinic shall maintain the following equipment, which only qualified medical personnel may utilize: Sphygmomanometer (Blood pressure cuff) Ultrasound machine Thermometer Examination Table and Light 2) A flashlight will be in readiness for use at all times and located in readily accessible areas. Two sets of batteries shall be kept with the flashlight. Flashlights will be tested regularly, and batteries will be replaced as needed. 3) The ultrasound machine will be serviced when necessary. 136 P O L I C Y A N D P R O C E D U R E M A N U A L Chapter 10 Infection Control 137 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Universal Precautions Infection Control All staff (employees and volunteers) of Alpha Center shall apply the Universal Precautions for Infection Control established in the following procedures. Blood and body fluids provide a vehicle for the transmission of infectious diseases, and because infectious clients may not always be identified, this policy is critical. Procedure: A. Hand Washing 1) Hands must be washed to reduce the spread of microorganisms from one person to another; to ensure cleanliness and keep hands free of infection and to reduce the spread of infection. Remember: Hand washing before and after contact with patients is the single, most important means of preventing the spread of infection. 2) If hands come in contact with the following substances, they shall be washed immediately with soap and water. Blood Body fluids of any kind Moist tissues of the body Urine Feces Oral secretions or vomitus 3) Hands must be washed: After direct patient contact During performance of routine procedures After personal use of the toilet After sneezing or coughing Prior to invasive procedures 4) Fingernails are to be washed carefully, as they harbor bacteria. 5) Hand washing is a procedure that must be practiced faithfully by all medical staff and volunteers. Wet hands, apply soap, and work up lather. Rub hands together. Pay particular attention to the skin crevices, between fingers and around nails where dirt, body oils, perspiration and microbes accumulate. Rinse hands thoroughly. Dry with paper towel. Turn faucet off with paper towel. B. Personal Protective Equipment 1) To protect hands against direct contamination from body substances staff shall wear non-sterile gloves. Gloves do not replace hand washing. Gloves are to be used once, then discarded. 2) A lab coat shall be worn at all times when patient contact is likely to result in soiled clothing. 3) Masks and protective goggles shall be used when it is likely that the eyes and/or mucus membranes could be splashed with body substances. 4) Gloves shall be worn by staff that is likely to come in contact with any infectious substance and for the following tasks: a) Cleaning up spills, work areas, exam rooms and bathrooms b) Touching instruments or surfaces that have been or are suspected of being contaminated by the following fluids: 138 P O L I C Y A N D P R O C E D U R E M A N U A L Blood Body Fluids Moist tissues of the body Urine Feces Oral secretions c) Performing urine tests d) Assisting with invasive procedures. 5) There is no specific technique for the application of non-sterile gloves. However, the glove should be long enough to cover exposed skin. 6) To remove gloves, grasp the opening at the wrist and pull off the glove inside out. 7) Gloves should be removed before masks and discarded in the appropriate receptacle lined with a red biohazard bag. 8) Hands should be washed after the gloves are removed but before masks or lab coats are removed. C. Soiled Linens or Paper Products 1) All linen or soiled paper products will be considered potentially infectious. 2) Check linen before removing from the exam table to be certain there are no instruments or patient belongings inside. 3) Roll linen into a firm bundle, as it is removed, to prevent needless contamination of the environment. 4) Place rolled bundles of linen into a hamper lined with an impervious plastic bag, and place all soiled paper in a waste receptacle lined with a red biohazard plastic bag. D. Disinfecting Equipment and Work Area Stethoscope: Ear pieces of stethoscopes must be cleaned with alcohol sponge before and after use. Exam Rooms: 10) Put on gloves. 11) Linens are to be folded in a firm bundle and placed in laundry receptacle. 12) Exam table covers and disposable drapes are folded in a similar manner and placed in trash. 13) Exam table, dressing table and any contaminated work surfaces are to be sprayed with 5.25% sodium hypochlorite (household bleach) diluted 1:10 with water and wiped down and left to air dry. (PURSUE disinfectant cleanser may also be used instead of bleach.) 14) Remove gloves. 15) Wash hands. E. Disposal of Infectious Wastes 1) Infectious waste shall be contained and disposed of in a manner consistent with the requirements of the local and state Departments of Health Services and/or other regulatory agencies, including OSHA guidelines. 2) Infectious waste is material that contains recognizable blood, fluid blood products, containers, or equipment containing blood. Examples of infectious waste include: items used in vaginal exams, 139 P O L I C Y A N D P R O C E D U R E M A N U A L specula, gloves, instruments used in the removal of laminaria, and urine cups that contain visible blood. Urine, unless containing blood, is not considered infectious waste and therefore can be discarded in the toilet. Urine cups that do not contain visible blood can then be thrown in the trash. A discarded material contaminated with excretion, exudates, or secretions from humans who may be potentially infectious is also infectious waste. 4) Infectious waste shall be segregated from other waste at the point of origin and contained for storage and disposal in foot operated trash cans lined with red biohazard bags. 5) Infectious waste shall be contained for storage and disposal in disposable red plastic bags which are impervious to moisture and have strength sufficient to preclude ripping, tearing, or bursting under normal handling conditions. Bags shall be securely tied to prevent leakage or expulsion of contents during handling. 6) Red bagged infectious wastes are to be stored in leak-proof rigid plastic containers which shall be used only for infectious waste. These containers shall be stored in a designated enclosed and marked area. 7) The transfer of infectious waste will be made only to a hauler who is currently registered as hazardous waste hauler by the State Department of Health Services. Stericycle has been identified as our sharps hauler. F. Definitions 1) Occupational Exposure means skin, eye, mucous membrane or parenteral contact with blood or other potentially infectious materials that may result from the performance of the volunteer/employee's duties. 2) Exposure Incident means a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that resulted from the employee's duties. 3) Bloodborn Pathogen means pathogenic micro-organisms that are present in human blood and that can cause disease in humans. These pathogens include hepatitis B virus (HBV) and human immunodeficiency virus (HIV). 4) Contaminated means the presence of blood or other potentially infectious materials on an item or surface. 5) Decontaminated means the use of physical or chemical means to remove, inactivate, or destroy bloodborn pathogens on a surface or item to the point where surfaces/items are no longer capable of transmitting infectious particles and are safe for handling. 6) Parenteral means piercing the skin barrier through such events as needle sticks, human bites, cuts and abrasion. 7) Invasive procedures mean surgical entry into tissues, cavities, or organs. 8) Personal protective equipment is specialized clothing or equipment worn by employee/volunteer for protection against a hazard, i.e. lab coats, masks, goggles, or gloves. 9) Infectious wastes consist of any waste trash material which contains infectious agents which might gain entrance to a host through wound inflictions or by splashing onto mucous membranes. 10) Source-Individual means any individual whose blood or other potentially infectious material may be a source of occupational exposure to the employee/volunteer. 140 P O L I C Y A N D P R O C E D U R E M A N U A L 11) Regular non-infectious waste means any waste which does not contain agents likely to gain entrance to a host through wound infection or by splashing onto mucous membrane. Examples are: Perineal Pads Disposable drapes/ paper exam table covers Urine cups without visible blood 12) Tasks and procedures in which occupational exposure may occur: Contact with blood products or body fluids or objects contaminated thereof Invasive procedures Handling disposal of waste Cleaning/processing of contaminated equipment Handling of soiled linen or disposable paper products. Cleaning/decontamination of environmental surfaces. 141 P O L I C Y A N D P R O C E D U R E M A N U A L Policy: Ultrasound Infection Control 1) Clean gloves will be worn for each scan. 2) Disinfectant will be used to clean the transducer after every patient. T-Spray or an equivalent shall be sprayed on the transducer, allowed to sit for 45 seconds and then wiped dry. 3) US machine will be cleaned daily according to manufacturer’s recommendations. 4) Prior to each insertion, the vaginal transducer will have ultrasound gel applied to the top of the transducer and will then be covered by a latex sheath. K-Y Jelly will be applied to the top of the transducer and then inserted into the client. For Bloodborne Pathogens Training Record Form GA, see appendix 142 Appendix Appendix 143 Pregnancy Test Release Form A and Medical Consent and Release 144 Client Initial Visit Form B 145 Client Contact Information Form C 146 Client Pregnancy History Form D 147 Client Pregnancy Test Form E 148 Video Release Form F 149 Release for Publication Form G 150 Evaluation Sheet Form H 151 Pregnancy Verification Form I 152 Standing Orders Form J 153 Client Medical Record Checklist Form K 154 Medical Records Release Form L 155 Statement of Policy on Adoption Form M 156 Ultrasound Consent, Waiver, and Release Form N 157 Ultrasound Referral Form O 158 Ultrasound Information and Appointment Sheet Form P 159 Ultrasound Report Form Q 160 Ultrasound Exit Interview Form R 161 Feedback Form S 162 Feedback Log Form T 163 Medical Personnel Record Checklist Form U 164 Staff Health Report Form V 165 Tuberculin Testing Form W 166 Hepatitis B Vaccine Information Form X 167 Volunteer Interest Form Y 168 Policies and Procedures in Case of Disaster Form Z 169 Volunteer Interest Letter Form AA 170 Volunteer Orientation Checklist Form BA 171 Bomb Threat Information Sheet Form CA 172 Walk-Through Monthly Inspection Form DA 173 Exposure Incident Report Form EA 174 Hazardous Material Masters List Form FA 175 Bloodborn Pathogens Training Record Form GA 176 Statement of Commitment Form HA 177 Statement of Faith Form IA 178 Statement of Abstinence Form JA 179 Application for Employment Form KA 180 Tenured Employee Evaluation Form LA 181 Performance Evaluation Form MA 182 Confidentiality Information Agreement Form NA 183 Unique Aspects of Job/Environment Form OA 184 Safety Rules Form PA 185 Designated Work-Related Medical Provider Form QA 186 Consent for Release of Information Form RA 187 Material Assistance Donations Log Form SA 188 Pregnancy Retest Form TA 189 Suspected Child Abuse Reporting Form UA 190 Material Assistance Intake and Concepts Shared Form VA 191 Spanish Material Assistance Intake Form WA 192 Progress Notes Form XA 193 RMFF Referral Form YA 194 195 196 197
