1 - Norm



8.1

PATIENT COURTESY

Courtesy makes our lives and jobs much more enjoyable. To the patient, you represent ____. When patients leave, they remember not only the doctor, but the personal touch too. They appreciate a smile, a genuine, "Good Morning, how may I help you?" and a "Good-bye." Address patients by name when possible (Mr. or Ms. as appropriate). These personal touches distinguish our service as something special. We are all part of _____'s Public Relations Team!

Here are some additional helpful tips to remember when dealing with patients:

▪ Greet patients promptly and courteously.

▪ Smile. Develop the ability to be cheerful, even when the situation may justify the opposite.

▪ Be a good listener. Let the patient explain their needs or problem. Do not interrupt or express your opinion before they have had a chance to finish what they want to say. Be attentive and patient.

▪ Be frank and honest.

▪ Be friendly and professional, while avoiding over familiarity.

▪ Avoid loud, boisterous, or profane language.

▪ Don’t argue or lose your temper.

▪ Avoid horseplay. It destroys a professional image and is dangerous to persons and property.

▪ Keep promises.

▪ Be alert to what is happening around you.

▪ Show your appreciation. Say “Thank you.”

▪ Look professional.

A small percentage of patients will, at times, be rude and abusive toward employees. This is a fact of our business and especially so in this day and age. If you are so treated, remember, part of your job is to "keep your cool." Most patient complaints can be courteously resolved. Anything less than professional behavior is inappropriate, sets a poor example for other employees, and will not be tolerated. At the same time, we expect our staff to be treated courteously by patients and/or their family. Immediately report to management any rude or abusive behavior you feel is “out-of-line.”

8.2

ETHICAL STANDARDS

Employees are expected to observe the highest standards of business and medical ethics. Employees are responsible for their role in our practice. Honesty and reliability are very important and we expect to be able to trust each employee. Staff members must avoid situations where their personal interest may conflict or appear to conflict with practice policy or with the welfare of our patients.

As "professionals," we require each employee to strive for conduct that reflects the highest standards of ethics and professionalism.

8.3

PROBLEMS? QUESTIONS? WHO TO SEE?

Because of the tremendous time commitments of the physicians at ____, management personnel have been hired to conduct, administrate and monitor the day-to-day operations of the practice. Any problems, questions, or matters which affect the office are to be brought to the attention and discussed with appropriate management, not the physicians. Employees are asked to adhere to the hierarchical chain of command (except as provided in the sexual harassment policy).

8.4

CONFIDENTIALITY

How healthcare providers treat health care information is undergoing a dramatic transformation in the United States. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 included a wide array of provisions designed to make health insurance more affordable and accessible. Congress included provisions in HIPAA to require Health and Human services (HHS) to adopt national standards for certain electronic healthcare transactions, codes, identifiers and security. It also set a deadline for Congress to enact comprehensive privacy legislation to protect medical records and other personal health information. The final rule that addresses this mandate is known as the Standards for Privacy of Individually Identifiable Health Information. The privacy regulations have two purposes, the first purpose is to control the use and disclosure of health information held by covered entities, and second, to give individuals rights with respect to their health information. The regulations define protected health information and governs what you can do with it internally and whom you can give it to externally.

“Protected health information” (PHI) is defined as individually identifiable health information – whether in electronic, oral or paper formats – that identifies an individual’s physical or mental health condition, the health care that the individual has received, or payments for such care.

Patients have a right to privacy. Privacy rights may be governed by federal (as shown above) and/or state law. As an employee you are in a position to observe the personal care of patients. Consequently, it is mandatory you refrain from discussing private health information and/or other sensitive office issues either within or outside the practice with anyone not having a legitimate reason to know. This includes discussions with your spouse. Be particularly discreet in conversations in elevators, eating places, other public areas, and in the medical center. Careless talk, rumors passed along as the truth by some employees, and information regarding patient care or activities may result in serious harm to patients, employees, or _____. When you hear a rumor ask management about it. They will attempt, as appropriate, to get the correct facts for you to the extent possible, practical, and allowed by law. Private health information shall only be released with appropriate written authorization or as allowed by law. Breach of patient confidentiality may be cause for corrective action up to and including dismissal. Our patients put us in a position of trust and we cannot betray it. Finally, if a “patient care” employee personally knows a patient please notify management who will in turn inform the physician. It may be in the best interest of all concerned to have someone unknown to the patient assist him or her.

Examples of how important the patient confidentiality issue is and how easily it can be violated follows:

▪ Two medical assistants standing in the hallway discuss a patient’s healthcare without regard to who is around to hear the conversation.

▪ A receptionist uses a sign-in sheet that asks for personal health information from a registering patient (e.g., Reason for appointment?).

▪ It can be argued, that if an employee goes home after work and tells his/her spouse that he/she saw a friend of theirs (by name) at the practice that day, and doesn’t even reveal why the friend was there, the employee, in fact, violated the friend’s privacy and has committed a breach of patient confidentiality.

▪ Another example would have an employee at a party over-hearing that a person was fired from his/her job because they failed their substance abuse test, and then coming forward and correcting the person who made that statement by stating that the person did not fail his/her test because the employee happened to see the results and knew for a fact that the results were negative. Even though the employee was actually defending the reputation of the person who was supposedly fired for failing a substance abuse test, the employee has violated that person’s privacy and patient confidentiality.

Further, all information pertaining to ____ and its employees is considered confidential and may only be released by management to authorized personnel or outside third parties. Confidential information includes names, address, salaries, phone numbers, financial records, trade secrets, business practices, etc. Any request for information about employees should be referred to management. If you are questioned about the business of the practice by patients, reporters, photographers, attorneys, or any third party, etc. refer them to management. It is imperative all employees make certain they in no way reveal or divulge any confidential information and such information is used only in the performance of their duties. Failure to adhere to this policy will result in disciplinary action.

Quite simply, whatever an employee knows about a patient, another person, employee, or the company as a result of employment with the practice, must stay in the practice, and must not be shared with anyone outside of the staff during and after employment.

8.5

ATTENDANCE AND PUNCTUALITY

Regular and punctual attendance by all employees is necessary and expected. The fact is attendance at work is a basic requirement of your job. In addition to possessing the skills necessary to perform the job, you must be willing and able to demonstrate these skills by coming to and remaining at work on a regular basis. The practice is not obligated to tolerate erratic or unreliable attendance. Absence is any time away from normal scheduled work time. Punctuality, is being at work on time and is part of good attendance. When you are late or absent unexpectedly (unscheduled absence) an extra burden is placed on fellow employees. Timely notification can help ensure arrangements to cover your assignment. A good attendance record is an indication of your conviction and interest in your job. Attendance and punctuality are also key factors in _____'s performance evaluation program, and thus affect raises and future consideration for promotion. The better your attendance record, the higher your overall performance evaluation.

If for any reason you cannot report to work when scheduled, telephone the practice manager or clinical coordinator (as appropriate) no less than one (1) hour prior to the start of your scheduled work. You are responsible for proper notification. Do not rely on friends, relatives, or other employees to report your absence or tardiness -- speak directly with management. Appropriate telephone numbers are readily available from management.

State why you will be late, when you expect to arrive, or why you will be absent.

If the call is not timely received by the practice manager or clinical coordinator at the designated report-off time, the absence/tardy may result in disciplinary action. However, timely notification to management of an absence/tardy by the employee does not necessarily absolve it from possible disciplinary action. An attendance/punctuality issue may not result due to the reason for the absence/tardy, but rather due to its excessive and/or patterned frequency. Even justifiable absences/tardiness must be maintained within limits to assure adequate staffing for office operations and patient care. Attendance and punctuality issues can be characterized by disruption to work flow, job not getting completed, and/or creating hardships on co-workers.

Examples of attendance and punctuality issues that may result in disciplinary action include:

a. No notification

b. Inadequate notification

c. Patterned or excessive tardiness/absenteeism (as deemed by management and with or without a physician’s statement.)

Patterns that will be reviewed will include but not be limited to:

a. Series of Thursday or Monday absences.

b. Weekend absences during which work is scheduled.

c. In conjunction with a day off.

d. Day preceding or following holidays.

e. Calling in on days requested off and not granted.

f. Pattern of time off which appears abusive.

Failure to report-off according to procedure may result in no sick pay for the day(s) of the absence.

All employees are expected to work when scheduled unless notified the office will be closed. If you are unable to report to work during inclement weather, notify management as outlined in the inclement weather policy.

All employees are expected to strive for perfect attendance by:

▪ Maintaining reasonable health standards and taking precautions against illness.

▪ Not permitting minor indispositions or inconveniences to keep you away from the job.

▪ Making every effort to live and work safely – observing and practicing safety rules, both on and off the job..

▪ Attending to personal affairs and obligations outside the working hours.

If at any time your work schedule presents a temporary hardship, please discuss it with management.

Bereavement Leave, Jury Duty, Military Leave, or pre-scheduled paid time off are not considered occurrences of absence under this policy.

The practice reserves the right to request a physician’s statement regarding fitness to perform job duties for any length of absence due to illness/disability. In addition, when an absence due to illness/disability is over three consecutive work days, a physician's statement may be required releasing the employee to return to work.

The practice reserves the right to authorize or refuse a request by an employee to be absent both with or without pay.

8.6

INCLEMENT WEATHER/EMERGENCY

All employees are expected to report to work at their regular scheduled time or as soon as possible during inclement weather. The only exception is when the office is officially closed by the physician(s). However, employees are expected to use good judgment and not unnecessarily endanger themselves, others, or vehicles. Employees will be notified of the office’s status by management thru a predetermined plan available from management.

Office Closed Full Day

▪ Exempt employees (salaried): Paid

▪ Non-Exempt employees (hourly): Employees may take available vacation/personal time off to get paid.

Office Opens Full Day but Employee Unable to Report

▪ Exempt and non-exempt employees may take available vacation/personal time off to get paid.

Office Opens Late or Closes During the Day

▪ Exempt employees: Paid if employee reports to work or has reported to work and office closes.

▪ Non-Exempt employees: Employees reporting to work will be paid for the whole day. Employees unable to report may take available vacation/personal time off to get paid.

When the office is closed due to an emergency situation (e.g., extraordinary circumstances where an evacuation is due to weather, bomb threats, etc., and/or extensive damage to or destruction of the building and/or equipment, etc.), each salaried employee will receive pay for a maximum of five working days, and hourly employees will receive their normal day’s pay (when regularly scheduled to work) for the first and second days the office is closed, and 50% pay for the third, fourth and fifth days the office is closed. If the office is closed for more than five working days, the employee may elect to use any available vacation leave or be off without pay.

____ cannot offer pay beyond the exhaustion of the above-mentioned paid time off. However, at the practice’s discretion and circumstances, employees may be offered their positions upon resumption of normal business operations.

8.7

DRESS CODE

As you represent _____ to our patients and public, it is essential you take pride in your personal appearance at all times. The basic dress code will apply uniformly to all employees throughout _____.

It is not the intent of _____ to dictate or restrict what employees wear but rather to assure a professional work environment. ______ will not impose uniform requirements on business office personnel, as long as, employees show reasonable judgment in their dress attire to maintain a professional business look as determined by the practice. Inappropriate casual wear includes sweat suits, T-shirts, shorts, jeans, short or tight-fitting attire, and etc.

Male employees are encouraged to wear dress pants and shirts. Jackets are optional.

Clinical staff will be required to wear approved uniforms. Those employees are responsible for coordinating uniform style and color to established standards and scheduling. Generally, white is always appropriate. White skirt or slacks with color-coordinated tops are also acceptable. Shoes can be a professional nursing shoe or conservative athletic shoe (e.g. Reeboks). All shoes must be mostly white, clean and in good repair.

All employees' clothes must be neat, clean, and appropriate for professional nursing and administrative work, and enhance the image that _____ must project to its patients, visitors, and public. Hair styles, clothing, jewelry, makeup, perfume, hands, nails, and personal hygiene must conform to the best business and nursing standards. Mustaches and beards may be worn if they are full and neatly trimmed. An unprofessional appearance may make patients uncomfortable and any interference with normal work may adversely affect the level of patient confidence in ________________________________. Any “dress” that is disruptive to the workplace as determined by management and accepted professional business practices will be subject to disciplinary action including termination.

All employees are required to wear an identification name badge which enables you to be readily identified by patients. You must wear your name badge at all times while on duty. Please wear the badge on the upper torso area. Do not attach decals, pictures, stickers, etc. to your name badge. A name badge is made available to you at no cost at the time of employment. Lost name badges will be replaced at a nominal cost to the employee. Broken badges will be replaced at no charge, if turned in at time of the request.

Personnel Protective Equipment: See OSHA - Occupational Exposure Control Plan.

8.8

GRIEVANCES

Employees are encouraged to bring to management's (not physician's) attention any problems or grievances they may have regarding employment. We know little problems can get to be big ones if they go unresolved. Your problem will be held in confidence to the extent possible and practical, and every effort will be made to resolve any problem you may bring to management.

A positive approach to problem solving is always the best means. If you have a problem, we would like to know what solution(s) you may have to offer to correct it. We certainly want your ideas and input so that a mutually satisfying resolution can be achieved.

Like any piece of equipment or machinery, our practice cannot run efficiently and productively unless all of its components or members work in harmony with each other. Good working relationships are very important if we are to properly provide the service expected from our patients. Consequently, domestic problems, petty jealousies, and personality conflicts are to be left outside the office. Employees are expected to be courteous and friendly to each other at all times. Further, employees who are not busy are expected to help fellow employees who are very busy without being asked to do so. All of us share a common goal of helping the physicians provide the best possible medical care to our patients. Snide remarks, “backstabbing”, and “cold shoulders” have no place in the office and will not be tolerated.

Employees who encounter problems with other employees while at work, are encouraged to strive to bring about reasonable resolutions between themselves, before asking for direct involvement of management. It is appropriate to begin by discussing the problem with the other employee(s), privately, in a positive, professional manner, with the goal of arriving at a solution that is acceptable to all. If after a reasonable period of time (approximately 2-4 days) the problem has not been resolved, a second attempt should be made to immediately resolve it. Then, if after a second attempt, the problem remains unresolved, management should be contacted. All employees are cautioned that intentional refusal to promote harmony and foster understanding is grounds for disciplinary action, including termination.

Problems of a serious nature (affecting or having serious potential to cause harm to an employee, patient, or employer, etc.) should be immediately reported to management. No employee should feel that his or her problem(s) are too small or unimportant to take to management.

8.9

UPDATING PERSONNEL RECORDS

When you began employment with ____ you completed various forms which contained important information. Keeping this information correct and current enables us to reach you in an emergency, forward your mail and W-2 forms, maintain your insurance and other benefits, and compute payroll deductions. Please notify administration promptly (within one week) of changes in:

▪ Address and telephone number

▪ Marital status

▪ Name

▪ Beneficiary or dependents listed in your insurance policy

▪ Number of dependents for withholding tax purposes

▪ Person to notify in case of accident

If you have furthered your education in any way it should also be recorded in your personnel records. This is helpful in determining your qualifications for promotion or transfer within ____.

8.10

OPEN FILE POLICY

(Personnel Records)

A personnel record of each employee is maintained by management. The content of the record may include application, other personal data, references and such employment reports as evaluations, commendations, reports of unusual occurrences, corrective action reports, etc.

It is the position of _____ that all personnel records are company property. Employees of _____ may be granted permission to examine relevant portions of their personnel records in accordance with the need-to-know rule, with a member of management present, and at reasonable times determined by management. Employees who have terminated employment will not be granted permission to review their personnel file without proper court documentation.

Access to personnel records, unless authorized, is limited to the following:

▪ Physicians

▪ Management

8.11

SEXUAL AND OTHER HARASSMENT

_____ is committed to providing a professional work environment. In keeping with this commitment we strive to maintain a policy prohibiting unlawful harassment, including sexual harassment, and any conduct that has for the purpose or effect of interfering with an individual’s work performance or creating an intimidating, hostile, or offensive work environment. Other forms of continuous behavior that is deemed as annoying, intimidating, abusive, or inappropriate by _____ management is prohibited. This policy applies to all employees including supervisory and non-supervisory employees. It prohibits harassment in any form including verbal, visual, and physical harassment. This includes, but not limited to, means of communication like e-mail, faxes, handouts, and voice-mail, etc.

Sexual harassment is a behavior which undermines the integrity of the employment relationship. All employees must be allowed to work in an environment free from unsolicited and unwelcome sexual overtures, sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature. Sexual harassment does not refer to occasional compliments. It refers to behavior which is not welcome, is personally offensive, reduces morale, and unreasonably interferes with employee effectiveness and work performance.

Generally, two categories of sexual harassment exist. The first, “quid pro quo” (something for something) may be defined as an exchange of sexual favors for improvement in an employee’s working condition and/or compensation. The second category, “hostile work environment,” can be described as unwelcome conduct that has the purpose or effect of creating an intimidating, hostile or offensive work environment or unreasonably interfering with an individual’s work performance.

Examples of sexual harassment include, but not limited to, offensive or unwelcome physical contact, lewd or sexually suggestive comments, sexual propositions, sexually-oriented teasing or kidding, jokes of a sexual nature, or any display of sexually explicit pictures, photos, cartoons, books, magazines, greeting cards, or other objects.

All employees must respect the rights of one another and shall refrain from any behavior or conduct toward any other employee that could be interpreted as sexual harassment.

Any employee or supervisor who believes they have been harassed and/or intimidated by a co-worker, supervisor, or any other person, has the responsibility to promptly report the facts of the incident or incidents and the names of the individuals involved to management. You do not have to complain to the offending person -- contact another manager or physician whom you would feel comfortable. Employees are encouraged to report harassment to management before it becomes severe or pervasive. All concerns brought to management’s attention will be kept confidential so far as is possible and practical. Any investigation may include interviewing the individual charged, and/or witnesses. No employee shall purposely provide or make an untrue statement of fact regarding a complaint of harassment or in an investigation. Retaliation against anyone who complains of harassment or who participates in an investigation is strictly prohibited.

Our aim is to investigate all incidents and have resolutions prompt with appropriate management personnel involved. If the practice determines that harassment did occur, appropriate disciplinary action will be taken against the offending employee, up to and including termination. If the individual who harassed the employee is not employed by the practice, the practice will take corrective action to the extent practical and possible. However, if the investigation determines that the complaint is not bona fide or that the employee has provided false information regarding the complaint, disciplinary action may be taken against the individual who filed the complaint or who gave false information.

If an investigation reveals that sexual harassment has occurred, the harasser may also be held legally liable for his or her actions under the state or federal anti-discrimination laws in a separate legal action.

8.12

TELEPHONES

_____ understands the importance of communications in our lives. Infrequent calls to arrange transportation, calls to check on the safety of family, and other important calls are permissible. It is not the intent of ____ to restrict access to necessary communications. To do so punishes many for what a few may abuse. However, it is management’s responsibility to maintain a professional climate in the office. Frequent and lengthy personal conversations do not further this objective. Excessive calls interfere with everyone’s duties -- including your own. It is unprofessional and does not set a good example for others. Remember, telephone use at _____ is a company courtesy and not a personal privilege. Always set a good example!

Personal telephone call privileges are subject to change or termination at any time. For example, and not to be limiting, if the practice telephone lines become overloaded with calls or an employee is found spending more than just limited time on personal calls, this privilege may be revoked either generally for all staff or specifically as to the offending employee.

▪ Please keep calls local and restrict them primarily during breaks, lunch, and at quitting time.

▪ Staff should inform all potential callers that interruptions are limited to necessary calls.

▪ Limit calls to three minutes.

▪ Patterned abuse of telephone privileges is unacceptable and subject to disciplinary action.

▪ To insure consistency and professionalism the telephone answering procedure is as follows:

1. Answer the telephone within three rings. Promptly answering the telephone establishes good rapport.

2. Speak clearly with a pleasant tone of voice. Over ninety percent of the time, the customer’s perception of you is determined by the tone of your voice.

3. Identify your department and your name. This provides personal attention to the caller.

4. Listen carefully so you will know what your customer wants.

5. Follow through. Stay with the caller until he/she is satisfied. Be considerate to the caller when transferring a call; stay on the line until you reach the person to whom you are transferring. Avoid multiple transfers.

6. Ask the caller’s permission to put him/her on hold.

7. Be a responsible voicemail user. Always associate a name or department with your extension. Update your message to reflect current data. Acknowledge each voice mail message you receive within twenty-four hours.

8.13

PERSONAL PROPERTY

____ tries to prevent loss of any kind. We urge you not to leave valuables or cash unattended. ____ will not assume responsibility for missing items.

8.14

SMOKING AND OTHER TOBACCO PRODUCTS

(Attention: Select Policy Statement of Choice)

_____ is committed to providing a safe and healthy environment in which to provide care to our patients and work. In light of this commitment, smoking and the use of tobacco is prohibited.

Tobacco breaks will not be allowed. If you must use tobacco, restrict it to your lunchtime and do so away from the office.

If an employee is found to be smoking or using tobacco products on ______ premises, disciplinary action will be taken, up to and including termination.

If a patient or visitor is smoking or using other tobacco products, kindly inform them that this is a no smoking/tobacco use facility and please refrain from its use.

____ is committed to providing a safe and healthy environment in which to provide care to our patients and in which to work. In light of this commitment, smoking and the use of tobacco is discouraged as an unnecessary health hazard.

Employees will only be allowed to smoke or use tobacco products during authorized times as defined in the lunch and break privilege policies, and only in designated area(s) outside the office. It must be remembered that break(s) cannot interfere with patient care or practice operations.

If an employee is found to be smoking or using tobacco products in any non-designated area, at an inappropriate time, or fails to maintain a clean designated break area, disciplinary action may be taken.

If a patient or visitor is smoking or using other tobacco products, kindly inform them that this is a no smoking/tobacco use facility and please refrain from its use except in designated areas.

All employees are encouraged to assist in the enforcement of this policy.

8.18

HIV/AIDS

____ recognizes that AIDS and HIV infection maybe disabilities in accordance with its policy on Equal Employment Opportunity (EEO) and the requirements of the Americans with Disabilities Act of 1990. In addition to the provisions of ____'s EEO policy on non-discrimination and reasonable accommodation for disability, the following guidelines are intended to assist management in maintaining a work environment that is responsive to the workplace issues created by AIDS and HIV infection and the concerns of employees who may request management assistance.

While there is no medical basis for employees to refuse to work with HIV/AIDS-infected employees during ordinary workplace contact or provide patient care under universal precautions, ____recognizes the unique setting of healthcare and the many possible opportunities that exists for HIV/AIDS transmission. Therefore, concerns of our employees will be taken seriously and will be addressed with appropriate information and counseling. ____ will educate as necessary its employees about HIV and AIDS. Our educational effort will take a balanced view of the medical evidence. Specialists and other healthcare experts will be brought in if necessary. It is our belief that a well-educated work force is better prepared to handle itself and less likely to make impossible demands on ____ if employees contract the disease.

_____ will encourage management and co-workers to convey sensitivity and understanding to employees and patients affected with HIV or AIDS. We may also provide outside referral and benefits counseling as appropriate.

Any employee, who after educational counseling, continues to refuse to work with or around another healthcare worker, employee, or patient because of individual unfounded fear of HIV/AIDS or related problems may be subject to disciplinary action, including discharge.

A primary objective of the practice is to protect the health and welfare of all patients and employees while providing a safe work environment. As such, infected, but non-exposure prone employees, are encouraged to voluntarily disclose their health status to management. Infected, and exposure prone employees* should report any suspected or confirmed diagnosis of HIV or AIDS infection to management. All employees are further subject to an ongoing evaluation of their ability to adequately and safely perform the patient care duties required by his/her position. Changes in work assignments are determined on an individual basis after consultation with management and medical personnel. Medical personnel may include: personal physician, infectious disease specialist, public health official, and a healthcare worker with expertise in the job/procedures performed by the infected employee.

If an employee who performs exposure-prone procedures is suspected of having HIV or AIDS, management in consultation with medical personnel will determine appropriate testing and treatment for the employee based on the individual's current available medical information. Follow-up testing may be indicated and performed when necessary. Failure to consent to recommended testing will result in:

• Appropriate counseling being provided for the employee.

• Other appropriate action consistent with _____ policies, after all attempts to address employee's concerns are undertaken.

An employee will not be automatically transferred or terminated because he/she has contracted HIV or AIDS. Terminations may be necessary where an employee is unable, with reasonable accommodation, to perform the essential functions of the job or the employee cannot perform the job without posing a direct threat to the health or safety to themselves or to others

(e.g., employees performing exposure-prone procedures). These determinations will be made on an individual, case-by-case basis, by management and medical personnel. Generally, employees with HIV or AIDS may not be allowed to perform exposure-prone medical procedures in which the employee might be cut or injured and the employee's blood contact a patient. All medical information will be maintained by management in a confidential manner and will be disclosed only to persons having a legitimate need to know and only to the extent required to protect the health, welfare, and safety of patients and employees. Any leave of absence or termination will be consistent with existing policies and procedures, including those for eligibility for leave of absence.

______ strives to follow the progress of medical research on HIV and AIDS infection. If any significant developments are noted, these guidelines will be modified accordingly. Any questions concerning AIDS-related issues should be directed to management.

Management and medical personnel will determine the necessity of any patient notification or follow-up following a HIV/AIDS incident.

All ____ employees must observe all infection control policies/procedures and universal precautions.

*Exposure Prone Employee:

Employees who, during the performance of their duties, are reasonably anticipated to have skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials, are deemed to have “occupational exposure”. This definition covers any person whose job duties include activities that, if the person is HIV/AIDS positive, could reasonably infect another person with HIV/AIDS.

An employee who performs surgery where open wounds or body cavities are exposed, those who assist in such surgery where the assisting individual will directly touch open wounds and body cavities while sharp instruments are present, or those who will touch sharp instruments which will immediately come into contact with an open wound or body cavity, and emergency room personnel who would be expected to touch open wounds, perform emergency surgery, or place their hands or fingers in body cavities. Under this definition, not all employees who are present in surgical or emergency rooms are included. For the purpose of this policy, those employees who do not place their hands or fingers on open wounds, or near or into open body cavities while sharp instruments are present are not considered to be exposure prone employees.

8.19

SUBSTANCE ABUSE

____ strives to provide a safe work environment and encourages personal health. Our objective is to detect substance abuse among employees, provide an opportunity for rehabilitation and/or discipline as appropriate for substance abuse related incidents in the workplace; and to ensure that the services provided to our patients are performed by persons free of the effects of drugs or alcohol. Consequently, the practice considers the abuse of any substance, legal or illegal, which adversely affects an employee’s ability to perform his/her duties to be unsafe to co-workers, patients, other individuals, and counterproductive to work. Any employee violating this policy may be subject to disciplinary action up to and including discharge.

The use, manufacture, possession, distribution, or sale of illegal drugs or alcohol* while on practice property (including parking lots), on or off the job so as to adversely affect job performance or reputation of the practice, is strictly prohibited.

An employee may be indefinitely suspended without pay pending the resolution of a suspected substance abuse matter.

The practice retains the right, at its sole discretion, to ask an employee to submit to a drug and/or alcohol screening when:

       Χ There is reasonable suspicion that an employee is under the influence of any substance, legal or illegal, which adversely affects (as determined by management) an employee’s ability to perform his/her duties, or otherwise violates this policy.

       Χ There is any mishap or accident involving the employee in which injury to persons or damage to property has occurred.

An employee reporting for work visibly impaired (as determined by management) is considered unable to properly perform required duties and will not be allowed to work. If possible, management will first seek another manager’s opinion of the employee’s status. Then management may consult privately with the employee about the observation, to rule out any problems that may have been caused by prescription drugs. If, in the opinion of management, the employee is considered impaired, he or she may be asked to submit to a drug/alcohol test at an approved lab.

Prescription drugs prescribed by the employee’s physician may be taken during work hours. The employee should notify management if the use of properly prescribed prescription drugs will impair the employee’s work performance. Abuse of prescription drugs will not be tolerated.

Management will attempt to counsel an employee whenever they see changes in performance that suggest an employee problem. Management may suggest or require that the employee seek help from an appropriate healthcare provider.

An employee who for the first time has a positive test may be referred to an appropriate healthcare provider at the company’s discretion. Such employees may be granted leave with a conditional return to work depending on successful completion of the agreed upon appropriate treatment regimen. Failure to follow through with appropriate provider counseling and/or subsequent positive tests may result in dismissal.

All employees agree that once determined by management to be under the influence, to allow searches and inspections of their person, clothing, motor vehicle, or any other property brought onto _____ premises for illegal drugs or alcohol. Employees are advised that refusal to submit to a search or testing will be subject to discipline, up to and including discharge.

When an employee is involved in the use, manufacture, possession, transfer, or sale of a substance in violation of this policy, the practice may notify appropriate authorities.

Employees agree to notify management of any criminal drug statute conviction for a violation occurring in the workplace no more than five (5) calendar days after the conviction. “Criminal conviction” means finding of guilt, an imposition of a sentence, a plea of no contest, or a plea of guilty.

       Χ Alcohol and drug testing will be performed in accordance with an appropriate testing method.

       Χ Testing will be performed by an approved laboratory.

       Χ Initial positive test results will be confirmed by a second test.

       Χ To assure specimen integrity, samples for testing will be obtained and maintained in accordance with the procedure specified by the laboratory selected for analysis.

       Χ Test results will be kept confidential, given only to management and officials on a need-to-know basis.

* Illegal drugs mean any drug (a) not legally obtained or (b) legally obtainable but not legally used. Therefore, the term includes prescription drugs obtained illegally -- and prescription drugs not being used for prescribed purposes. It also includes marijuana, cocaine and heroin and derivatives of those drugs, among other illegal drugs.

Alcohol is defined as any beverage that may be legally sold and consumed and has an alcoholic content in excess of 3 percent by volume.

8.20

WORKPLACE PRIVACY

As an instrumental part of ____’s effort to assure a theft and drug free environment, workplace searches may be conducted. The practice reserves the right to conduct searches of both person and property on or brought onto its premises. All employees are hereby notified that employees, packages, lockers, work areas, desks, vehicles, etc. are subject to reasonable searches at any time, at random or upon cause as management may determine. ____’s objective is to provide a safer and more secure environment for patients, employees, visitors and others.

Χ Employees may not use personal locks on company property.

Χ Searches in and of themselves do not imply or constitute an accusation of wrongdoing.

Χ Employees that refuse a search may be disciplined (including dismissal) for insubordination or refusing to cooperate in an investigation.

Χ Information regarding a search will be confidential and limited to management and officials on a need-to-know basis.

8.21

COMPUTER SYSTEM

INTRODUCTION

The computer system at _____plays a crucial role in all our daily activities. _____ runs its system(s) by combining various hardware and software applications. This complexity brings with it an inherent level of sensitivity. Since each part of our system is linked to another, it is important that the “big picture” is considered when dealing with even the smallest computer concern.

We depend on the ability of the system and the integrity of the data it contains. As a system user, you are an integral part of seeing that we maintain that stability and integrity. The policies described in this section have been developed in order to assure that ____ is able to develop and maintain a stable computer system.

COMPUTER SYSTEM SECURITY

_____ assigns security and access based on the tasks assigned to particular individuals. In most cases, individuals are assigned a unique user log in and password. The sharing or exchanging of individual passwords is prohibited.

In some cases, a user log in password is assigned to a workstation rather than an individual. In this case, the sharing of passwords is permitted but only between other employees.

Management will maintain a list of user log in codes and passwords and may, on occasion, give an employee “supervisor level” access or passwords to certain parts of the system. Sharing individual passwords and/or “supervisor level” passwords with any other employee is prohibited.

COMPUTER SOFTWARE

Employees may not load software that has not been licensed to _____. Bringing in software from home or offices outside of _____ is not permitted.

All software is the property of ___ and will not be taken from the premises. The “loaning of software” is not permitted. All software is to be stored in a secure “locked” place. Employees are not permitted to store software at their desks.

COMPUTER HARDWARE

All hardware is supplied by _____. Employees must obtain approval from the management prior to adding any hardware device. Employees will not move any piece of computer and/or computer-related equipment without first obtaining approval from management.

All computer and computer-related equipment is the property of _____ and will not be taken from the premises. The “loaning” of any computer or computer-related equipment is not permitted without the written consent of management.

SYSTEM SUPPORT

Employees will not contact our computer system vendor directly without first obtaining approval from management.

COMPUTER TRAINING

Various computer training is available to all employees. Specific training may vary depending on the employee’s position and need for the computer to perform the job.

Specific protocols have been developed covering many areas of our computer system. Employees are responsible for adhering to all written and verbal system protocols.

INTERNET ACCESS

Employees may access the Internet only for business reasons. Use of the Internet for entertainment purposes is prohibited. Violations will be subject to disciplinary action.

8.22

INTERNAL AND EXTERNAL ELECTRONIC COMMUNICATION

POLICY

____ provides and maintains the following forms of electronic communication, messaging agents and electronic facilities: Internal and external electronic mail (e-mail), telephone voice mail, Internet access, and computer hardware and software: As a condition of providing the previously identified communications access to its employees, _____ places certain restrictions on workplace use of the same.

OBJECTIVE

The internal communication systems, as well as the equipment and data stored, are and remain at all times the property of the practice. Accordingly, all messages and files created, sent, received, or stored within the system should be related to practice business and are and will remain the property of the practice. System or practice wide distributions of e-mail (announcements, bulletins, etc.) requires management approval in advance of the distribution.

The practice reserves the right to monitor, record, retrieve and review any message or file composed, sent or received. No employee should have any expectation of privacy as to any electronic communication. It should be noted that although a message or file is deleted or erased, it is still possible to recreate the message. Therefore, ultimate privacy of messages cannot be assured to anyone. Although electronic mail and voice mail may allow the use of passwords for security, confidentiality cannot be guaranteed. It is possible for messages to be retrieved and viewed by someone other than the intended recipient. Furthermore, all passwords are known to the practice as the system may need to be accessed by the practice in the absence of an employee.

When utilizing e-mail, etiquette is important. The strategies for effective e-mail communication are as follows:

▪ Communicate urgent matters for immediate response, to communicate with several people quickly or any other time sensitive matter.

▪ Keep all messages as brief as possible to minimize reading time for recipients, therefore keeping communication efficient.

▪ Be as complete as possible by using the simple rules of who, what when, where and why to answer any anticipated questions.

▪ Avoid communicating through email on a sensitive subject should be addressed in person; if possible.

▪ Communicate confidential information in another form other than email.

▪ Check for accuracy and apply all good business writing, using correct grammar, spelling and punctuation.

▪ Follow up if a response has not been received in a timely manner.

▪ Read all messages and respond regularly.

▪ Avoid the use of typing a message in all capital letters

▪ Be careful not to use the “Reply All” function when not intended, i.e., system wide distribution.

▪ Ensure that messages are deleted or saved; the server should not be used to permanently store messages.

While _____ encourages employee use of the Internet, its use is restricted to the following:

▪ to communicate with employees, vendors, or clients regarding matters within an employee’s assigned duties;

▪ to acquire information related to, or designed to facilitate the performance of regular assigned duties; and

▪ to facilitate performance of any task or project in a manner approved by an employee’s supervisor.

DEFINITIONS

The contents of e-mail or voice mail messages for any file may not contain anything that would reasonably be considered offensive or disruptive to any employee. Offensive content would include, but is not limited to, sexual comments or images, racial slurs, gender specific comments or any comments that would offend someone on the basis of their race, color, religion, sex, age, national origin, disability or military status.

Regarding Internet and e-mail access and usage, be advised that use of the Internet and e-mail provided by ____ expressly prohibits the following:

1. Dissemination or printing of copyrighted materials, including articles and software, in violation of copyright laws.

2. Sending, receiving, printing or otherwise disseminating proprietary data, trade secrets or other confidential information of ____ in violation of company policy or proprietary agreements.

3. Offensive or harassing statements or language including disparagement of others based on their race, national origin, sex, sexual origination, age, disability, religious or political beliefs.

4. Sending or soliciting sexually oriented messages or images.

5. Operating a business, usurping business opportunities or soliciting money for personal gain, or searching for jobs outside _____.

6. Sending chain letters.

7. Gambling or engaging in any other activity in violation of local, state or federal law.

8. The circulation of jokes, comics or non-job related computer graphics.

PROCEDURES

Disciplinary action for violation of this policy may include, but is not limited to, termination, suspension, or transfer of the offending employee. In cases involving less serious violations, disciplinary action may consist of warning or reprimand. Remedial action may also include counseling, changes in work assignments, or other measures designed to prevent future misconduct. The measure of discipline will correspond to the gravity of the offense as determined by management by its potential effect on the practice and fellow employees.

8.23

FRAUD & ABUSE COMPLIANCE

The Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, authorizes an unprecedented effort to stop medical fraud and abuse, including fraudulent and abusive medical claim practices. ________________________________ recognizes, for compliance purposes, that this mandate is best achieved through a commitment from our physician(s) and employees to understand and participate in an ongoing oversight responsibility that effectively detects and prevents inappropriate medical claim reimbursement. Therefore, a Medical Fraud & Abuse Compliance Plan has been developed to chart our course of action and demonstrate due diligence to clearly and unequivocally demonstrate our commitment to comply with the requirements of federal statutes and regulations regarding Medicare, Medicaid, and other third-party-payor reimbursement. As such, ____ is prohibited from making false statements or false representations of any material fact in making claims for payment, including claims for excessive charges or unnecessary services. ____ is prohibited from failure to disclose or provide accurate information requested by medical claim payors. ____ understands that statutes prohibit, and provide criminal penalties for, individuals or entities that knowingly and willfully offer, pay, solicit, or receive remuneration in order to induce business reimbursed under the Medicare, Medicaid, or other third-party-payor programs. The types of remuneration specifically covered include kickbacks, bribes, and rebates made directly or indirectly, overtly or covertly, in cash or in kind. In addition, prohibited conduct includes remuneration intended to induce referral of patients, and remuneration intended to induce the purchasing, leasing, ordering, or arranging for any good, facility, service, or item paid for by Medicare, Medicaid, or other third-party-payor programs.

The Compliance Plan is reasonably designed, implemented and enforced so that it generally will be effective in preventing and detecting inappropriate and criminal conduct. Prevention and detection of wrongdoing demonstrates due diligence and addresses the issue of potential criminal intent. The compliance plan includes the following seven elements:

1. Commitment to Compliance

2. Designation of a Compliance Officer

3. Effective training/education program

4. Auditing and monitoring

5. Effective lines of communication

6. Internal investigation and disciplinary process

7. Response to offenses, corrective action

All employees, including owners are subject to the Fraud & Abuse Compliance Plan, and are required to read and sign a copy of the plan (See Management).

8.25

VISITORS IN THE WORKPLACE

To provide for the safety and security of employees and the practice, only authorized visitors are allowed in the workplace. Employees expecting personal visitors must inform management of such visits prior to their arrival. Restricting unauthorized visitors helps maintain safety standards, protects against theft, ensures security of equipment, protects confidential information, safeguards employee welfare, and avoids potential distractions and disturbances.

All visitors should enter the practice at the main entrance. Authorized visitors will receive directions or be escorted to their destination. Employees must remain cognizant of visitor conduct and safety.

If an individual is observed in an unauthorized area of the practice’s premises, employees should immediately notify their supervisor or, if necessary, direct the individual to the front lobby.

8.26

PERSONAL HYGIENE

Personal cleanliness in our practice is an absolute necessity for quality patient care and customer service. In order to assure that a consistent professional image is maintained, you must practice good personal hygiene by keeping your body clean and free from odor.

Wash your hands frequently during work time to prevent the spread of germs. Always wash your hands prior to contact with a patient and after restroom use.

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