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" The Voice Of Interventional Pain Management "

Pain Management Center
Policy and Procedure Manual
Table of Contents

VOLUME I

EXECUTIVE SUMMARY
SECTION I. ORGANIZATIONAL FUNCTIONS
1. Purposes

A. Mission
B. Vision
C. Values
D. Goals
E. Objectives
F. Code of Ethics
G. Services 2. Governing Body
A. Responsibilities
B. Organization
C. Organizational Structure
D. Chief Executive Officer
E. Conflict of Interest

3. Administration

A. Principles
B. Administrator
C. Director of Insurance
D. Staff Recruitment and Retention
E. Licensure and Certification
F. Job Performance Review
G. Information Management

4. Fiscal Management

A. Principles
B. Financial Records
C. Business Procedures
D. Collections
E. Financial Expenditures

5. Administrative Policies

A. Smoking Policy
B. Non-Discrimination
C. Use of Outside Resources
D. Review of Contract Services
E. Loss or Theft of Property or Money
F. Solicitation and Distribution of Literature
G. Visitor Injury/Mishap
H. Incident Reports

6. Medical Staff

A. Goals
B. Objectives
C. Organization of Medical Staff
D. Medical Staff Membership
E. Medical Staff Credentialing
F. Medical Staff Executive Committee
G. Medical Staff Management
H. Impaired Physician
I. Independent Clinical Staff
J. Patient Management

SECTION II. PATIENT FOCUSED FUNCTIONS

1. Purposes
A. Principles
B. Patient's Bill of Rights
C. Patient Responsibilities

2. Patient Rights

A. Patient Complaints
B. Informed Decision Making
C. Access to Medical Records
D. Informed Consent
E. Patient Confidentiality
F. Confidential Messages
G. Patient Valuables
H. Discrimination Policy
I. Patient Directives
J. Care of Terminally ill Patient
K. Research and Experimentation
L. Speech or Hearing Impaired Patients

3. Patient Consent
A. Consent Policy
B. Consent for Evaluation
C. Consent for Invasive Procedures
D. Consent - HIV Testing
E. Consent to Photograph

4. Patient Abuse

5. Patient Management

A. Patient Assessment – Pain Management
B. Patient Assessment – Physical Therapy/Psychology
C. Patient Assessment – Medical Group
D. Storage of Medications
E. Emergency Carts
F. Patient Transport
G. Patient/Family Education
H. Continuum of Care
I. Discharge Against Medical Advice
J. Protection of Patients From Hazardous Materials
K. Restraints and Seclusion
L. Death at the Center

SECTION III HUMAN RESOURCES

1. General Principles

A. General Policies
B. Employment
C. Personnel Records
D. Classification of Employees
E. Performance Assessment
F. Verification and Control Systems
G. Confidentiality
H. Dress Regulations
I. Attendance
J. Employee Communication
K. Work/Salary
L. New Employee Orientation
M. Employee Requests for Time Off
N. In-Service Education Program
O. Sexual Harassment
P. Personal Telephone Calls
Q. Disciplinary Procedure
R. Termination of Employment

2. Employee Health

A. Objectives
B. Employee Health Program
C. Exposure Control Plan
D. Tuberculosis Screening Program
E. Immunizations
F. Post Exposure Prophylaxis of Hepatitis
G. Exposure to HIV
H. Exposure to Meningococcal Meningitis.
I. Illness Reporting
J. General Safety for All Employees
K. Reporting Injury on the Job
L. Worker's Compensation

3. Policies of Administrative Personnel

A. Director of Public Relations
B. Director of Human Resources
C. Chief Transcriptionist
D. Admissions Coordinator
E. Medical Records Coordinator
F. Director of Maintenance and Safety
G. Physical Therapy - Admissions Coordinator
H. Transcriptionist
I. Insurance Coordinator
J. Admissions Clerk/Receptionist
K. Medical Records Clerk
L. Administrative Assistant

4. Policies of Nursing Personnel

A. General Policies
B. Clinical Coordinator
C. Employee Health Nurse
D. Staff Nurse
5. Policies of Professional Personnel
A. Clinical Director
B. Director of Psychology
C. Physical Therapist
D. Physical Therapy Assistant
E. Physical Therapy Technician
F. Radiologic Technologist
G. Physician’s Assistant
H. Nurse Practitioner

6. Policies of Physician Personnel

A. Medical Director
B. Physician

7. Ancillary Personnel

A. Statistician and Programmer
B. Janitor
C. Laundry Coordinator
8. Education and Training
A. General Policies
B. Educational Profiles
C. Cardiopulmonary Resuscitation Certification
D. Continuing Education

VOLUME TWO
SECTION IV ENVIRONMENTAL SAFETY

1. Purposes

A. Principles
B. Environmental Security
C. Physical Facilities
D. Risk Management
E. Environmental Performance Improvement

2. Fire Safety

A. Introduction
B. Prevention of Fire in an Oxygen Enriched Atmosphere
C. Evacuation Procedures
D. Responsibilities, Admissions Coordinator

3. General Safety

A. Statement of Policy
B. Safety Education
C. Safety Surveillance Program

4. Environmental Control

A. Safety
B. Environmental Security
C. Departmental Safety: Business Office, Front Desk
D. Departmental Safety: Laundry
E. Departmental Safety: Laboratory
F. Departmental Safety: Medical Records
G. Departmental Safety: Nursing Department
H. Departmental Safety: Maintenance
I. Departmental Safety: Radiology
J. Department Safety: Physical Therapy and Psychology
K. Departmental Safety: Pharmacy
L. Medical Device Problem and Recall

5. Emergency Preparedness

A. Preface
B. Emergency Response
C. Bomb Threat
D. Earthquake
E. Explosions
F. Disaster Plan
G. Patient Flow in the Event of a Disaster
H. Cardiopulmonary Resuscitation Policy
I. Cardiopulmonary Resuscitation Protocol
J. Cardiopulmonary Resuscitation Procedure

6. Hazardous Materials Management

A . Hazardous Materials
B. Chemical Waste

SECTION V. PERFORMANCE IMPROVEMENT

1. Organizational Performance

A. The Program
B. Program Evaluation

2. Quality Management and Improvement

A. Objectives
B. Scope of the Program
C. Peer Review
D. Quality Improvement
E. Risk Management
F. The QMI Program
G. Utilization Review
H. Quality of Care
I. Sentinel Events Policy
J. Environmental Performance Improvement

3. Medical Records

A. Function
B. Protection and Availability
C. Authentication

4. Infection Control

A. Principles
B. General Rules
C. Hand Washing
D. Universal Precautions
E. Employee Infection Control
F. Disposal of Sharps
G. Housekeeping Procedures
H. Isolation Techniques
I. Needle Stick Protocol
J. AIDS/HIV Positive Guidelines
K. Biohazard Waste
K. Infectious Waste

5. Miscellaneous Policies

A. Professional Inquiries
B. Publishing Activities
C. Staff Improvement
D. Teaching
E. Patient Satisfaction Survey

SECTION VI PAIN MANAGEMENT PROGRAM

1. Purposes

A. Organization
B. Scope of Services
C. Program Description
D. Program Evaluation
2. General Rules and Regulations
A. Program Standards
B. Staffing
C. Scheduling

SECTION VII MEDICAL GROUP

1. Purposes
A. Organization
B. Scope of Services
2. General Rules and Regulations
A. Staffing
B. Scheduling
C. Patient Care Guidelines

SECTION VIII PHYSICAL THERAPY AND PSYCHOLOGY

1. Purposes

A. Organization
B. Program Description
C. Scope of Services
D. Physical Therapy Guidelines

2. General Rules and Regulations

A. Staffing
B. Scheduling
C. Patient Care Guidelines

3. Operational Policies and Procedures

A. Physical Therapy
B. Psychological Services
C. Program Admission Criteria
D. Physical Therapy Procedures

SECTION IX ANCILLARY SERVICES

1. Radiological Services

A. Principles
B. Radiation Exposure Monitoring
C. Contrast Reactions

2. Pharmaceutical Services

A. Principles
B. Expired Drug Policy
C. Narcotic Policy

3. Pathology and Clinical Services

A. Principles
B. Quality Control
C. Blood Drawing

Model Compliance Plan
Table of Contents

TABLE OF CONTENTS

Preface

Healthcare Compliance Overview

Introduction and Background

Applicable Laws

False Claims Act

Anti-Kickback Laws

Self-Referral Laws (Stark)

Controlled Substance Abuse Law

Compliance Program Overview

Benefits of a Compliance Program

What is a Compliance Program?

What a Compliance Program is Not

Elements of an Effective Physician Practice Compliance Program

Implementation of a Compliance Program

The Baseline Audit

Practice Standards

Compliance Officer/Committee/Contacts

Education and Training

Response Mechanism and Corrective Action

Open Lines of Communication

Disciplinary Process

Conclusion

Appendix A Key Documents to Review

Appendix B Duties of the Compliance Officer/Committee

Appendix C Reporting and Investigating Misconduct

Appendix D Document Retention/Destruction

Appendix E Model Compliance Program

E-1 Introductory Letter

E-2 Compliance Commitment & Acknowledgment

E-3 Practice Standards

E-4 Ethical Coding & Billing Standards

E-4.1 Acknowledgement of Ethical Coding & Billing Standards

E-5 The Compliance Committee

E-6 Disciplinary Protocol

Appendix F Additional Sample Policies and Forms

Duties of the Compliance Officer Policy

F-2 Compliance Committee, Its Powers and Responsibilities

Policy

F-2.1 Form: Compliance Program Survey

F-3 Responding to Compliance Hotline or Other Reports Policy

F-3.1 Form: Hotline Report

F-3.2 Form: Compliance Program Report

F-3.3 Form: Compliance Hotline Report Log

F-4 Non-Retaliation Policy

F-5 Exit Interviews Policy

F-5.1 Form: Compliance Program Exit Interview

F-6 Employee and Contractor Screening Policy

F-7 Document Retention Policy for Compliance Program Documents and Documents Associated with Claims Processing Policy

F-8 Refunding Overpayments Policy

F-9 Compliance as an Element of Performance Evaluations Policy

F-10 Documenting Discussions with Third Party Payors Policy

F-10.1 Form: Confirmation Letter to Payor

F-11 Waiver of Co-payments and Deductibles Policy

F-12 Vender-Promotional Training Policy

F-13 Responding to Government Investigations Policy

Pain Management Center Policy and Procedure Manual Table of Contents

Model Compliance Plan Table of Contents

Pain Management Center
Policy and Procedure Manual
Table of Contents

Model Compliance Plan
Table of Contents