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New, updated and archived policies and procedures: September 2022

September 23rd, 2022 by Ginnie Occhipinti

The following policies and procedures have been recently updated. Below is an update on key changes and where to find the updated policies and procedures.

  • Leave of Absence Policy: This policy provides a means for departments to maintain continuity of service in instances where an employee requires time off for planned, unplanned, or medical reasons.
  • Paid Parental Leave Policy: This policy provides up to 6 weeks of paid parental leave to employees following the birth of an employee’s child, the placement of a child with an employee in connection with adoption or foster care, or parenthood by surrogacy. The purpose of paid parental leave is to enable the employee to care for and bond with a newborn, a newly adopted, or a newly placed child.
  • Suicide Precaution Procedure: This procedure provides guidelines for the assessment, documentation, and care for patients at risk for intentional self-harm or suicidal behavior.  The Alaska Native Medical Center (ANMC) provides the least restrictive, safe, and effective environment possible for all patients.  In those cases where staff identifies a patient has the potential for self-injury, the following procedures will be followed to provide proper patient care in a safe, therapeutic environment while providing for the safety of the patient, other patients, visitors, and staff.
  • Dental Health Aides and Therapists Policy: This policy allows Dental Health Aides and Dental Health Aide Therapists to provide services at ANMC under the applicable supervision of licensed and privileged dentist within their scope of practice for which they are certified by the Alaska Area Native Health Service Community Health Aide Program Certification Board.
  • Subpoenas, Warrants, and other Legal Documents that Request Disclosure/Release of Health Records Procedure: This procedure describes the process for staff to take when served with court orders, search warrants, depositions, and subpoenas for disclosure/release of patient medical records. The title has been changed; this procedure was formerly known as Coordination of Legal Correspondence or Requests to Appear and Discharge Release of Health Records Procedure.
  • HIPAA and the Privacy Act of 1974 Adopted by ANMC as it Applies to Release of Protected Health Information (PHI) from the Health Record Procedure #1000-01: Changes to this procedure include: the scope was edited to be consistent with all ANMC P&Ps; Legal made edits to be consistent with HIPAA and 42 CFR Part 2; definitions were changed from “Record” and “System of Records” to “Designated Record Set” and from “Individual” to “Authorized Individual”; we added that patients have the right to access their designated record set within “30 days” of the request, that HIM should be contacted with questions, wording to explain circumstances where ANMC may deny a patient access to their records, a timeline for sending a denial letter, and identified a designated reviewing official. Also, redundant or duplicative sections were deleted.
  • Release of Information for Medical Records Procedure: This procedure was formerly known as Reproduction and Facsimile of Medical Records Procedure.  The title was changed to more accurately reflect the purpose of the procedure. References to “reproduction and faxing” were changed to “release of information.” Legal made edits to comply with HIPAA, 42 CFR Part 2, and the Privacy Rule. Sections were revised to say that misdirected faxes must be reported to Compliance, we added reference to “verbal authorization” for content to disclosure, and at the end of the document, we added the “Request for PHI, or TPO, form” as an attachment.
  • Notice of Privacy Practices Procedure: Changes to the procedure include: Legal made edits to be consistent with HIPAA and to delete redundant or duplicative sections; and we deleted a section regarding electronic systems such as RPMS, MS4, and Signature because it was unnecessary. 
  • Disclosures to Law Enforcement or Regarding Threats Procedure: Changes to the procedure include: Legal added the words “judge-ordered” before any mention of subpoenas, court orders, or warrants. Department names were updated throughout.
  • Patient Right to Request to Amend Health Information Procedure: Changes to the procedure include adding a section to include oral requests made by a patient. Also at the end of the document, we added “Request for Amended of Protected Health Information” form and “Request for Protected Health Information” form, also known as TPO, as attachments.
  • 1135 CMS Waiver Procedure: The 1135 Waiver procedure is an outline of the process for requesting and operating under a CMS 1135 waiver during a disaster. This document is a Joint Commission written requirement.
  • Emergency Preparedness Drill and Exercise Procedure: The Emergency Preparedness Drill and Exercise procedure is an overview of the process for how the hospital and accredited campus conducts exercises and drills. It outlines the different types of drills, the process for conducting a drill, and the frequency of drills per JC regulation.
  • C. difficile Infection Control Procedure: This is a new procedure that outlines methods to reduce the risk of transmission and guidance to prevent C. difficile infection.
  • Infection Control Procedure for High Risk and Aerosolizing Procedure: ARCHIVED
  • Preventing Central Line-Associated Blood Stream Infection (CLABSI) Procedure: This NEW procedure provides guidelines which have been developed to provide best practices for the prevention and monitoring of Central Line-Associated Blood Stream Infections (CLABSIs) at ANMC. 

All policies are available here (best used in Chrome or Edge browsers) or the Ethics and Compliance SharePoint site. This update should replace any previous procedure you may have printed or posted in your department.

If you have questions regarding policy or procedure updates, please discuss with your supervisor, Human Resources at 907-729-1301 or Ginnie Occhipinti, Policies and Procedures Manager at 729-1971 or