ANNUAL TRAINING & ORIENTATION MANUAL 2020 Welcome to Montefiore Nyack Hospital The Center for Education & Professional Development at Montefiore Nyack Hospital Directions: This resource guide is the 2020 Mandatory Annual Education and Orientation Manual for MNH affiliates. Allied Health Students, Agency Nurses and Medical Staff must read Sections I-VIII. Contractors, Vendors, Volunteers must read Sections I-VII (Forensic/RPR are excluded). Read all required information, policies and related links. Everyone must complete Section IX. Send the completed Post-test and Attestation Statement to your Department Manager. Send the HIPAA Security/Confidentiality Form to Susan Backman at
[email protected] to gain computer access. Thank you, CEPD. TABLE OF CONTENTS I. ORGANIZATION OVERVIEW 1 Mission Statement /Vision / Values 1 Just Culture 1 We Care Standards 1 MNH Policies and Procedures 2 Dress Code / Staff and Vendor Identification 2 Electronic Communication 3 Staff Competence/ Ongoing Training 3 II. COMPLIANCE/ HIPAA/ RISK MANAGEMENT 3 Compliance Program 3 Code of Conduct 5 Gender Idenitiy Discrimination 5 Impaired Professional / Disruptive Behavior 7 Delineation of Privileges and Credentialing 7 Health Insurance Portability and Accountability Act (HIPAA) 7 Medical Record Documentation and Downtime Process 8 Corrections to the Medical Record 8 Unapproved Abbreviations 8 Risk Management and Safety Event Reporting 8 Sentinel Events 9 Regulatory Agencies: NYS DOH, Joint Commission, OASAS, Justice Center 9 III. LIFE SAFETY / EMERGENCY RESPONSE 9 Emergency Response 9 Emergency Codes 10 Rapid Response Team (RRT) 10 Active Shooter /Code Silver 11 Fire Prevention / RACE / PASS 11 RACE: Fire Alarm 11 Medical Waste 11 Oxygen (O2) Safety 12 Magnetic Resonance Imaging Safety 12 Safety Data Sheets (SDS) 12 IV.