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Policy Approval Workflow Policy Approval Workflow *Clinical Workgroup broadly includes any medical staff committee, nursing committee such as Patient Care Leadership Team, administrative committee, and/or other ad hoc workgroups. Alameda Health System Executive Summary for Board of Trustees Policies and Procedures January 2020 TOPIC or Last Next review date Document Purpose Summary of Changes History of Review TITLE OF POLICY Approved after BOT Owners Committee Date approval AHS System Policies Abuse Identification – N/A 3/2022 Manager, Care It is the policy of Alameda Minor revisions • Departmental Reporting and Patient Management Health System (AHS) to 3/2019 Protection report, in accordance with • Legal Review the provisions set forth 9/2019 herein and applicable laws and regulations, known or • HR review 10/2019 suspected abuse or neglect • CPC 10/2019 relating to children, elders or dependent adults. Central Venous Catheters N/A 8/2022 Director of To ensure the effective use, Minor revisions • Departmental (Central Infection Control safe and sterile insertion, 8/2019 Lines/PICC/PORT-a- proper maintenance and • CPC 11/2019 CATH)-Insertion, prompt removal of central Maintenance and line catheters. Removal Inpatient Influenza N/A 9/2022 VP Patient Influenza vaccination will Updated with CMS • Departmental Vaccination Policy Services be offered to eligible adult recommendation 9/2019 in-patients. Influenza • P&T Committee vaccination will be offered 9/2019 October through May (or longer as determined by • CPC 10/2019 state/federal public health entities). Distribution will be determined by vaccination supplies or any special determination by the CMS, CDC and/or state and local public health entities each year. Interdisciplinary Verbal N/A 9/2022 VP Patient To ensure that verbal or Updated with current EPIC • Departmental Orders and Patient Services telephone orders are system 10/2019 Safety v2 accurately transcribed and • CPC 10/2019 carried out. CONFIDENTIAL PROTECTED UNDER CALIFORNIA EVIDENCE CODE 1157 Page 1 of 4 Alameda Health System Executive Summary for Board of Trustees Policies and Procedures January 2020 TOPIC or Last Next review date Document Purpose Summary of Changes History of Review TITLE OF POLICY Approved after BOT Owners Committee Date approval Medications: Hazardous N/A 9/2022 System Personnel preparing Minor Revisions • Environment of Drugs Preparation and Medication hazardous drugs will take Care: 9/2019 Handling Safety Officer all necessary precautions, • Environmental as outlined, in order to protect themselves and the Services: 9/2019 environment from • Employee Health: hazardous medications. 9/2019 Specific disposal • Infection Control procedures for the Dept.: 9/2019 materials used in the • Pharmacy & preparation of these drugs, as outlined below, will be Therapeutics: followed. 10/2019 • Clinical Practice Council: 11/2019 Pharmacy Therapeutic N/A 4/2022 System To authorize Clinical Minor Revisions • System Clinical Drug Monitory Policy Medication Pharmacists to order Pharmacy 3/2019 Safety Officer selected drug levels and • System P7T 4/2019 related laboratory values • for the inpatients of CPC 11/2019 Alameda Health System to enhance the safe and effective use of these drugs Restraint and Seclusion N/A 5/2022 System Director To provide guidance for Minor Revisions • Departmental Use in Acute Care Regulatory staff use of restraints 9/2019 Affairs and/or seclusion while • Legal Review maintaining patient safety and dignity. 11/2019 • CPC review 11/2019 CONFIDENTIAL PROTECTED UNDER CALIFORNIA EVIDENCE CODE 1157 Page 2 of 4 Alameda Health System Executive Summary for Board of Trustees Policies and Procedures January 2020 TOPIC or Last Next review date Document Purpose Summary of Changes History of Review TITLE OF POLICY Approved after BOT Owners Committee Date approval Highland Hospital Autosubstitution N/A 9/2022 System Director Decrease calls to the Minor revisions • Pharmacy Outpatient ED Policy Pharmacy emergency department Leadership :9/2019 providers for routinely • ED Leadership: prescribed medications that are not covered by 9/2019 insurance and therapeutic • System Pharmacy alternatives are available & Therapeutics: within the same medication 9/2019 class. This will in turn • Clinical Practice improve reimbursement of Council: 10/2019 medications, improve patient adherence, and prevent gaps in treatment. John George Psychiatry Hospital Medical Care of Patients N/A 10/2022 Chair of To establish standards and New Policy • Departmental: at John George Psychiatry guidelines for medical care 10/2019 Psychiatric Hospital of patients at John George • Clinical Practice (JGPH) Psychiatric Hospital (JGPH). Council: 10/2019 San Leandro Hospital Pyxis ES Policy N/A 6/2022 System Director To provide medication New Policy • Pharmacy Pharmacy safely, effectively, &Thearapeutics: efficiently, securely, and 8/2019 with appropriate • Clinical Practice documentation. Council: 9/2019 Alameda Hospital Submitted by: Marie Diane Schilly Date: 12/27/2019 A regular meeting of the CPC Committee was held on December 5, 2019. CONFIDENTIAL PROTECTED UNDER CALIFORNIA EVIDENCE CODE 1157 Page 3 of 4 Alameda Health System Executive Summary for Board of Trustees Policies and Procedures January 2020 TOPIC or Last Next review date Document Purpose Summary of Changes History of Review TITLE OF POLICY Approved after BOT Owners Committee Date approval CONFIDENTIAL PROTECTED UNDER CALIFORNIA EVIDENCE CODE 1157 Page 4 of 4 CHILD, ELDER, OR DEPENDENT ADULT ABUSE OR NEGLECT REPORTING Department Social Services Effective Date 3/03 Campus All Date Revised 11/2017, 3/2019 Category Clinical Next Scheduled 3/2022 Review Document Manager Care Executive VP, Care Management Owner Management Responsible Printed copies are for reference only. Please refer to electronic copy for the latest version. PURPOSE California law designates certain professions as “mandated reporters.” Mandated reporters have an individual duty to report known or suspected abuse or neglect relating to children, elders or dependent adults. Although there are many mandated reporters under the statute, not everyone is a mandated reporter. Despite the aforesaid, a non-mandated reporter may nonetheless report any known or suspected abuse or neglect relating to children, elders or dependent adults. In view of the foregoing, the purpose of this policy is to provide guidelines on what reporters (regardless of “mandated reporter” status) are required to report, when it must be reported, and to whom. POLICY It is the policy of Alameda Health System (AHS) to report, in accordance with the provisions set forth herein and applicable laws and regulations, known or suspected abuse or neglect relating to children, elders or dependent adults. DEFINITIONS − “Child” means a person under the age of 18 years. − “Elder” means any person 65 years of age or older. − “Dependent Adult” means a person, regardless of whether the person lives independently, between the ages of 18 and 64 years who has physical or mental limitations that restrict his or her ability to carry out normal activities or to protect his or her rights, including, but not limited to, persons who have physical or developmental disabilities, or whose physical or mental abilities have diminished because of age. − “Mandated Reporter” is a person who is required by law to report a particular category or type of known or suspected abuse or neglect to the appropriate law enforcement and/or social service agency. (A list of “Mandated Reporters” is included in Appendix A) PROCEDURES I. Obligations of Mandated Reporters & Non-Mandated Reporters As indicated above, “mandated reporters” are statutorily required to report known or suspected abuse or neglect relating to children, elders or dependent adults. AHS, however, recognizes that a non-mandated reporter may report any known or suspected Page 1 of 10 abuse or neglect relating to children, elders or dependent adults. In view of the foregoing, an AHS employee designated as a “mandated reporter” who (a) receives information and/or (b) knows or reasonably suspects that a child, elder or dependent adult is a victim of abuse or neglect is ultimately responsible for making the report to the appropriate authorities. A non-mandated reporter who (a) receives information and/or (b) knows or reasonably suspect that a child, elder or dependent adult is a victim of abuse or neglect may (1) make the report to the appropriate authorities in accordance with the provisions set forth herein, or (2) inform a mandate reporter of a known or suspected abuse or neglect. II. Reporting Known or Suspected Child Abuse and/or Neglect a. California law requires specified health care practitioners and other persons who have knowledge of or observe a child in his or her professional capacity or within the scope of his or her employment whom he or she knows or reasonably suspects1 has been the victim of child abuse or neglect to report the known or suspected instance of child abuse immediately or as soon as practicably possible by telephone and to prepare and send a written report thereof within 36 hours of receiving the information concerning the incident. b. Forms of Child Abuse and/or Neglect – i. In accordance with the California Penal Code, the following categories of abuse and neglect must be reporter when a mandated reporter knows or reasonably suspects that a child has been the victim of child abuse or neglect: 1. A physical injury or death that is inflicted by other than accidental means on a child by another person; 2. Sexual
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