Northern Inyo Hospital June 21 2017 Regular Meeting June 21 2017 Regular Meeting - June 21 2017 Regular Meeting Agenda, June 21 2017 Regular Meeting Draft Agenda, June 21 2017 Regular Meeting...........................................................3 Budget, Fiscal Year 2017-2018 Budget, 2017-2018 Fiscal Year ...................................................................................6 Nursing Department Policies and Procedures Licensure of Nursing Personnel Policy and Procedure.........................................38 Language Access Services Program Policy and Procedure.................................40 Annual Policy and Procedure Approvals Annual Policy and Procedure Approvals ................................................................44 Board Resolution 17-01, Appropriations Limit Board Resolution 17-02, Annual Appropriations Limit ..........................................50 Board Resolution 17-02, 401(A) Retirement Plan Contribution Board Resolution 17-02, 401(A) Plan Contribution ................................................51 Radiology Services Agreement Radiology Services Agreement................................................................................52 Email Use Policy and Procedure Electronic Communications (Email) Use Policy and Procedure...........................74 NIHD Password Policy NIHD Password Policy and Procedure ....................................................................79 Workplace Violence Prevention Policy and Procedure Workplace Violence Prevention Policy and Procedure .........................................80 Learning Internships, Clinical or Academic Rotations, Career Shadowing Opportunities Policy and Procedure Learning Interships, Rotations, Career Shadowing Policy and Procedure .........85 Consent Agenda 2013 CMS Survey Validation Monitoring .................................................................87 Financial and Statistical Reports for April 2017 .....................................................92 May 17 2017 Regular Meeting Minutes ..................................................................100 AR Days Report by Discharge Summary ..............................................................105 Chief of Staff Report Chief of Staff Report, June 21 2017 Meeting.........................................................106 Medical Staff Policy and Procedure Approvals ....................................................108 Powered by TCPDF (www.tcpdf.org) DRAFT AGENDA NORTHERN INYO HEALTHCARE DISTRICT BOARD OF DIRECTORS REGULAR MEETING June 21, 2017 at 5:30 p.m. In the Northern Inyo Hospital Board Room at 2957 Birch Street, Bishop, CA 1. Call to Order (at 5:30 pm). 2. At this time persons in the audience may speak on any items not on the agenda on any matter within the jurisdiction of the District Board (Members of the audience will have an opportunity to address the Board on every item on the agenda. Speakers are limited to a maximum of three minutes each.). 3. Old Business A. Approval of NIHD Operating Budget for Fiscal Year 2017 / 2018 (action item). B. Approval of vendor change for NIHD Benefits Manager (action item). 4. New Business A. Approval of Nursing Department Policies and Procedures (action items): • Language Access Services Program • Licensure of Nursing Personnel B. Hospital Wide Policy and Procedure annual approvals, Attachment A to this Agenda (action item). C. Approval of Annual Appropriations Limit, Resolution No. 17-01 (action item). D. Ratification of NIHD 401(a) Retirement Plan Contribution, Resolution No. 17-02 (action item). E. Radiology Coverage and Administration Services Agreement (action item). F. Electronic Communication (Email) Acceptable Use Policy (action item). G. NIHD Password Policy (action item). H. Hospital wide Policy and Procedure approval: Workplace Violence Prevention Policy (action item). I. Hospital wide Policy and Procedure approval: Learning Internships, Clinical or Academic Rotations, and Career Shadowing Opportunities (action item). ----------------------------------------------------------------------------------------------------------------- Page, 2, Agenda, NIHD Board of Directors Regular Meeting, June 21, 2017 Consent Agenda (action items) 5. Approval of minutes of the May 17, 2017 regular meeting 6. 2013 CMS Validation Survey Monitoring, June 2017 7. Financial and Statistical Reports for the period ending April 30, 2017 ------------------------------------------------------------------------------------------------------------------ 8. Data and Information Committee report (information item). - Health Information System replacement recommendation 9. Chief Executive Officer report (information item). - Information Technology Security Report - Reorganization of select departments 10. Chief Operating Officer Report (information item). 11. Chief Financial Officer Report (information item). 12. Chief Nursing Officer Report (information item). 13. Chief Human Relations Officer Report (information item). - PPAC Committee 14. Chief of Staff Report; Joy Engblade, MD: A. Policies/Procedures/Protocols/Order Set approvals (action items): • Provider-Performed Microscopy Competency • Pre-operative EPT Testing Protocol • ALARA Program • Critical Value Reporting of Lab Results • Dead on Arrival • Emergency Operations Plan/HICS Plan • Sterilization Recall Policy • Food and Drink in Patient Care Areas • In-service in Infection Control • Formalin Use and Spill Management • Infection Prevention Considerations for Immunosuppressed and Pregnant Employees (formerly ‘Chickenpox and Shingle’ policy) 6/13/2017, 11:21 AM Page, 3, Agenda, NIHD Board of Directors Regular Meeting, June 21, 2017 • Severe Acute Respiratory Syndrome (SARS) Coronavirus (SARS-CoV) or Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Infection Control Recommendations for Patients • Prevention of Catheter Associated Urinary Tract Infections (CAUTI’s) guidelines • Bloodborne Pathogen Exposure Control Plan • Infection Prevention Plan • Safe Handling and Disposal of Occupationally Hazardous Drugs and Environmentally Hazardous Drugs • Employee Consent Form: Hazardous Drug Risk Acknowledgement B. Employee Health Pillars and Infection Prevention Pillars (information items) C. Medical Staff Appointment/Privileges (action items) • Young Song, MD (radiology, provisional active staff) • David Kim, MD (radiology, provisional active staff) D. Medical Staff Resignation, Robert Nalumaluhia, PA-C (effective 4/21/17) (action item). 15. Reports from Board members (information items). 16. Adjournment to closed session to/for: A. Hear reports on the hospital quality assurance activities from the responsible department head and the Medical Staff Executive Committee (Section 32155 of the Health and Safety Code, and Section 54962 of the Government Code). B. Confer with Legal Counsel regarding pending and threatened litigation, existing litigation and significant exposure to litigation, 4 matters pending (pursuant to Government Code Section 54956.9). C. Discuss trade secrets, new programs and services (estimated public session date for discussion yet to be determined) (Health and Safety Code Section 32106). D. Discussion of a personnel matter (pursuant to Government Code Section 54957). 17. Return to open session and report of any action taken in closed session. 18. Adjournment. In compliance with the Americans with Disabilities Act, if you require special accommodations to participate in a District Board meeting, please contact administration at (760) 873-2838 at least 48 hours prior to the meeting. 6/13/2017, 11:21 AM NORTHERN INYO HOSPITAL POLICY AND PROCEDURE Title: Licensure of Nursing Personnel Scope: Nursing Services Manual: NAM – Utilization of Nursing Staff and Staffing Budget Source: Chief Nursing Officer Effective Date: 11/1/14 PURPOSE: To ensure that all Northern Inyo Hospital RN’s and LVN’s who practice nursing have a current active California license to practice nursing before starting work and thereafter. POLICY: 1. RN and LVN whose job descriptions meet the requirements for nursing practice in the State of California will maintain a current license to practice as a RN or LVN. a. RN license granted from California Board of Registered Nurses. b. LVN license granted from California Board of Vocational Nurses and Psychiatric technician examinees. 2. According to California law, RN’s or LVN’s may be granted temporary permit licenses. 3. RN and LVN staff that does not have an active current license will not be allowed to practice nursing. 4. All licenses including temporary licenses must be renewed on or before the expiration date. 5. Graduate nurses who possess an interim Permit from the California Board of Nursing may practice professional nursing at NIH under the supervision of an RN. 6. The Nursing Services Administrative Assistant/CNO verifies licensure with the Board of Registered Nursing primary verification site. 7. The Nursing Services Administrative Assistant/CNO in collaboration with Human Resources monitors and verifies RN and LVN licensure prior to expiration of Licensure. 8. Nurses are responsible for obtaining their own license and renewal. 9. Advanced Practice Nurse Licensure as an RN and Advanced Practice Nurse shall be maintained by the Medical Staff Office. 10. A RN or LVN with an Interim Permit who fails the examination or does not receive licensure prior to the Interim Permit Expiration, will no longer practice as a nurse. a. Staff failing boards may apply for any open position to which they are eligible. PROCEDURE: 1. Upon