Administrative Guide – New or Recently Updated
|Policy Number||Policy Name/Link||Synopsis of Changes|
|3.1.16||Standards and Best Practices for Pages on the UAMS Website|
|3.1.27||HIPAA Research Policy||Time for review: minor changes throughout policy.|
|3.1.28||Use and Disclosure of PHI and Medical Records||Time for review: one change in section 9, page 16, #7 due to a change in Arkansas Code|
|3.1.29||Request for Data Extracts|
|3.1.40||Employees Authorized to Have Work Stations at Home||Time for review: minor changes throughout policy.
|3.1.41||Information Access for Transfers and Terminations||Time for review: minor changes throughout policy.
|3.1.42||Job Shadowing||Time for review: minor changes throughout policy.|
|3.1.44||Photographing Patients||Time for review: minor changes throughout policy.|
|4.4.09||Ethical Conduct/Gift Policy||Added letter H under Procedure #4 for appearances at events in official capacity for UAMS|
|4.4.18||Surreptitious Recordings||Edited to allow for UAMS Automatic recorded system recordings (police dispatch, clinical program call centers, etc.)
|11.2.10||Space Management and Inventory Policy|
|12.4.01||Use of Conference Room Facilities||
|February 2013||Policy Name||Synopsis of Changes|
|3.1.30||HIPAA Education and Training|
|3.1.01||General Administration, Smoking/Tobacco Use Policy||Time to review: no changes made other than review date.
|3.1.17||General Administration, Mobile Device Safeguards||Time to review: added references to portable hard drives, Bluetooth, texting and Smartphones; added statements concerning immediate reports of lost or missing devices; specified encryption in policy statement.
|3.1.29||General Administration, Request for Data Extracts||Definitions added.
|3.1.30||Administration, General Administration, HIPAA Education and Training||Change made to address rehired employees to UAMS and the HIPAA training requirement for them. Also added sanctions statement.
|7.3.01||Information Technology, IT Security Incident Identification & Handling Policy||Time to review policy; corrections include clarifications; grammar corrections; links updated; sanctions statement revised to match the current version of sanctions statement within the HIPAA policies.|
|11.1.10||Campus Operations, Vehicle Driver Safety Program||Periodic Review -Minor changes were made to clarify the policy
|11.1.12||Campus Operations, Travel Insurance||One change to deductible for vehicle accidents increased from $500 to $1000 per insurance company.|
|11.1.13||Campus Operations, Insurance Claims||Time to review: no changes made other than review date
|11.2.10||Campus Operations, Guidelines for Space Committee and Assignment||A new process was implemented to make space assignments and the Space Committee more efficient and effective. The updated policy reflects the current process, has information that people need to know, and contains information about the form that is used to initiate space requests.|
|11.4.02||Campus Operations, Hazard Communication||Reviewed policy for accuracy and updated to correct format – added policy statement; added students to scope; corrected references to MSDS (Material Safety Data Sheet) to its new name SDS (Safety Data Sheet); corrected Joint Commission name; removed outdated reference and deleted sample sheet.|
|11.4.03||Campus Operations, Holiday Decorations||Reviewed policy for accuracy and updated to correct format – added policy statement|
|11.4.04||Campus Operations, Occupational Exposure Assessment and Control||Time to review: no changes made other than review date|
|11.4.07||Campus Operations, Electrical Safety for Personal Medical Devices and Appliances||Time to review: no changes made other than review date
|11.4.08||Campus Operations, Laboratory Safety||Reviewed policy for accuracy and updated to correct format – added policy statement. Removed the word “Material” in material safety data sheet.|
|11.4.09||Campus Operations, Radioactive Substances||Reviewed policy for accuracy and updated to correct format – added policy statement; added description of how radioactive materials are to be ordered; clarified when “call in” orders are to be made.|
|11.4.11||Campus Operations, Abandoned Hazardous Chemicals||Reviewed policy for accuracy and updated to correct format – added policy statement and added students to scope
|11.4.13||Campus Operations, Handling Chemotherapy Drug Spills in Clinical & Research||Reviewed policy for accuracy and updated to correct format – added policy statement
|11.4.14||Campus Operations, Respiratory Protection||Deleted “Pt 1” from policy name; reviewed policy for accuracy and updated to correct format – reworked policy, scope and purpose statements.
|11.4.15||Campus Operations, Unsafe Equipment and Furniture||Reviewed policy for accuracy and updated to correct format – reworked policy and purpose statements|
|11.4.16||Campus Operations, Microwave Oven Survey Policy||Reviewed policy for accuracy and updated to correct format – added policy statement
|11.4.17||Campus Operations, Fire Retardant/Resistant Materials and Furnishings||Time to review: no changes made other than review date.
|11.4.18||Campus Operations, Exposure Control Plan (Part I)||Time to review: no changes made other than review date.
|11.4.19||Campus Operations, Occupational Exposure to Hazardous Chemicals in Laboratories (Pt. 1)||Time to review: no changes made other than review date.
|11.4.21||Campus Operations, Use of Space Heaters on Campus||Time to review: no changes made other than review date.
|11.4.22||Campus Operations, Removal, Disposal, and/or Transfer of Equipment used with Radioactive Materials||Reviewed policy for accuracy and updated to correct format – added policy statement
|11.4.24||Campus Operations, Hazardous Materials & Waste Management||Reviewed policy for accuracy and updated to correct format -updated policy statement, removed outdated link; updated responsibilities and updated references
|11.4.25||Campus Operations, Fire Safety and Prevention Program||Time to review: no changes made other than review date.
|11.4.26||Campus Operations, Employees with Latex Allergy||Time to review: no changes made other than review date.
|12.3.01||Academic Affairs, Library Services||The old Library Services policy was very outdated, so it has been rewritten to make it current.
|12.5.01||Academic Affairs, Faculty Grievance Policy||New Policy – currently there is no common grievance procedure for faculty. Some of the colleges have their own or refer to a 1996 policy from the 1996 Faculty Handbook, which no longer exists. The Council of Deans developed this common policy for all faculty in all colleges and with primary appointments in the AHEC Regional Programs and the Division of Academic Affairs. It supplants all previous or college policies.
|March 2013||Policy Name||Synopsis of Changes|
|3.1.28||Administration, Use and Disclosure of PHI & Medical Records||Edits due to new HIPAA ruling.|
|4.3.10||Employer Provided Cell Phones||Will be deleted from the Admin Guide. The policy was for accounting for the personal use of employer provided cell phones. There was a change in tax laws, so the policy is no longer necessary.|
|4.4.11||Human Resources, Conflict of Interest for Non-Academic Staff Members||Edits made to comply with U of A System audit recommendations.|
|4.4.17||Human Resources, Reductions in Force||New policy – we currently have Reductions in Force regularly, usually due to grants ending, but have no policy for the process. Was reviewed in Dec 2011 – resubmitted.|
|4.4.19||Human Resources, Communications with Federal, State, and Local Government Officials||Policy is new; it was concluded a written policy was needed to appropriately communicate guidelines to the faculty, staff and students in dealing with public officials.|
|8.7.03||Finance, Non-Patient Receivables||New policy to improve procedures that will tighten internal controls on campus in relation to non-patient billing.|
|11.4.01||Pregnant Employees Working with Ionizing Radiation||Reviewed policy for accuracy and updated to correct format – added policy statement; added title to declaration of pregnancy page. Note: Legal wanted HR to review, and HR recommending adding references to the Leave of Absence without pay and FMLA policies, which the department has now added.|
|11.4.12||Campus Operations, Emergency Medical Response including Code Blue||Updated to reflect changes in UAMS Medical Center policy PS 1.03; added new review date; expanded the name to reflect emergency response for campus; added responses of Code Team for visitors and staff for non-traditional areas, based on UAMS Medical Center PS 1.03; Updated reference to sections; II.B changed name of CARTI to Radiation Oncology Center; III listed Areas as A., B., C. instead of in paragraph form; V.(Q) updated name of College of Health Professions; VI. added per policy PS 1.03; VII added per Policy 1.03; added definition of Code Blue; removed the team composition list, felt that the Campus policy did not need all the team details; added statement on who comprised the team with reference to Policy PS 1.03; in Procedures removed team responsibilities and added a general statement with reference to policy PS 1.03; in II. Activation- A.2 there may be events on campus that do not involve a patient, but added “if patient is involved”; II.B added statement about pediatric code blue; F.2, added statement concerning PRI staff notification (PS 1.03); G.2made changes based on Hospital Policy PS 1.03|
|11.4.23||Campus Operations, Indoor Environmental Quality (IEQ)||Added policy statement, changed names of departments to reflect current name (Physical Plant now Engineering & Operations); added clarification of standards overseers; few other small edits.|
|11.4.27|| Campus Operations, Compressed Gas
|Added policy statement, changed names of departments to reflect current name (Physical Plant now Engineering & Operations); added clarification of standards overseers; few other small edits.
|16.1.14||Research Administration, Grant Proposal Review||New policy|
|May 2013||Policy Name||Synopsis of Changes|
|3.1.05||Sexual Harassment||Policy overdue for an updated, not revised since its creation in 1995. The process has changed and now policy reflects current process. Added Scope, added disciplinary statement regarding non-employees, and clarified/corrected titles.|
|3.1.30||HIPAA Education and Training||One edit to change required HIPAA Privacy and Security training must be completed within 30 days not 60 days.|
|3.1.46||Protected Health Information Breach Notification and Reporting||Edits due to new Final HIPAA Omnibus Rule. These edits included edits and additions to the definitions and some small grammatical and formatting corrections.|
|June 2013||Policy Name||Synopsis of Changes|
|This policy has been updated because the payroll office will not release the final terminal vacation check until the clearance form is signed, completed, and sent to the OHR Records Office. This effort is to promote timely terminations in SAP. Terminal vacation checks will be processed after the completed and signed employee separation form is submitted to OHR.|
|8.7.02||Petty Cash Funds||This policy is being adjusted to fall in line with other academic medical centers with a major research component. This policy in the past had a large internal control structure pertaining to the collection of SSN’s. Because of the reduction in these type of research subject petty cash accounts, the policy was reviewed to match peer institutions which will alleviate some of the administrative burden on administrators.|
|July 2013||Policy Name||Synopsis of Changes|
|3.1.21||Notice of Privacy Practices||Time for review. Edits made for clarification. PHI definition changed due to Final ruling in the HIPAA Omnibus Rule.|
|3.1.37||Verification of Identity and Authority to receive PHI||Reviewed and edits made based upon the new HIPAA Ruling and clarification of the existing policy.|
|4.1.09||Unemployment Insurance||Overdue for an update. Created 4/1/1995 with no revisions. Process has changed since that time, so updates made to reflect current process. Added Scope, changed state dept name from Arkansas Employment Security Department (ESD) to Department of Workforce Service (DWS), updated form names, added step #3, edited HR department name, edited number of days to respond and edited appeal process.|
|8.7.03||Non-Patient Receivables||Edit made to exclude student billing process that is in the student financial services system.|
|11.1.08||Maintenance of Smoke/Fire Barriers||Formatted to match policy format, moved information around , corrected names of Engineering and Operations and Information Systems, added references.|
|11.1.11||Hot Work Permits||Updated names to reflect current names (E&O); rearranged information to make policy clearer and remove redundancy; added references.|
|11.2.04||Visitor Waiting Areas||Policy had verbiage that was out of date and policy was not in correct current format. Added Scope and Policy statements; added language to match Hospital Policy HR2.05|
|11.2.07||Damage to UAMS Property||Time for review – edited to reflect current policy format.|
|11.2.08||Interim Life Safety Measures (ILSM) and Infection Control Risk Assessment (ICRA)||Basic policy did not change, tried to make it easier to read and be clearer in its meaning. Terminology was changed to update titles of staff (shop foreman to service manager) responsible for implementation of policy.|
|11.4.31||Asbestos Management NEW POLICY||Asbestos has been managed for years without a formal policy in place. This new policy defines the processes and responsibilities for asbestos management.|
|12.1.02||Academic Policy Development Process NEW POLICY||Common Academic Policies apply to a specific segment of UAMS. The Council of Deans has approved such policies in the past. The Council of Deans believes it is important to have these policies separate from the large admin guide and housed within Academic Affairs. At the recommendation of the VC for Compliance, Dr. Rahn designated the VCAA as the approver of these policies and directed the VCAA to draft this policy.|
|August 2013||Policy Name||Synopsis of Changes|
|3.1.15||Confidentiality Policy||Time for review. Changed due to Final ruling in the HIPAA Omnibus Rule and to reinforce the existing policy.|
|3.1.20||Release of Patient Directory Information||Time for review. Result of system changes/decisions made in EPIC. Form “Request to be excluded from the Patient Directory” will no longer be used.|
|3.1.23||Reporting of HIPAA Violations||Time for review. UAMS Workforce definition changed to agree with designated HIPAA definition list. Sanctions statement edited to agree with the standard Sanctions statement on all HIPAA policies. Added the HIPAA website as an additional source to report HIPAA violations.|
|3.1.25||Minimum Necessary Policy||Time for review. Reinforcing and clarifying existing policy.|
|7.3.02||Generic Accounts||Time for review. Reinforcing and clarifying existing policy.|
|11.2.11||Alcohol Possession and Use Policy||Clarification of existing policy regarding possession and use of alcohol at UAMS/UAMS events.|
|September 2013||Policy Name||Synopsis of Changes|
|3.1.33||Business Associate Policy||Changes were required due to HITech Final rule that was recently released. Definitions added and updated; clarification on signature authority.|
|11.3.06||Bomb Threat Plan (Code Amber)||Update to clarify duties and responsibilities during a Bomb Threat and to eliminate redundant wording.|
|November 2013||Policy Name||Synopsis of Changes|
|7.3.07||Security Log In Monitoring||Policy Deleted, incorporated into the new versions of 7.3.04 and 7.3.12|
|7.3.10||UAMS Data Encryption||Policy Deleted, incorporated into the new versions of 7.3.04 and 7.3.12|
|7.3.15||Malicious Software Preventions||Policy Deleted, incorporated into the new versions of 7.3.04 and 7.3.12|
|3.1.18||Request for Alternative Method of Communications of PHI||Reviewed and edits made due to new Final HIPAA Omnibus Rule. Reinforcement and clarification of the policy|
|3.1.36||Use of PHI for Marketing||Reviewed and edits made due to new Final HIPAA Omnibus Rule. Reinforcement and clarification of the policy.|
|7.3.04||Information Access Management||Policy 7.3.07 Security Log In Monitoring was incorporated into this policy as well as other small edits based on the Omnibus ruling. 7.3.07 will be removed from the Admin Guide upon approval of this policy.|
|7.3.12||Enterprise Data Integrity & Encryption||Policies 7.3.10 UAMS Data Encryption and 7.3.15 Malicious Software Preventions were incorporated into this policy as well as other small edits based on the Omnibus ruling. 7.3.10 and 7.3.15 will be removed from the Admin Guide upon approval of this policy.|
|December 2013||Policy Name||Synopsis of Changes|
|3.1.01||Smoking/Tobacco Use Policy||The policy is required by the Joint Commission for accreditation of the hospital and is required for academic campuses by state laws, ACT 134 and ACT 734. The only change is the addition of “e-cigarettes” to the description of tobacco products. E-cigarettes create difficulties in enforcement and disposal. Many times e-cigarettes look very similar to actual cigarettes which will make enforcement very difficult.|
|3.1.02||Inclement Weather||Reflect the Chancellor’s announcement regarding NONESSENTIAL personnel|
|3.1.47||UAMS Events Policy and Master Calendar Procedure||Changes are not due to changes in the law. Changes include: added definition of “Internal UAMS Events” which are subject to the policy; added definition of UAMS “community outreach” events which are subject to policy; revisions to signing of contracts. Just further emphasis on following procedures. Changed Office of Contract Services to Office of Procurement as requested; additional explanation on the handling of ticketed fundraising events, Quid Pro Quo, and the donation of food, drinks, or other items for events. Bottom line: Purchasers of tickets to events do not always receive a charitable tax receipt, as it depends on the fair market value of goods/items received in return, and it does not matter if the goods/items received in return were donated to UAMS; further emphasis on completing a Gift-in-Kind Form for donors who give food, drinks, items to help with fundraising events; and further emphasis on following prospect management procedures before soliciting donors for food, drinks, items for events; and added entire section on Guidelines for Third Party Events. A Third Party Event is not a UAMS event. Instead, a third party is holding a fundraising event and donating proceeds to UAMS. This policy helps to clarify what is and what is not a “third party event.” Some call an event a “third party event” when it is actually a UAMS event, and if it is a UAMS event, UAMS should have more control over the event itself. This policy will help with that situation. It also helps for the situations in which the event actually is a third party event, and UAMS can assign a Development Director from Institutional Advancement to help the third party follow the limited guidelines UAMS has for such events, such as obtaining permission to use the UAMS logo, ensuring that the event is not marketed as a UAMS event, and other requirements for the protection of UAMS. Added separate Third Party Event Application Form.|
|4.4.02||Employee Discipline||Changed name from Employee Disciplinary Notice and updated with current practices of HR –it had not been updated since originally written in 2000. Item # B1 is new to the disciplinary process.|
|7.1.02||Software Licensing||Policy Deleted, incorporated into the new versions of 7.1.01|
|7.1.07||New Project Enhancement Requests||Policy Deleted, incorporated into the new versions of 7.1.01|
|7.1.01||Information Technology, Software, Hardware, Special Projects||Combined policies 7.1.02 Software Licensing and 7.1.07 New Project Enhancement Requests to make this new policy. 7.1.02 and 7.1.07 will be removed from the Admin Guide upon the approval of this policy. Added Principles of the IT Executive Steering Committee.|
|15.1.1||Excluded Parties Policy||The Office of the Inspector General has issued updated compliance guidance as of May 2013 which needed to be considered when updating this policy. Also, Arkansas Medicaid has included in their Hospital Provider Manual requirements on sanction screening which was incorporated into this revised policy. Additionally, the federal government has phased out the EPLS system which was referred to in the original policy and has replaced it with SAM (System for Awards Management) which is referred to in the revised policy.|
|3.1.02||Inclement Weather Policy||Includes edits from December related to non-essential areas closed and leave time as well as addressing student issues and edits to make the policy clearer.|
|12.2.01||Use of Conference Room Facilities||Updated names, terms and contact numbers to reflect reorganizations and to update from the original 1994 version. Added event approval process for external groups. Added Scope statement to meet formatting standards for current policies. NOTE – This policy was moved from 12.4.01 to this new number and moved to section 12.2, which was renamed Teaching and Learning Support. This section of the Admin Guide is being reviewed with many out of date, unnecessary policies (commonly due to the fact they are services, not policies) being deleted and the section being rearranged to properly reflect the current organization.|
|12.2.02||Instructional Equipment Repair||Updated names, terms and contact numbers to reflect reorganizations and to update from the original 1994 version. Added Scope and Policy statements to meet formatting standards for current policies.|
|Communications & Marketing|
|13.1.01||UAMS Communications Guidelines||Minor changes to include the addition of digital signs on campus and social media added as a communication tool that is to be cleared through the Office of Communications and Marketing.|
Updated February 18, 2014
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