Administrative Guide – New or Recently Updated

To Access These Policies Click on Compliance 360, then search the policy number or name.


Policy Number Policy Name Synopsis of Changes
January 2015
16.1.20 Gifts and Sponsored Awards: Classification and Administration NEW POLICY:  The policy assists UAMS employees in determining whether an award of private source external funding from a corporation or foundation is a gift or a sponsored award.  The policy clarifies that a “grant” can be gift or a sponsored award.  The determination of whether funding from a corporation/foundation is a gift or sponsored award is important for the following reasons:  a. For appropriate compliance with applicable laws and with the terms and conditions of agreement accompanying the gift or sponsored award; b. Because approval, financial reporting, budgeting and agreement practices differ depending on whether funds are categorized as a gift or a sponsored award;  c. To ensure that the appropriate UAMS division, office or department provides administrative oversight of the receipt and use of the funds.
The processes and procedures for individuals submitting grant proposals will not change.
April 2015
Human Resources
4.8.03 UAMS ERP Systems User Security Access and Annual Review Process NEW POLICY: Created in response to the FY2014 External Audit Findings (PWC)




16.1.07 The Committee on Clinical Research This revision is in response to the members of Committee on Clinical Research seeing a need to repurpose the committee in order to enhance functionality.  This will be especially important as we move forward and receive the competing renewal of the CTSA, where good communication and cooperation across the entities will be vital to the CTSA mission. This was not due to any changes in policies or laws.


May 2015
3.1.40 Authorized Remote Use of Confidential Information (name change) Change name from “Employees Authorized to Work at Home” to more accurately explain purpose of policy; updated definition of PHI to be consistent with 2014 version of the term; a form is referenced in the policy and the policy language was revised to provide clarification related to the form and reference the policy that governs the use of such form; and reformatted numbering of the policy sections and subsections.


Human Resources  
4.4.17 Redeployment Policy This represents a revision of an existing policy.  It removes language regarding reduction-in-force, which will be included in a new reduction-force policy.  It also updates the language regarding discriminatory practices to mirror the language used in our Anti-Discrimination policy, adds language indicating our compliance with the Arkansas Veterans’ Preference Act, and adds veteran status and disability status as two additional criteria to include in the spreadsheet departments are required to create that lists all existing employees in similar jobs that may be affected by a redeployment.
4.4.20 Reduction in Force NEW POLICY.  It is the result of removing language regarding reduction-in-force from the Redeployment policy.  It includes language regarding discriminatory practices that mirrors the language of our Anti-Discrimination policy and language indicating our compliance with the Arkansas Veterans’ Preference Act.


Support Services    
5.1.19 P-Card Procurement NEW POLICY:  To put into policy detailed instructions on the P-Card Process.


5.1.20 SAP MRBR Resolution (Receiving) NEW POLICY:   From Internal Audit (Procurement) recommendation (January 2015) findings: Issue #4  “Vendors are not paid in a timely manner, which may result in late fee and interest payment charges along with added administrative costs related to working with vendor personnel to resolve these issues”. “Procurement Services is responsible for monitoring the “blocked invoice” report on a daily basis and contacting the department requisitioner or vendor to clear the discrepancy so the invoice and payment can be processed”.   Recommendation:  Items on the blocked invoice report should be resolved timely.


3.1.45 Confidential Shred Bin Usage Added one new location for shred bin, in Central Kitchen wash area.


June 2015
Human Resources
4.4.10 Conflict of Interest for Academic Staff Members Definition of UAMS Official was updated to correspond with the definition in the Industry Interaction Policy (4.4.12) that was changed in August 2014.


4.4.13 Institutional Conflict of Interest in Research Definition of UAMS Official was updated to correspond with the definition in the Industry Interaction Policy (4.4.12) that was changed in August 2014.


4.4.18 Surreptitious Recordings Policy addition was recommended to help assure compliance with National Labor Relations Act. A recent court case suggested that any rule prohibiting employees from making secret audio recordings might be unlawful under the NLRA unless the policy provided an exception for concerted activity under Section 7 of the NLRA.


September 2015
Human Resources
4.1.08 Workers Compensation Policy has not been updated since its creation in 2000; updated to reflect current process.


4.5.31 Employment Security Checks The revisions are recommended by the General Counsel’s office to help assure compliance with federal and state regulations – 42 USC §§ 1320a-7a; Arkansas Medicaid Provider Manual § 142.500; 42; CFR § 1003.132.


Campus Operations  
11.4.01 Employee/Student Incident/Injury Reporting Policy needed to be updated due to changes in the workers compensation process- new company to review workers comp claims (Company Nurse – mandated by the State of Arkansas Worker’s Compensation Commission).  Hospital Policy ML.104 is in the process of being changed and these changes are incorporated in these changes.   Language and formatting was also improved to make it clearer.


11.4.19 Occupational Exposure to Hazardous Chemicals in Laboratories (Pt. 1) Federal Regulation (Hazard Communication Standard, 1910.1200) updated to reflect the Globally Harmonized System of classification and labeling of chemicals.  All countries are required to update their programs to reflect the changes.  Change from Material Safety Data Sheet to Safety Data Sheet.


October 2015
2.1.42 HIPAA Sanctions Policy      NOTE:  All HIPAA policies have been moved to a new Section within Compliance 360, all starting with the number 2.  This section 2 was added as a holding place for this one policy on the current Admin Guide Site, but the other HIPAA policies will not be updated on the existing site as it will be deleted in two weeks.


In August the Campus Compliance Committee met and was in favor of a policy setting forth HIPAA sanctions with varying levels and associated disciplinary.

8.1.11 Management of Student Information System Chart of Accounts NEW POLICY:  The policy has been established to define the authority of who manages the chart of accounts for the student information system.  A policy was lacking and needed.


8.7.01 Cash Handling Policy This policy references a new policy created for UAMS to give guidance on meeting IRC 6050I. (8.7.04) – Also removed attachments/samples from policy.


8.7.04 Cash Payments Received Exceeding $10,000 NEW POLICY:  Created for UAMS to give guidance on meeting IRC 6050I.


16.1.09 Research Registration and Billing


Policy was revised to included language regarding new EMR system (Epic) and workflows related to current interfaces between EMR and research systems (CLARA, CRIS) to ensure research participants on clinical trials are linked to the study in the EMR and research-related charges are billed correctly and in compliance with Medicare rules.


November 2015
Human Resources
4.5.28 Services and Assignments for “Non-Employees” The small change requested to policy 4.5.28 was approved by the Policy Subcommittee as non-substantial and was signed by the Chancellor.
December 2015
Human Resources
4.5.17 Employee Transfer/Promotion This policy was edited to provide departments who invest training, orientation and recruitment of an employee only to have them apply and seek another position at any time at UAMS.  Most organizations have a period of waiting before an employee can transfer or apply to another position. CLP has had such a policy in place for three years and it has been very beneficial to their ability to retain competent employees.  There have been no issues or negative feedback from any new or current employees regarding the policy.


Campus Operations    
11.2.10 Guidelines for Space Management and Assignment of Space The changes are due to new requirements for the assignment of space.


Academic Affairs  
12.2.01 Use of Facilities The changes are due to clarifications, limiting use to UAMS excluding outside organizations.


2.1.42 HIPAA Sanctions Policy Level 1 sanctions corrected bullet points.


16.1.09 Research Registration and Billing Policy corrected to refer to required training.


4.2.15 Delegation of Authorization to Approve Pay Increases NEW POLICY:  Policy is required as a result of a payroll audit and will ensure we are compliant with the audit’s recommendations.
4.2.16 Incentive Pay NEW POLICY:  This new policy identifies existing compensation incentive programs and establishes uniform guidelines within UAMS regarding the administration of the incentive programs with the purpose of ensuring compliance with existing legislation.
Human Resources
4.4.10                    Conflict of Interest for Academic Staff Members Non-Substantial Changes:  AAHRPP (the IRB’s accrediting organization) requested a slight revision to the COI policies during the current review of our IRB.  The only change in this policy is the addition of one definition concerning significant interests related to research.  No other changes are requested at this time.


4.4.11 Conflict of Interest for Non-Academic Staff Members Consistent with the recent changes to an integrated clinical enterprise, the two COI committees—Hospital and Campus—will merge into one committee to review all disclosed financial interests of non-academic staff members.  The edits to this policy reflect this merger.


4.4.13                    Institutional Conflict of Interest in Research Non-Substantial Changes:  AAHRPP (the IRB’s accrediting organization) requested a slight revision to the COI policies during the current review of our IRB.  The only change in this policy is the addition of one definition concerning significant interests related to research.  No other changes are requested at this time.
4.5.31 Employment Security Checks Act 1103 of 2015 was enacted in the last legislative session.  This act requires criminal background checks for all employees with supervisory fiduciary responsibility over all fiscal matters of UAMS.  This language mirrors the language in Act 294 of 2015.


Support Services  
5.1.04 Sole Source Procurements The changes in Policy and Procedures are made to clarify how requests for Sole Source procurements will be reviewed and approved. The changes to the Sole Source Form are made to bring our UAMS SS Form better in line with the current Procurement Regulations instruction regarding proprietary or sole source procurements [R1:19-11-232].


Communications & Marketing  
13.1.01 UAMS Communication Guidelines General updates to revise the language used when referring to websites/digital properties.  New branding guidelines developed and updated links for reference.  Inclusion of social media.


January 2016

Policy Number Policy Name/Link Synopsis of Changes
January 2016
2.1.32 IT Security Incident Identification & Handling Policy Definition of IT Security Incident was broadened to include log on credentials that are compromised due to phishing scams or sharing passwords and attacks by cyber hackers.  Section A(3) was revised to expand Level I incidents to include possible loss of user log on credentials and the notification procedures applicable to such incidents. The policy includes references to mobile devices. The examples of such devices were revised to include mobile devices commonly used by current UAMS workforce members, staff and faculty. Section C regarding Sanctions was revised to reference the new HIPAA Sanctions Policy.


2.1.43 Phishing and Fraud NEW POLICY:  Audit results
Human Resources  
4.4.21 Dress Code/Appearance NEW POLICY:  New institutional policy to coincide with new Clinical Program dress code.


8.7.05 Debt Management Policy


NEW POLICY:  Audit results


Institutional Compliance  
15.1.06 Export Control Management and Compliance Policy NEW POLICY:  To implement the Export Control program.





Updated 1/12/16
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