Administrative Guide – New or Recently Updated
|Policy Number||Policy Name/Link||Synopsis of Changes|
|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.|
|3.2.01||Record Retention||New Policy|
|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 This section of the Admin Guide is being reviewed with many out of date, unnecessary policies (commonly due to the fact they are services, not policies) being deleted and the section being rearranged to properly reflect the current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.|
|1.1.01||Campus Policy Development Process||Added Scope; added language to allow review of slight edits to go directly to Administrative Guide Committee; deleted VC for Administration as member of Admin Guide Committee and added Chief of Staff and representative from General Counsel’s office; edited explanation of Procedures section in the Appendix|
|3.1.19||Faxing of Protected Health Information or Other Confidential Information||Annual review and update of policy – one change was to add sentence under Procedure 3, confidentiality language: “Alternate language may be used with approval from the HIPAA Office.”|
|7.3.03||Computer Device Custodial Practices||Annual review and update of policy – Deleted reference to policy that was recently deleted (7.3.10 Encryption Policy) and added information related to reporting lost or stolen items in Procedure 8.|
|11.4.32||Investigational Laser User Privileges||New policy. This policy outlines the approval policy for individuals who seek to use lasers for investigational purposes. Lasers classified as Class IIIB or Class IV lasers have the potential of doing harm to operators and those around them. Several organizations outline procedures to be followed in use of these lasers. The organizations include the American National Standards Institute (ANSI); the Center for Devices and Radiological Health (CDRH) of the Food and Drug Administration (FDA); the Department of Labor’s Occupational Safety and Health Administration (OSHA); and the Council of Radiation Control Program Directors (CRCPD).|
|12.5.02||Mediation Policy for Faculty||New policy to create formal process for mediating issues among faculty members.|
|3.1.05||Sexual Harassment||Policy Deleted, incorporated into the new Title IX policy, 3.1.48. See below.|
|3.1.10||Anti-Discrimination||Revisions are necessary to comply with revisions to Section 503 of the Rehabilitation Act of 1974, revisions to VEVRAA, and the enactment of the Title II of the Genetic Information Non-Discrimination Act (GINA) of 2008. Revisions are also necessary to provide uniformity throughout campus regarding the basis of prohibited discrimination. Currently, gender expression and gender identity are included in the student Grievance policy, but not in the Anti-Discrimination policy. Gender identity is also protected under Title IX. The revisions reflect the creation of the Center for Diversity Affairs (CDA) and refer to the CDA as the unit responsible for monitoring and reporting to the Chancellor the University’s progress in this area.Changes made to the policy:a. Updated list of applicable federal and state laws regarding equal opportunity and affirmative action.
b. Added the words “and inclusion” to follow mention of diversity.
c. Changed prohibited discrimination to state: race, color, religion, national origin, creed, service in the uniformed services (as defined by state and federal law), status as a protected veteran, sex, age, marital or family status, pregnancy, physical or mental disability, genetic information, gender identity, gender expression, or sexual orientation.
|3.1.32||Patient’s Request to Amend Medical Records or PHI||Annual Review and Update of Policy. Minor edits include edits to definition of PHI, adding requirement that only Patient or Patient’s legal representative can make the request (Procedure 1); removed underline from “one” in procedure 3; corrected missed number 4 and following numbers in procedures; separated item C in procedure 4 into 2 parts (C & D); and referred to policy ML 2.12 for correcting errors in procedure 7.|
|3.1.38||Safeguarding Protected Health Information||Annual Review and Update of Policy. Edits include edits to definition of PHI, addressing Cloud storage (Procedure 1.L), new patient tracker boards requiring approval; use of non-UAMS emails forbidden for use of PHI transmission; clarification on Social Networking; and destruction of ePHI on returned equipment.|
|4.4.16||Employee Grievance Procedure||The policy must be updated to remove Violations of Sexual Harassment from the exemption due to Title IV. I have also included another exemption that is necessary with the process. See new #8 and removed #8 under Definition of Grievance.|
|4.4.17||Organizational Redesign||This represents a revision of the existing policy. As UAMS moves forward with “Performance Excellence”, the performance excellence team and HR saw the need to have the existing policy go beyond addressing issues related to reductions-in-force. One of the core functions that will come out of “Performance Excellence” is redeployment of staff after organizational design has occurred. The existing policy has very little language devoted to the practice of redeployment. Additionally, the term reduction-in-force carries a negative image that doesn’t fit well thematically with “Performance Excellence”.|
|4.5.01||Affirmative Action||Revisions are necessary to comply with revisions to Section 503 of the Rehabilitation Act of 1974, revisions to VEVRAA, revisions to Arkansas Code Annotated 21-3-302 and 303, and OPM Policy No. 30.20. The revised federal regulations take effect March 24, 2014. Changes made to the policy:
a. Revision of definition of protected veteran
b. Added the terms “physical or mental” to the term Individuals with Disabilities
c. Added Arkansas Code Annotated sections 21-3-302 and 303 and OPM Policy No. 30.20 and stated UAMS will comply with this statute and policy.
d. Incorporated language regarding recruitment efforts related to individuals with physical or mental disabilities and protected veterans to comply with newly revised regulations.
e. Incorporated language regarding voluntary self-identification of individuals with disabilities and protected veterans.
f. Changed our tagline used on official letterhead, publications, advertisements and solicitations to reflect revised regulations.
g. Updated list of applicable federal and state laws regarding equal opportunity and affirmative action.
h. Changed prohibited discrimination to state: race, color, religion, national origin, creed, service in the uniformed services (as defined by state and federal law), status as a protected veteran, sex, age, marital or family status, pregnancy, physical or mental disability, genetic information, gender identity, gender expression, or sexual orientation.
|11.1.06||Campus Motor Pool Vehicle Checkout||Policy Deleted, program no longer exists, making policy unnecessary.|
|3.1.08||Employee Debt Collection||We have many employees that owe us for tuition. However, we have not exercised the involuntary payroll deduction option that is permitted by U of A System policy and is included in the procedures used by our sister institutions. The attached is a revision of our current employee debt collection policy which includes language referencing involuntary payroll deductions. We also eliminated a lot of language that was contradictory or unessential to the policy itself.|
|3.1.31||De-Identification of Protected Health Information and Limited Data Set Information||Annual review. Updated definition of PHI per Omnibus Act regarding health information of those deceased more than 50 years.|
|4.8.01||Employee Records||NEW POLICY: Result of the Records Retention policy and defines the contents of Personnel records.|
|5.1.05||Emergency Procurement||This policy was changed to reflect the bid limit increases in the last legislative session. The competitive bid limit was raised to $10,000.00 from $5,000.00|
|3.1.26||Accounting of Disclosures of PHI||Annual review and update of policy. Updated definition of PHI per HiTECH Act, updated UAMS Workforce definition, added an EPIC option on Procedure F, and updated name of Medical Records to Health Information Management.|
|3.1.35||Policy on Use and Disclosure of PHI for Fundraising||Annual review and update of policy made in response to changes in the HIPAA rules with respect to the use and disclosure of PHI for fundraising activities. Updated the scope, purpose, edited and added to the definitions, and made several changes throughout Procedures.|
|11.3.07||Workplace Violence Prevention Plan||Added Students to Scope. Further clarify workplace violence and add the aspect of prevention to the policy. Establish a behavioral assessment team to assist in the prevention of violence.|
|12.5.01||Faculty Grievance Procedure||The faculty policy mirrors the employee policy for this section. Recently, the employee policy was revised to remove Violations of Sexual Harassment from the exemption due to Title IV and another exemption was added that is necessary. This revision allows the employee (non-faculty) and faculty employee grievance policies to be consistent with one another.|
|15.1.04||Responding to Government Investigations||NEW POLICY: This is a new policy that outlines the procedures for UAMS employees to follow in the event of a non-routine on-campus investigation by a government agency, such as DOL, CMS, FBI, etc.|
|15.1.05||Subpoenas and Other Legal Notices||NEW POLICY: This is a new policy that provides guidelines and procedures for UAMS employees to follow when receiving or responding to a subpoena or other legal notice.|
|3.1.14||Drug Testing||Updated to reflect current practice related to drug testing. Additions are (1) waiting six months to reapply if testing positive; (2) selection of random tests within 30 days of hiring exempt from test; and (3) test only valid for 30 days.|
|3.1.49||Political Activity||NEW POLICY: Needed to establish guidelines for individuals that seek a political office while employed at UAMS.|
|4.2.04||Pay Differential||New state requirements for classified shift differential payments effective 7/1/14. At the same time we have combined two other similar policies to simplify administration. Policies 4.2.05, On Call Pay, and 4.2.10, Non-Classified Patient Care Incentive Program will be deleted once this amended policy is approved. Deletion request also attached.|
|4.2.05||On Call Pay||Deleted|
|4.2.10||Non-Classified Patient Care Incentive Program||Deleted|
|4.3.02||Definition of Workday, Shift and Pay Provision||Deleted|
|4.4.12||Industry Interaction||Updated to reflect current outside employment approval process.|
|4.8.02||Work Schedules||NEW POLICY: Currently there are 2 similar policies in place. While auditing current polices, it was decided that it would be in the best interest of UAMS to combine the policies into one new one for clarity and administration. Combines 4.2.03, Flex Schedules and 4.3.02, Definition of Workday, Shift and Pay Provision into this new policy. 4.2.03 and 4.3.02 will be deleted once this policy is approved. Deletion request also attached.|
|11.1.10||Vehicle Driver Safety Program||UAMS Fleet management was recently changed from Engineering & Operations and OH&S to Parking Operations and OH&S. Changes to the policy reflect these changes, i.e. department name and phone number changes. Other minor changes were done to clarify statements in the policy.|
|11.1.13||Insurance Claims||UAMS Fleet management was recently changed from Engineering & Operations and OH&S to Parking Operations and OH&S. Changes to the policy reflect these changes, i.e. department name and phone number changes. Other minor changes were done to clarify statements in the policy.|
|11.4.29||Emergency Eye Wash/Shower Inspection Policy||The major change in the policy is the separation of research/education areas from Healthcare and who is responsible for conducting weekly testing. Research/Education areas are responsible for conducting weekly testing of eyewashes with monthly testing by Engineering & Operations (E&O). Quarterly testing of emergency showers will be the responsibility of E&O. All Healthcare areas will be tested by the Engineering & Operations staff (weekly and monthly testing). Quarterly testing of emergency showers will be the responsibility of E&O.|
|16.1.18||Policy for Registration and Maintenance of Clinical Trials||The revision to the policy was undertaken upon review of the current policy due to the enactment of a new Medicare National Coverage Determination (NCD), Section 310.1. The new NCD Manual requires all clinical investigations that are qualified for coverage and could potentially be submitted to a Medicare contractor be registered in the ClinicalTrials.gov database. Revisions were also made to clarify the current UAMS procedure for registering and maintaining trials registered by UAMS that was not adequately covered in the initial policy. The changes include: (1) Change in title; (2) updated purpose; (3) updated scope; (4) updated definitions; (5) added section on registering a trial to better inform investigators of their responsibilities and who is available to help them; (6) added section on maintaining a trial in the database; (7) added section on non-compliance; (8) added attachments; and (9) updated references.|
Updated July 23, 2014
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