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 This section of the Admin Guide is being reviewed with many out of date, unnecessary policies (commonly due to the fact they are services, not policies) being deleted and the section being rearranged to properly reflect the current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|
Administration 3.1.19Faxing of Protected Health Information or Other Confidential InformationAnnual 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.”
Information Technology 7.3.03Computer Device Custodial PracticesAnnual 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.
Campus Operations 11.4.32Investigational Laser User PrivilegesNew 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).Academic Affairs 12.5.02Mediation Policy for FacultyNew policy to create formal process for mediating issues among faculty members.April 2014 Administration 3.1.05Sexual HarassmentPolicy Deleted, incorporated into the new Title IX policy, 3.1.48. See below.3.1.10Anti-DiscriminationRevisions 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.3.1.32Patient’s Request to Amend Medical Records or PHIAnnual 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 22.214.171.124Safeguarding Protected Health InformationAnnual 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.Human Resources 4.4.16Employee Grievance ProcedureThe 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.4.4.17Organizational RedesignThis 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”.4.5.01Affirmative ActionRevisions 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.General 11.1.06Campus Motor Pool Vehicle CheckoutPolicy Deleted, program no longer exists, making policy unnecessary.May 2014 Administration 3.1.08Employee 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.
3.1.31De-Identification of Protected Health Information and Limited Data Set InformationAnnual review. Updated definition of PHI per Omnibus Act regarding health information of those deceased more than 50 years.Human Resources 4.8.01Employee RecordsNEW POLICY: Result of the Records Retention policy and defines the contents of Personnel records.Support Services 5.1.05Emergency ProcurementThis 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 $5,000.00June 2014 Administration 3.1.26Accounting of Disclosures of PHIAnnual 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.
3.1.35Policy on Use and Disclosure of PHI for FundraisingAnnual 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.
Campus Operations 11.3.07Workplace Violence Prevention PlanAdded 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.
Academic Affairs 12.5.01Faculty Grievance ProcedureThe 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.
Institutional Compliance 15.1.04Responding to Government InvestigationsNEW 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.
15.1.05Subpoenas and Other Legal NoticesNEW 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.
July 2014 Administration 3.1.14Drug 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.
3.1.49Political ActivityNEW POLICY: Needed to establish guidelines for individuals that seek a political office while employed at UAMS.
Human Resources 4.2.03Flex SchedulesDeleted4.2.04Pay DifferentialNew 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.
4.2.05On Call PayDeleted4.2.10Non-Classified Patient Care Incentive Program
Deleted4.3.02Definition of Workday, Shift and Pay ProvisionDeleted4.4.12Industry InteractionUpdated to reflect current outside employment approval process.
4.8.02Work SchedulesNEW 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.
Campus Operations 11.1.10Vehicle Driver Safety ProgramUAMS 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.
11.1.13Insurance 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.
11.4.29Emergency Eye Wash/Shower Inspection PolicyThe 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.
Research 16.1.18Policy for Registration and Maintenance of Clinical TrialsThe 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.
September 2014 Administration 3.1.23Reporting of HIPAA ViolationsAnnual review and update of the policy. Updated information to reflect current room number and current way to contact IT Security.
Annual review and update of policy. Updated options of who to notify in case of breach.
Human Resources 4.2.01Overtime CompensationAdded Scope, Definitions, removed procedures and updated policy section and updated references, including a link to procedures housed on the HR website.
4.2.08Career Service RecognitionAdded Scope, removed procedures detail and updated references, including a link to procedures housed on the HR website.
4.2.13Compensation for Employees Participation in ResearchChanged Procedure to Policy, made edits to Policy section, added Scope and updated references, including a link to procedures housed on the HR website.
Support Services 5.4.10Resale of State Owned Consumer Electronic Item(s) for Personal UseNEW POLICY: The Project Coordination office asked if a policy could be written to address the position of UAMS not reselling consumer electronic items to employees. This step would mitigate the risk of possible PHI information that could be housed within these devices.Campus Operations 11.1.10Vehicle Driver Safety ProgramThis addition was to bring UAMS in compliance with the State of Arkansas Office of Personnel Management Policy 70.12, “Political Activity” and the new UAMS Admin Guide Policy 3.1.49, “Political Activity”. Policy Committee approved a change of the policy’s appendix (Attachment 2, UAMS Vehicle Safety Program Authorization to Operate).October 2014 Human Resources 4.2.06Special Rates of Pay for Labor MarketDeleted4.2.07Special Entrance Rates for Exceptional Well Qualified Applicants
Deleted4.2.14Classified CompensationUpdated based on law changes for classified staff. Combined policies 4.2.06, Special Rates of Pay for Labor Market; 4.2.07, Special Entrance Rates for Exceptional Well Qualified Applicants; and 4.3.05, Compensation and Salary Adjustment, into this one policy. Those 3 were deleted.
4.3.05Compensation and Salary AdjustmentDeleted4.5.28Services and Assignments for Non-EmployeesPolicy 4.5.28 and Policy 4.5.30 were combined into one policy (4.5.28). The definitions of a non-employee were clarified and the assignment of who can enter a non-employee in the system was defined. (NOTE: 4.5.30 was deleted).
4.5.30Non-Employee AssignmentsDeletedInstitutional Advancement 9.1.01UAMS Naming and Recognition PolicyNEW POLICY: Generally the guidelines in this Policy have been followed by UAMS as a part of its naming and recognition practices. A UAMS Policy for Naming and Recognition is deemed appropriate as the number of naming and recognition opportunities is growing. This policy is similar to the policies of other institutions of higher education and in particular other academic medical institutions. A formal pre-approval process is required to maintain consistency with naming and recognition opportunities and to ensure that such arrangements best serve the interests of UAMS and those who are being honored.
Academic Affairs 12.1.01UAMS Academic VisitorAlign the Academic Visitor Policy with the 4.5.28 policy on Non-Employees.
November 2014 Human Resources 4.3.01Use of KRONOS Time and Attendance SystemEdits to be in compliance with recent Financial/HR Audit recommendations.
Campus Operations 11.2.10Campus Operations, Guidelines for Space Committee and Assignment of SpaceThe update of this policy was triggered by procedural changes in the way UAMS space will be managed in the future. The new policy requires leases to be managed the same as space owned by UAMS. The policy defines new categories of space to allow vacant space to be managed by the Space Committee. Also, the policy provides clear rules to allow better utilization of all available space.
Research 16.1.13Non-Human Research Use of DEA Controlled Substances
Changes are made to include information regarding purchasing of controlled substances from the UAMS Pharmacy for research use. Information is provided to assist researchers and to ensure that proper processes are followed in purchasing controlled substances from the UAMS Pharmacy.
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