safety and service recovery manual - dev.simedpl.comdev.simedpl.com/pdfs/ssrt/ssrt.pdfsafety and...

Southeastern Integrated Medical, PL 4343 Newberry Road, Suite 18

Gainesville, FL 32607 Last Updated: July 2012

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Table of Contents 1 Do No Harm ....................................................................................................................................... 4

1.1 Introduction ...................................................................................................................................... 4 1.2 Policy & Procedure Resources ........................................................................................................ 4 1.3 Reporting Incidents & Grievances ................................................................................................... 4 1.4 Training Standards for SIMED Employees ...................................................................................... 3 1.5 Patient Medical Expectation Policy & Procedures ........................................................................... 3 1.6 Medical Office Assessment ............................................................................................................. 5 1.7 Reporting Illegal Activities ................................................................................................................ 5

2 Disaster Plans, Emergency Protocols & Workplace Safety ............................................................ 6 2.1 Patient & Visitor Emergency Policy ................................................................................................. 6 2.2 Non Clinical Areas Emergency Protocols – 4343 Building .............................................................. 7 2.3 First Aid Kits / Crash Kits ................................................................................................................. 7 2.4 Automatic External Defibrillators (AED) ........................................................................................... 8 2.5 Workplace Safety Protocols........................................................................................................... 11 2.6 Emergency Protocols ..................................................................................................................... 15 2.7 Southern Market & Chiefland Campus Emergency Protocols ....................................................... 17 2.8 Southeastern Imaging and Diagnostics, Southeastern Rheumatology, Southeastern Urology &

Southeastern Interventional Pain Management Emergency Protocols ........................................ 18 2.9 Southeastern Allergy & Asthma Specialists Emergency Protocols ............................................... 19 2.10 Elevator Emergency Protocol ........................................................................................................ 22 2.11 Disaster Notification for Employees .............................................................................................. 23 2.12 Biomedical Waste Protocols ......................................................................................................... 24

3 Integrated Services Policies & Procedures ................................................................................. 25 3.1 Laboratory Protocols & Procedures ............................................................................................... 25 3.2 Pharmacy Standards ..................................................................................................................... 25 3.3 Radiology Standards ..................................................................................................................... 26 3.4 Physical Therapy Standards .......................................................................................................... 27 3.5 Sleep Center Standards ................................................................................................................ 27

4 Clinical Policies & Procedures ...................................................................................................... 29 4.1 Clinic Consents and Forms ............................................................................................................ 29 4.2 Prescription Pads ........................................................................................................................... 30 4.3 Time Out ........................................................................................................................................ 30 4.4 Drug Disposal Policy ...................................................................................................................... 30 4.5 Drug Representative / Vendor / Referring MD Gifts ...................................................................... 31 4.6 Employees as Patients Policy........................................................................................................ 32 4.7 New Injury Reporting – Workers Compensation ........................................................................... 33 4.8 Providing Interpreters for Patients ................................................................................................. 33 4.9 Patient Attendant and Wheelchair Use .......................................................................................... 34 4.10 Transportation of Patients ............................................................................................................. 34 4.11 Security and Staff Identifiers ......................................................................................................... 34

5 Medical Records Communication & Confidentiality ................................................................... 36 5.1 Medical Records Rights to Access ................................................................................................ 36 5.2 Medical Records Documentation ................................................................................................... 40 5.3 Employee Medical Records ........................................................................................................... 41 5.4 Effective Communication ............................................................................................................... 41 5.5 Electronic Communications and Patient Records ......................................................................... 42

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5.6 What You Say and What You Write .............................................................................................. 43 5.7 Families of Deceased Patients ...................................................................................................... 44 5.8 Health Insurance Portability and Accountability Act (HIPAA) ........................................................ 44 5.9 Workstation Privacy and Confidentiality ........................................................................................ 45 5.10 Confidentiality Policy ..................................................................................................................... 46

6 Patient Management ....................................................................................................................... 48 6.1 Patient Satisfaction & Customer Service ....................................................................................... 48 6.2 Patient Notification of Appointments .............................................................................................. 49 6.3 Refusal to Authorize Payment ....................................................................................................... 49 6.4 Patient Declination of Treatment ................................................................................................... 49 6.5 Controlled Substances and Narcotics Agreements & Contracts ................................................... 49 6.6 Controlled Substance Abuse ......................................................................................................... 50 6.7 HIV Consent and Testing Policy .................................................................................................... 51 6.8 Release of Test Results ................................................................................................................. 53 6.9 Critical Laboratory Values Policy ................................................................................................... 53 6.10 Treatment of Minors ...................................................................................................................... 53 6.11 Drug Screening of Minors ............................................................................................................. 54 6.12 Patient Exams or Diagnostic Testing Chaperones ....................................................................... 54 6.13 Identifying a Difficult Patient .......................................................................................................... 55 6.14 Disruptive Patient Procedures ....................................................................................................... 55 6.15 Patient Discharge Policy & Letter.................................................................................................. 56 6.16 Prisoners Who Are Patients .......................................................................................................... 56 6.17 Pharmaceutical Recall Policy ........................................................................................................ 56

7 Provider Policies ............................................................................................................................. 57 7.1 Compliance Plan and Code of Conduct ........................................................................................ 57 7.2 Basic Life Support (BLS) & Advanced Cardiac Life Support (ACLS) Training Requirements ...... 57 7.3 Provider Credentialing & Licensure ............................................................................................... 58 7.4 Physician Evaluations .................................................................................................................... 59 7.5 Disciplinary Protocols .................................................................................................................... 59 7.6 Harassment.................................................................................................................................... 60 7.7 Non-Retaliation .............................................................................................................................. 60 7.8 Clinic Cancellations ....................................................................................................................... 60 7.9 New Procedures ............................................................................................................................ 61 7.10 “Sidewalk” or “Hallway” Medicine Policy ....................................................................................... 61 7.11 Proper Authorizations / Signatures ............................................................................................... 62 7.12 Clinical & Medical Record Reviews .............................................................................................. 62 7.13 Description of Work Status ............................................................................................................ 62

8 Manual Approval & Addendums ................................................................................................... 64 8.1 Updates .......................................................................................................................................... 64 8.2 Approval ......................................................................................................................................... 64 8.3 Acknowledgement of Receipt ........................................................................................................ 66

CHAPTER 1: DO NO HARM

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1 Do No Harm 1.1 Introduction

o no harm. It is part of the Hippocratic Oath that every medical practitioner strives to uphold. When our patients seek our help, they are looking to us for comfort and healing. Whether we are medical practitioners or those who provide support to our medical staff,

we must uphold the basic tenet of “Do No Harm.”

Southeastern Integrated Medical’s Safety & Service Recovery Team incorporates various safety measures, educational opportunities and community relationship building to foster an atmosphere of risk prevention. This manual was created so that Physicians, Mid-Level Practitioners and selected employees of SIMED can learn and reference the Board approved policies and procedures used to promote safety and customer service. These policies and procedures were enacted to facilitate a positive clinical experience for our patients and to protect the clinician and organization from activities that could lead to unintended medical practices.

Please be aware that this manual is continually updated and revised. For the most current version, consult with your Supervisor, the Human Resources Department, a member of the Safety and Service Recovery Team (SSRT) or visit our website. Finally, when in doubt, ASK!

Your Medical Director is: Robert A. Guskiewicz, MD Medical Director 4343 Newberry Road, Suite 6 Gainesville, FL 32607 352-224-2200, ext 345

Your SSRT Team Representative is: Kristin Roberts Vice President of Support Services / SSRT Rep. 4343 Newberry Road, Suite 18 Gainesville, FL 32607 352-224-2200, ext 355

1.2 Policy & Procedure Resources

SIMED constantly strives to reduce risks and improve safety for our employees, patients and guests. SIMED utilizes several resources to provide appropriate policies and procedures with regards to operations, safety, compliance and employment. The SSRT manual is not a comprehensive list of every available policy and procedure and should be used in conjunction with your Employee Manual, Compliance Plan, Biomedical Waste Plan or other policies and procedures which have been or may be developed. To learn more about available policies not found in this book, contact a member of the Administration team.

1.3 Reporting Incidents & Grievances

Any time a patient, visitor or employee experiences an unexpected outcome or adverse event while visiting a SIMED location, the incident must be reported. The first step is to contact a member of

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SSRT. To do this, call the SSRT hotline at (352) 224-2355. You may also call any member of the management or administrative team for support.

Whether it is for transport via EMS to a local hospital, an injury or illness; or simply a patient concern, Incident Reports document the event and allow for appropriate follow up.

In accordance with the Safety & Service Program approved by the Board of Managers, all safety or service recovery incidents will be reported to the SSRT. The members of the SSRT will make the determination as to whether the issue is a safety, service recovery or Risk Management issue. The SSRT will then forward the incident for further review to the appropriate arm of the SSRT.

Blank Incident Reports may be found online on the SIMED website or the Division Manager may make them available. It is important that they are always filled out with as much detail as possible. Incident Reports should be completed and turned in to a member of the SSRT no more than 48 hours after the incident. Incident Reports are proprietary and should never be placed in a patient’s medical record. These are for the Risk Management team’s review only.

You may receive additional requests for information or need to meet with a member of SSRT for follow up questions or debriefing following any event. Records or other materials may be sequestered or reviewed as well. This is standard procedure following an event.

1.4 Training Standards for SIMED Employees

All SIMED employees are required to attend New Employee Orientation within the first two months of their employment. This training consists of OSHA (including Bloodborne Pathogens,) HIPAA, Compliance and Biomedical Waste. As part of the annual evaluation of employees, training is reviewed with each employee.

Physicians are required to participate in continuing education programs in order to maintain or renew appropriate credentialing for licensure, medical society membership, professional organizations, hospitals or other patient care facilities. As per the Board approved SSRT policy, select SIMED employees will also be trained on the SSRT manual and program.

1.5 Patient Medical Expectation Policy & Procedures I. Purpose The purpose of this policy is to define the protocol physicians, mid-levels and staff members should follow when a patient reports dissatisfaction or unmet expectations with a medical procedure or medical care.

II. General Information When a patient reports that they are dissatisfied or there has had an unmet expectation with an outcome resulting from a procedure performed by a SIMED Physician or Mid-Level practitioner, this policy should be adhered to. Within the scope of this policy, the term “Medical Care” shall incorporate all aspects of care performed by the Physician, Mid-Level or support staff including, but not limited to, administration of general medical care or medical procedures. The term


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“practitioner” or “clinician” shall include Physician and Mid-Levels (ARNP or PA-C) as employed by SIMED.

III. Procedures If the patient reports dissatisfaction due to the medical care received or there is an unmet expectation associated with medical care, the physician has a responsibility to discuss with the patient the medical course (see attached guidelines.) If the patient indicates that an attorney has been retained or may be retained in the near future, the physician is to immediately end the discussion and request the presence of the SSRT Representative or Chief Operations Officer.

The SSRT Representative, CEO (or his designee) or VP of Operations will then approach the patient and discuss the issues with the Physician present.

If the patient indicates that an attorney has been retained, the SSRT Representative, CEO or Chief Operations Officer will terminate the conversation. The MD will complete the medical aspects of the visit, but will not discuss the elements of dissatisfaction.

If the patient indicates that an attorney has NOT been retained, but may be in the future, the SSRT Representative, CEO or Chief Operations Officer will continue the conversation with the patient to try to search for a solution to the issue.

If the patient requests that additional care or his previous care have reduced or waived fees, that conversation will be held separately between the SSRT Representative, CEO or Chief Operations Officer and the patient. The Physician will NOT be present for any conversations regarding the fees assessed to the patient.

The Physician will be informed by the SSRT Representative, CEO or Chief Operations Officer of all outcomes.

From this point forward the Patient Liaison will take over communications with the patient regarding the negative outcome. The physician should confer with the Patient Liaison before contacting the patient further.

Physicians should be empathetic and feel comfortable in expressing sorrow and concern over the fact the patient is upset. However, at no point should the physician admit to a mistake (either yours or the staffs) or express guilt.

All discussions regarding discounting or forgiveness of fees should be held between the Patient Liaison and the patient. If asked, the physicians should say “I’m here to take care of your medical needs. All financial or business decision discussions need to take place between you and the Patient Liaison.”

Operational Grievances (Non-Medical)

It is important to recognize that a patient’s complaint may signal an impending problem. Regardless of the nature or how minor a complaint may seem, it is important to address it quickly


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and professionally. Just as important is ensuring that you “do what you say you will do.” If you tell the patient that the Division Manager will call them to address an issue be sure to communicate that to the Division Manager so they can contact the patient.

If possible, defer all non-medically related complaints or grievances to the Division Manager or Office Coordinator as they may be able to address the patient’s complaint in a more thorough manner.

All staff should adhere to these guidelines when discussing a patient complaint or grievance:

• Meet with the patient in a private area such as the Division Manager’s office or an exam room. Never discuss complaints in the lobby or hallway.

• Listen to the patient without interrupting and focus on what the patient is saying. • Clarify the patient’s needs or wants. • Notify the Division Manager or SSRT Representative regarding a patient complaint

immediately for follow-up action. • Respond to a complaint in a timely fashion. Do not wait several days before reporting a

complaint to your Division Manager. The sooner the Division Manager knows the sooner he or she may contact the patient for resolution.

• Provide the patient with the name and telephone number of the patient representative. • The Division Manager should document the patient’s complaint including the person

notified and the resolution. • Follow up with the patient to verify the resolution of the problem. During the next office

visit it is acceptable to inquire to the resolution. • Never discuss patient complaint’s with someone other than the patient or parties not

directly involved

1.6 Medical Office Assessment

As a SIMED employee it is our duty to maintain a safe and appropriate environment for our patients, visitors and employees. If you see a hazard, or if you observe inappropriate behavior by patients, visitors or employees please report it immediately to a Division Manager or member of the Administrative team.

SIMED maintains its facilities at 100% compliance with all state and federal guidelines and in accordance with all safety regulations. It is the responsibility of each employee of SIMED to report hazards, worn equipment, improper use of equipment or anything that would be considered a safety risk to a patient, staff member or visitor.

1.7 Reporting Illegal Activities

All suspected illegal activities, regardless of the nature, shall be reported to the proper authorities immediately. SIMED will cooperate with any law enforcement or regulatory agencies during an investigation. All SIMED employees are required to report any suspicious or unlawful activity to their supervisor, the SSRT representative or a member of the administrative team, respectively.

CHAPTER 2: DISASTER PLANS, EMERGENCY PROTOCOLS & WORKPLACE SAFETY

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2 Disaster Plans, Emergency Protocols & Workplace Safety

2.1 Patient & Visitor Emergency Policy

I. Purpose The purpose of this policy is to ensure that patients or visitors accidentally injured while on the premises of any SIMED building are attended to in an appropriate and timely manner.

II. General Information This policy should be followed by any SIMED employee when they observe a patient or visitor who has been accidentally injured on site.

III. Procedures If a patient or visitor incurs a life-threatening or serious injury on our premises, please call 911 immediately.

If it is not a life-threatening situation:

Patient: Present the patient with options: • Does he/she want SIMED to treat the patient if the injury falls within the scope

of their current physician’s knowledge, or • Does he/she want to go to a non-SIMED physician of his/her own choice? If so,

have front office staff facilitate an appointment with the indicated physician. • Would they like to be treated at First Care of Gainesville if we are a part of their

insurance network (or if they would like to self-pay?)

Visitor: Present the visitor with options • Does the visitor want to go to his/her Primary Care Provider for treatment? • Would they like to be treated at First Care of Gainesville if we are a part of their

insurance network (or if they would like to self-pay?)

Regardless of which occurs, please have your Office Coordinator (or Division Manager, if applicable) complete and submit an incident report form as soon as possible to the SSRT representative for further processing. Please note that this policy applies only to those situations whereby the injury would require treatment beyond basic first aid and would result in charges being generated.


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2.2 Non Clinical Areas Emergency Protocols – 4343 Building

If a visitor or patient experiences a medical event (injury or illness) in a non-clinical area of the 4343 Medical Building (e.g. atrium,) the following protocol is to be utilized:

An employee in Pharmacy contacts First Care of Gainesville to send a nurse or medical assistant to the atrium to assess the patient/visitor.

If the nurse or medical assistant deems appropriate, he/she may suggest treatment at First Care of Gainesville. Otherwise, the nurse will instruct the Pharmacy staff to contact 911. Regardless of the nature of the event, the pharmacy staff will immediately contact Emergency Medical Services (911) in all cases involving:

• uncontrolled bleeding • cardiac arrest • difficulty breathing • head trauma

• fractures • seizures • indications of extreme pain

Supervisory personnel must submit a completed incident report form to Safety and Service Recovery Team within 24 hours after the incident for further processing.

2.3 First Aid Kits / Crash Kits

I. Purpose To define First Aid and Crash Kits, their contents and where they should be used.

II. Protocol In accordance with Federal OSHA Regulation Standard 1910.151.b, each SIMED division should contain, minimally, a First Aid kit for use in emergency situations. The first aid kit will contain supplies recommended by the American National Standards Institute (ANSI) that may be used for any individual who is experiencing a minor injury or illness on SIMED premises. First Aid kits may be used until a trained medical provider is available to provide assistance and or direction, if needed. Additionally, kits containing additional medical supplies (“Crash kits”) may be used in divisions where high risk and/or invasive procedures are performed. Only divisions which meet the criteria for a crash kit are required to maintain these supplies for this purpose.

Each division and/or clinic location may add optional supplies based on the needs of the division.

Definitions First Aid Kit – A supply kit consisting of bandages and other basic supplies for treating minor injuries or illness. Supplies do not include those used in Advanced Cardiac Life


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Support. All SIMED divisions must have a basic first aid kit available. First Aid kits should contain minimally:

Crash Kit – A kit consisting of basic first aid materials but also includes additional medicines and supplies used in Advanced Cardiac Life Support. Crash Kits are generally used in divisions where high risk or invasive procedures are performed and are required for any division which has an Automatic External Defibrillator (AED) on site. Additional information on AED protocols can be found in the AED policy. Crash Kits should contain minimally:

AED (2) Preject Diphenhydramine (1) Valium (1 set) Extra pads (2) Solucortef (2) Albuterol Inhaler Batteries (for AED) (1) Ambu Bag (1) Sodium Bicarbonate Instruction Manual (2) Aminophylline (2) Clonidine Maintenance Log (2) Preject 2% Lidocaine (1) Flumazenil (2) 500cc 5% Dextrose in Water (2) Nalaxone (2-5) Sets of latex free gloves (2) 500cc lactated ringers (1) Verapamil CPR Instructions (5) 20 gauge needles (1) Nitroquick (1) Stethoscope (Opt.) (1) IV Starter kit with butterfly needles and tourniquets

(2) Promethazine (1) Suction

(2) Smelling salts (2) Nalbuphine (1) Laryngoscope (2) Preject 1:1000 Epinephrine (2) Lanoxin (2) Furosemide (2) Preject 1:10,000 Epinephrine (2) Preject Atropine (1) Procainamide

2.4 Automatic External Defibrillators (AED)

I. Purpose To regulate installation, education and use of Automatic External Defibrillators (AED).

II. Definitions Automatic External Defibrillators (AED) – A device that automatically analyzes the heart rhythm and, if it detects a problem that may respond to an electrical shock, that permits a shock to be delivered to restore a normal heart rhythm.

ACLS – Advanced Cardiac Life Support – Specific training in advanced resuscitation measures as well as advanced training in supporting individuals who may be suffering from cardiac arrest.

Various Adhesive Bandages Trauma Pad Burn Relief Cream Safety Pins or Latex Free Tape Sterile Eye Pad Instant Cold Compress Gauze Dressings (various sizes) Alcohol Cleansing Pads Aspirin Tablets Tweezers Antiseptic Cleansing Wipes First Aid Tape (1) Preject Epinephrine Pen Antibiotic Ointment First Aid Scissors Latex Free gloves First Aid Guide Eye Wash


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BCLS/BLS – Basic (Cardiac) Life Support - Training in performing cardiopulmonary resuscitation on an individual who may be suffering from respiratory or circulator decompensation.

Code – This term is used to indicate an individual who may be suffering from a respiratory or circulator decompensation event which may require the use of an AED.

CPR – Cardiopulmonary Resuscitation

High Risk Area – Any SIMED location which performs procedures which use an IV to infuse medications or are considered invasive. (For example – infusion IV therapy, invasive pain management procedures, etc…)

Provider - Any individual possessing an advanced medical degree such as a Medical or Osteopathic Physician (MD or DO) or an Advanced Registered Nurse Practitioner or certified Physician’s Assistant (ARNP or PA-C).

III. Procedures Automatic External Defibrillators (AED) shall only be placed for use in high-risk areas or areas required as part of a Research study. Physicians who perform high risk procedures shall be trained in Advanced Cardiac Life Support (ACLS) and an ACLS trained physician shall be immediately available at all times during such a procedure.

As part of the placement of an AED, the following will apply. 1. Training

a) Staff to be trained: (1) All Medical Providers (MD/DO/PA/ARNP or similar) who are

responsible for infusion therapy or perform high risk procedures.

(2) All MA’s/LPN’s in a Division which performs infusion therapy or high risk procedures.

b) Training will be completed by an ACLS certified physician, a certified CPR instructor with training on AED’s or an approved on-line course. Additional training for non-physician staff on administering medications (under specific instruction from a physician) may be performed by a non-ACLS certified physician if necessary. Training will be documented and kept in the employee’s file. Training will consist of the following: (1) Physicians, ARNP’s, PA-C’s

(a) ACLS certification is required if supervising or performing high risk procedures.

(b) Training on the specific AED Model kept in clinic. (c) Training on crash kit medicines, supplies and tools.

(I.e. Preject medicines, IV starter kits, ambubag, etc…) (2) MA’s/LPN’s


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(a) BLS Training is required (current certification to be kept in EE File)

(b) Training on the specific AED Model kept in clinic including use, maintenance and supplies required.

(c) MA’s/LPNs, although trained, should request immediate assistance from a Provider (MD/MLP) prior to administering BLS/AED support unless the patient is in apparent immediate distress (demonstrating all of the following signs): (i) Unconscious (ii) Not Breathing (iii) No apparent pulse

c) Training on administering drugs (only in the event an MD is NOT present or needs assistance). Training should include administering Preject supplies and the use of an Epi-Pen. Training will include instructions that medications are only to be given under the supervision of a physician, provider or EMS/911 personnel. (1) MA’s or LPN’s should defer to the instructions given to them

by a Provider (MD/MLP) or by an emergency 911 operator or EMS support personnel.

d) Training on proper information to relay to 911 support. 2. Emergency Supplies

a) As part of the AED, the following supplies should be kept in a readily accessible kit for emergency use. (1) AED (2) (1 set) Extra pads (3) Batteries (4) Instruction Manual (5) Maintenance Log (6) (2) 500cc 5% Dextrose in Water (7) (2) 500cc lactated ringers (8) (5) 20 gauge needles (9) IV Starter kit with butterfly needles and tourniquets (10) Smelling salts (11) Preject 1:1000 Epinephrine (12) (2) Preject Atropine (13) (2) Preject Diphenhydramine (14) (2) Solucortef (15) Ambu Bag (16) (2-5) Sets of latex free gloves (17) Resuscitation safety mask (Optional) (18) Stethoscope (Optional) (19) CPR Instructions (20) Maintenance Log for Emergency Supplies


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3. Maintenance of Equipment a) The division manager will assign one individual to be responsible for

maintaining the equipment. Their responsibilities will include: (1) Performing a self-check/function test on the AED and

documenting the test in the maintenance log for the AED, including initials, results of test and date performed. (Monthly unless recommended otherwise by the AED manufacturer and then in accordance with their standards).

(2) Reviewing the emergency kit for current supplies (3) Review stock to make sure it is appropriate (4) Review stock for near/expired medications and

ordering/restocking with current medications. (5) Log the date supplies checked and initial accordingly.

b) The Division Manager will make periodic checks of the equipment and logs to ensure the protocols are being followed (1-2 times per year recommended).

4. Usage Protocols a) AED’s should be kept reasonably close to the clinic area where high

risk procedures are being performed, or in an open, easily accessible area, allowing for rapid availability in the event of a code.

2.5 Workplace Safety Protocols

In accordance with OSHA standards, this protocol is intended to create and maintain a safe and healthy working environment for our employees. It is the policy of SIMED that employees report unsafe conditions and do not perform work tasks if the work is considered unsafe. Employees must report all accidents, injuries and unsafe conditions to their supervisors immediately. It is important that all employees report work-related injuries within 24 hours. If this is not done, benefits due to the employee may be denied or delayed.

Employee recommendations to improve safety and health conditions are important and will be given thorough consideration by management. Management will also take disciplinary action against an employee who willfully or repeatedly violates workplace safety rules.

The primary responsibility for the coordination, implementation and maintenance of this workplace safety program has been assigned to the Director of Human Resources. Senior management will be actively involved in establishing and maintaining an effective safety program. This workplace safety program will be incorporated as the standard practice of Southeastern Integrated Medical, PL and compliance with the safety rules will be required of all employees as a condition of employment.

Safety and Health Training

Upon hire, the new employee meets with the Human Resources Department to go over the required employment paperwork. During this orientation, we review our OSHA policy with regards


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to the Hepatitis B Vaccine and Bloodborne Pathogens, and we review various disaster protocols. The employee is given these protocols in their Employee Manual or as a supplement.

Within four weeks of employment, the employee must attend another safety training session that covers OSHA regulations and proper handling and disposal of biomedical waste. The training also includes what an employee should do if he/she has an occupational exposure. Employees are required to undergo annual training for OSHA and proper handling and disposal of biomedical waste. Once the employee finishes the training, the employee must take a quiz to ensure knowledge and understanding of safety rules and policies.

If an employee exhibits unsafe behavior or practices, the employee is counseled and retrained if necessary. Repeated violations of safety policies are subject to progressive discipline measures. All training records are maintained in the Human Resources Department.

First-Aid Procedures

Each of our offices maintains a first aid kit that meets ANSI standards. A designee in each office is responsible for maintaining the kit and replenishing any missing items. If an employee sustains an injury requiring first-aid, the employee is to report the injury to his/her supervisor. Then the employee may be treated using the contents of the first-aid kit; however, if treatment beyond first aid is required, the contents in the first-aid kit are not intended to substitute for treatment.

If injury is life threatening, or requires immediate physician care:

Any staff member who is first aware of, or is made aware of a medical emergency should immediately report this to the Office Coordinator/Division Manager and the attending physician. The physician will instruct office staff to call 911 if the situation warrants it. Then, the Office Coordinator should clear the area of unnecessary personnel and/or patients if necessary. The Office Coordinator or Physician should assign a staff member to contact the Human Resources or Safety and Service Recovery Team at the earliest available moment.

If a physician is readily available, he or she (or his designee) may utilize the emergency supplies as medically appropriate.

If a patient in the office goes into cardiac arrest or any other severe pulmonary or cardiac attack, and the patient is in need of Cardiopulmonary Resuscitation (CPR) the physician, the physician’s assistant, the registered nurse practitioner or any other CPR trained staff in the office will do the CPR. When contacting 911, inform EMS of the address along with precise instructions on the office location within the building (which floor, east side, west side, etc...) If 911 is called, the Office Coordinator or a designated staff person will meet the EMS vehicle outside the office and escort them to the patient.

The Office Coordinator and/or the Division Manager must complete an Incident Report Form immediately and submit it to Risk Management within 24 hours of the incident for further processing.


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If injury is non-life threatening, but requires treatment beyond first-aid: • Injury should be reported to the employee’s immediate supervisor • Supervisor or SSRT representative should instruct employee to go to First Care of

Gainesville (Urgent Care). • If patient works in offices outside of Gainesville and the medical condition allows, they

should still attempt to receive treatment at First Care of Gainesville. The SSRT Representative may suggest an alternate location for medical evaluation, if appropriate. The employee may be reimbursed for mileage and will continue to be paid while being treated for their injury.

• Supervisor will complete incident report and fax it to HR Director at (352) 224-2216 within 24 hours.

• First Care will communicate status of patient care to HR Director for any work restriction duties.

• HR will report the injury to the work comp carrier by phone or fax and communicate any necessary information to the Division Manager.

• Records will be kept confidential and maintained in the HR department. Injuries involving death of an employee or hospitalization of three or more employees must be reported to OSHA / Department of Health within 8 hours of the incident. Contact will be made by phone to the agency by the Risk Manager. If the Risk Manager is unavailable, the CEO or Chief Operations Officer will contact the agency to report the incident.

Accident Investigation All accident investigations are overseen by the SSRT representative. When an accident first occurs, the supervisor conducts a preliminary investigation using an Incident Report Form. This form allows supervisors and the SSRT Representative to assess what caused the accident, how to prevent future accidents and provide recommendations for corrective actions and/or additional safety training. All Incident Report forms are to be remitted to the SSRT Representative within 24 hours after the accident occurs.

Recordkeeping Procedures The Human Resources Department will maintain all incident reports and associated employee medical records. If an employee is injured, Human Resources will contact the workers’ compensation carrier to report the injury. The carrier will then complete a Workers’ Compensation First Report of Injury or Illness and remit that to the State of FL Division of Workers’ Compensation. The Carrier also remits a copy to Southeastern Integrated Medical, where it is kept with the employee medical record. Human Resources will keep the record on file for 5 years.

If the incident is reportable under OSHA regulations, the file will be maintained for the term of employment plus 30 years. All records will be kept confidential and employees will have access to their own records at any time.

General Office Safety • Do not place material such as boxes or trash in walkways and aisles. • Do not kick objects out of your pathway; pick them up or push them out of the way.


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• Keep floors clear of items such as paper clips, pencils, tacks or staples. • Straighten or remove rugs that do not lie flat on the floor. • Mop up and dry any liquids on floors and countertops (follow biomedical waste protocols if

necessary) • Carry pencils, scissors and other sharp objects with the tips pointing down. • Use a step stool to retrieve items above your head. • Do not run on stairs or take more than one step at a time. • Use handrails when ascending or descending stairs. • Obey all posted safety signs.

Furniture Use • Open only one file cabinet drawer at a time. Close the filing cabinet drawer you were

working in before opening another filing drawer in the same cabinet. • Use the handle when closing doors, drawers and files. • Put heavy files in the bottom drawers of file cabinets. • Do not tilt your chair on its back two legs while you are sitting in it. • Do not stand on furniture to reach high places.

Equipment Use • Do not use extension or power cords that have the ground prong removed or broken off. • Do not use frayed, cut or cracked electrical cords. • Use a cord cover or tape down cords when running them across aisles, between desks or

across entrances or exits.

Compressed Gas Cylinders • Do not handle oxygen cylinders if your gloves are greasy or oily. • Store all compressed gas cylinders in the upright position and properly secure them in

OSHA approved carts or areas. • Do not lift compressed gas cylinders by the valve protection cap. • Do not store compressed oxygen cylinders near sources of heat or in areas where they can

come into contact with chemicals labeled “corrosive”. • Do not store oxygen cylinders near combustible materials such as oil or grease.

Hazardous Materials Follow the instructions on the label and in the corresponding Material Safety Data Sheet (MSDS) for each chemical product you will be using in your workplace. Do not use chemicals from unlabeled containers or bottles.

Although SIMED generally does not purchase carcinogenic chemicals, corrosives, reagent chemicals or those that can cause mutations, we maintain an MSDS on items purchased. MSDS sheets may be found on the SIMED website at www.simedhealth.com in the employee files section.

Lifting Procedures • Plan the move before lifting; ensure that you have an unobstructed pathway. • Test the weight of the load before lifting by pushing the load along its resting surface.

http://www.simedpl.com/�


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• If the load it too heavy, get assistance from a co-worker or use a dolly which can be obtained with assistance from the Physical Plant Manager.

• If assistance is required to perform a lift, coordinate and communicate your movements with those of your co-worker.

• Position your feet 6 to 12 inches apart with one foot slightly in front of the other. • Face the load. • Bend at the knees, not at the back. • Keep your back straight. • Get firm grips on the object using your hands and fingers. Use handles when they are

present. • Hold the object as close to your body as possible. • While keeping the weight of the load in your legs; stand to an erect position. • Perform lifting movements smoothly and gradually; do not jerk the load. • If you must change direction while lifting or carrying the load, pivot your feet and turn your

entire body. Do not twist at the waist. • Set down objects in the same manner as you picked them up, except in reverse. • Do not lift an object from the floor to a level above your waist in one motion. Set the load

down on a table or bench and then adjust your grip before lifting it higher. • Never lift anything if your hands are wet or greasy.

For Employees Having Direct Patient Contact: • Do not use gloves which are torn, cut or punctured. • Discard disposable needles or medical sharps into the containers labeled “Biohazard

Sharps.” • Do not reach into containers when discarding sharp items. • Wear latex or vinyl gloves and full face and body protection whenever large amounts of

blood or body fluids are present or anticipated. • Place protective equipment contaminated with human blood or bodily fluids in red

containers labels “Biohazard.” • Wash hands and other exposed skin surfaces on the arms and forearms with soap and

water immediately upon removal of protective gloves.

2.6 Emergency Protocols

In the event of an emergency, the following protocols must be adhered to. Every employee is responsible for learning these protocols. Some Divisions may require additional protocols due to procedures performed or equipment used specific to that specialty. Those protocols can be found in the subsequent sections of this manual.

Medical Emergency Protocol For information on Medical Emergencies, see the section above entitled “Workplace Safety” with the sub-heading “First Aid Procedures.”


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Bomb Threat Protocol The majority of bomb threats that are called in to targets are made with the intent of disrupting normal business. However, every bomb threat must be considered real until investigated to ensure the safety of building occupants. Normally, the call will be very brief, but if you do get a call, attempt to keep the caller on the line:

• Try to get as much information as possible. • Upon hanging up, immediately call 911 and give specific details. If possible, use a

confidential manner of communication to reduce the possibility of panic. • Next, notify your immediate supervisor that a bomb threat has been received. • If your immediate supervisor is not available, then contact the next available person in

this order: o Division Manager o SSRT Representative o The Chief Executive Officer

• The Chief Executive Officer or his/her designee, in consultation with the staff above, will make the decision whether to evacuate the building.

• If the building is to be evacuated, employees are to follow the evacuation protocols.

Fire Protocol All employees should be familiar with the locations of fire extinguishers and fire alarm pull stations. Fire extinguishers are located in each hallway and employees need to learn the location of the nearest extinguisher. Fire extinguishers are maintained regularly in accordance with the law. Do not attempt to fight a fire before activating the fire alarm pull station and calling the fire department.

A. If a fire is discovered inside the building: 1. Activate a fire alarm pull station. Follow the instructions on the pull station. Make sure

the handle is pulled all the way down and released. 2. Notify the fire department at 911. Give exact location (building name, address, floor,

etc...) 3. Evacuate the building using the Evacuation protocol instructions. Make sure that all

patients are evacuated out of the building. B. Personal safety and safety of others are the most important factors when deciding when to

fight a small fire. Considerations for using the portable fire extinguisher: 1. If it is a small, contained fire (e.g., wastebasket.) 2. If unable to extinguish in 15 seconds, leave the area. If possible, close off the area.

Make sure the area is empty of personnel and patients. C. If the decision is to use the fire extinguisher, follow these operating instructions by

remembering the PASS word: 1. Pull the pin. 2. Aim extinguisher nozzle at the base of the fire (approach no closer than 8 feet from the

fire.)


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3. Squeeze trigger while holding the extinguisher upright. 4. Sweep the extinguisher from side to side, covering the area of the fire with

extinguishing agent. D. If there is a fire outside the building, call 911 and report the fire. Do not activate the fire

alarm system.

Evacuation Protocol Continuous sounding of the fire alarm speakers and the flashing of the fire alarm strobe lights located on your floor shall be the signal for immediate evacuation from the building.

• Evacuate the building immediately according to the evacuation route posted closest to your location.

• Stop what you are doing and walk, do not run, to the primary or alternate stairwell. Close all doors behind you.

• Use the stairs. Do not use the elevators. If the power fails, you may become trapped in the elevator. During fire alarms, elevators are taken out of service and returned to the ground floor.

• Ensure work areas are evacuated and doors are closed, not locked. • Ensure rest rooms are evacuated. • Office Managers and/or Division Managers are to coordinate assistance for injured or

incapacitated personnel. • Once evacuated, proceed to your designated gathering area located in the parking lot

directly in front of your office. If you are on the second floor west of the 4343 building, please meet in the parking lot west of the building. If you are on the second floor east of the 4343 building, please meet in the parking lot east of the building.

• Report to your immediate supervisor for a headcount. Visitors must report to the office manager for headcount.

• Do not re-enter the building until the all clear announcement is given by a member of the administrative management team

• Report to the SSRT Representative on evacuation status* and employees requiring assistance.

*Fire wardens will confirm evacuation status with supervisors or Division Managers.

2.7 Southern Market & Chiefland Campus Emergency Protocols

I. Purpose The purpose of this policy is to educate staff and providers regarding emergencies which may occur in or on the Southern Market (Ocala, The Villages, McIntosh or Chiefland Campuses.)

II. Procedures In the event of a medical emergency within the perimeters of the Southern Market or Chiefland campuses the following protocols are to be followed:


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Inside Clinic Area: • Determine nature of event (Patient Unconscious, bleeding, unresponsive, etc...) • Call 911 if unresponsive or not breathing. Follow instructions of the 911 operator until

help arrives. • Call for nearest physician or provider assistance. Do not move the patient. Follow

instructions of provider. • Assign an individual to retrieve the AED if appropriate (In Ocala only). In the event that the

patient is in apparent cardiopulmonary arrest, an AED is available in the following areas: o Interventional Pain Management (3309 Building), Rheumatology (on procedure

days) (3304 Building) • Begin CPR immediately if instructed to do so by a provider or 911 operator. • Once the patient is stable, inform a Division Manager of the situation (or assign someone

to seek a manager for assistance). Call Risk Management immediately at (352) 224-2355 to inform of situation.

Outside Clinic Area (Parking Lot, Sidewalk, etc…): • Determine nature of event (Patient Unconscious, bleeding, unresponsive, etc...) • Call 911 if unresponsive or not breathing. Follow instructions of the 911 operator until help

arrives. • Call for nearest physician or provider assistance. Do not move the patient. Follow

instructions of provider. • Assign an individual to retrieve the AED if appropriate (Ocala only) • In the event that the patient is in apparent cardiopulmonary arrest, an AED is available in

the following areas: o Interventional Pain Management (3309 Building) o Rheumatology (3304 Building)

• Begin CPR immediately if instructed to do so by a provider or 911 operator. • Once the patient is stable, inform a Division Manager of the situation (or assign someone

to seek a manager for assistance). Call Risk Management immediately at (352) 224-2355 to inform of situation.

2.8 Southeastern Imaging and Diagnostics, Southeastern Rheumatology, Southeastern Urology & Southeastern Interventional Pain Management Emergency Protocols

In the event of an injury or health emergency within the Imaging & Diagnostics, Rheumatology or Interventional Pain Management locations:

The employee, who is attending to the patient, should designate someone to contact the nearest physician immediately and begin performing CPR, if necessary. The clinic assistant or other available staff member will contact the Safety and Service Recovery Team (extension 355.)

If CPR or airway management is necessary, the employee attending the patient or his/her designee will: A) immediately call 911; B) send for an ACLS trained physician; and, C) send for the Emergency


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Drug and Resuscitation Kit and Automatic External Defibrillator (AED). The employee attending to the patient will assign an employee go to the suite that the ACLS physician is located and physically escort him/her to the code along with the Emergency Drug and Resuscitation Kit and Automatic External Defibrillator (AED.)

If CPR or airway management is NOT deemed necessary, the employee attending the patient will: A) stay with the patient continuously until the situation is resolved; and, B) designate someone to contact the ACLS physician.

For emergencies within the MRI Suite: Before assisting the patient, the Technologist, the Radiology Manager, the ACLS physician, and other attending personnel must remove all metal objects from their person before entering any magnetic field.

When the ACLS on call physician arrives, he/she and the Radiology Manager will direct the removal of the patient from the scanner and bring the patient to the hall. If the incident occurs in the MRI Room, the patient must be removed from the scanner and brought into the hall or the emergency items will stick to the magnet.

If the patient already has an IV started, it should be left in. If the patient does not have an IV, the attending physician if present and the ACLS Physician should assess whether an IV should be started on the patient, and insert an IV if it is determined that an IV is necessary.

The physician, manager or SSRT Representative will then assign a staff member to clear the area adjacent hall of all unnecessary personnel.

A clinic assistant or a representative from SSRT should be assigned by to escort the EMS team to the emergency location. Once the EMS team takes over, our employees should remain clear of the patient.

2.9 Southeastern Allergy & Asthma Specialists Emergency Protocols

Allergic Reaction / Anaphylaxis Guidelines

Definition: An Allergic reaction is an exaggerated immune system response to a foreign antigen. The clinical syndrome includes pruritis (itching,) generalized erythema (red rash,) urticaria (hives,) or minor swelling.

Anaphylaxis is a severe hypersensitivity reaction characterized by cardiovascular collapse and respiratory compromise. The clinical syndrome affects two or more systems, including the skin (erythema, urticaria or angioedema), respiratory (dyspnea, stridor or wheezing), cardiovascular (chest pain, tachycardia, or hypotension), gastrointestinal (nausea, vomiting, or diarrhea) and central nervous system (altered mental status).


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Goal: Determine if patient is experiencing an allergic reaction, or the more severe anaphylaxis, and to neutralize, stabilize, and reverse this cascade of events. Here is what to look for: History:

• Previous allergic reactions to food, drugs, environmental exposures or immunotherapy. • How rapid was symptom onset. • Symptoms such as dyspnea, pruritis, urticaria, nausea, vomiting, diarrhea, chest pain, light-

headed, or sense of impending doom. • Past medical history, especially respiratory (asthma) or cardiac (angina, MI) problems,

previous reactions to immunotherapy, significant reactivity to environmental allergens by testing.

• Medications, particularly Beta-blockers (which may predispose patients to more severe reactions.)

• Interventions prior to arrival, such as Benadryl or EPI-pen. Others: Patients on immunotherapy can have significant reactions depending on “pollen count.”

Physical Exam: • Must be brief and not delay treatment of Epinephrine • Special attention to serial vital signs • Airway patency and evidence of stridor (upper airway swelling) • Presence of angioedema (swelling of face, lips, tongue, throat, or neck) • Breath sounds and adequacy of ventilation • Mental status • Skin exam for generalized erythema or urticaria

Differential Diagnosis: Asthma, pulmonary embolus, myocardial infarction, airway obstruction, volume depletion, vasovagal reaction, anxiety or panic disorder, or infectious etiology.

Allergic Reaction / Anaphylaxis Guidelines

Call for the nearest physician or mid-level provider to assist immediately. Initiate BLS care. Call 911 if indicated.

For allergic reaction, with flushing pruritis, urticaria generalized with or without systemic symptoms:

Place patient in position of comfort. If there is light-headedness or signs of low blood pressure, have patient lay in bed or floor and elevate legs.

Immediately administer epinephrine 1:1000 dilution, 0.3cc - 0.5 cc for adults IM into the thigh or deltoid (do not delay.) (Peds 0.01 cc/kg to max 0.3 cc. IM in thigh. See doses below) may repeat every 5 minutes as necessary to control symptoms and BP.


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If indicated, (i.e. BP < 90mm Hg) initiate vascular access and start IV fluids (to be run at a rate to maintain BP systolic ≥ 100 mm Hg - adult ≥ 50 mm Hg- children.

If patient hasn’t responded to 2 IM epinephrine give 1:10,000 epinephrine (0.1cc of 1:1000 of epinephrine, in tuberculin syringe, insert into vein or IV tubing, draw 0.9cc of blood or IV fluids to dilute to 1:10,000) this may be given IV 0.1 – 0.2 cc over several minutes as needed every 10 minutes to restore blood pressure and monitor BP continuously.

Administer diphenhydramine (Benadryl) 50mg IM (peds 1 mg/kg /dose IM (or IV if available.) See chart below): if able to swallow: adults 50 mg, children (see chart below)

Administer methylprednisolone (Depomedrol) 40 mg IM (Peds 0.5 mg/kg IM see chart below); if able to swallow: Prednisone 60 mg / po to adults, peds. (see chart for doses.)

If wheezing, administer Albuterol unit dose or Xopenex 1.25 mg via nebulizer, monitor pulse O2, and give O2 2L per minute if indicated.

Age 3 years 6 years 10 years Average Wt 15 kg (33 lbs) 20kg (48 lbs) 30kg (66 lbs)

Epinephrine 1 mg/ml .15cc .2cc .3cc Benedryl PO 12.5 mg/ 5 cc 1 ½ - 2 tsp 2 tsp 25-50 mg Benedryl IM (50mg/cc) 15mg (0.3cc) 25mg (0.5cc) (0.5 – 1cc) Prednisone PO Prelone 15 mg / 5 cc

(1 tsp) Prelone 15mg / 5cc (2 tsp)

15mg Prednisone

Depomedrol IM (40mg/cc) 7.5mg (0.2cc) 10mg (0.25cc) 15mg (0.375cc) Precaution: epinephrine is relatively contraindicated in patients with known coronary artery disease, angina, or previous MI except in life threatening circumstances.

Treating MD to fill out separate Anaphylaxis management form and discuss case with MD in charge of patient and offer recommendations. Risk and Benefits of continuing IT will be reassessed.

Scratch Test Protocols In order to make sure that all patients and staff are protected by unforeseen workplace accidents and hazards, the following policies are effective immediately.

• When administering scratch tests, all patients must be sitting or lying down.

• Staff conducting scratch tests should follow all appropriate bio-medical waste handling protocols.

• If you have any questions about this, please refer to your Division Manager.


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2.10 Elevator Emergency Protocol

In case of elevator problems (i.e. passengers trapped in the elevator) the following protocol will be followed.

Gainesville 4343 Building • Identify which of the two elevators is having the problem: the elevator closest the

Pharmacy (# 1) or the elevator closest to the atrium stairs (#2) • NEVER rescue passengers stuck in the elevator unless the power to the elevator has been

turned OFF (see below.) • Contact the administrator on-call to assist in resetting the power (See below.) In 95% of all

elevator problems, the resetting of the power to the elevator will resolve the problem. • If you cannot rescue the passengers after the power has been reset, return to the elevator

control room and turn the power to the elevator in question OFF. • After the power has been turned OFF, use the special elevator door key (one located on the

bulletin board in the Maintenance office room and one located in Pharmacy,) to open the door to the elevator on the floor where you expect the passengers to be stuck. Once all passengers are freed from the elevator, leave the power to the elevator in the OFF position.

• Notify the Maintenance Department who in turn will call our elevator maintenance company to report the problem with that elevator.

Passengers trapped in the elevator If the alarm button is pushed, the Pharmacy personnel will notify the Physical Plant Manager or a member of the SSR team.

If the emergency phone is used, the monitoring company will notify either the Physical Plant Manager or member of the SSR Team. In case neither person is in the building, the monitoring company will notify the Alachua County Fire and Rescue Department.

In addition there will be an administrator on call who has been trained in the basic operations of the 4343 building. The on-call person may be reached via beeper at 352-377-2380. The schedule for the on-call person shall be maintained by the Physical Plant Manager.

Ocala Elevator Emergency Protocols In case of elevator problems the following protocol needs to be followed.

• Determine whether a passenger is trapped in the elevator (Alarm button pushed, emergency phone used to call monitoring company, voices/yelling coming from elevator, etc...) see protocol below.

Passengers trapped in the elevator • If someone is trapped in the elevator, call the Ocala maintenance man, the building and

grounds manager or the Southern Division Operations manager to evaluate the problem. If you cannot reach any of the above staff, call 911.


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• NEVER rescue passengers stuck in the elevator unless the power to the elevator has been turned OFF. The fuse box is located in the elevator control room adjacent to the elevator. Each of the above three (3) staff members has a key to this room. In 95% of all elevator problems, resetting the elevator by turning the power off and then on again, will resolve the problem.

• If you cannot rescue the passengers after the power has been reset, return to the elevator control room and turn the power to the elevator in question OFF.

• After the power has been turned OFF, use the special elevator door key (one located in the elevator control room adjacent to the elevator) to open the door to the elevator on the floor where you expect the passengers to be stuck. Once all passengers are freed from the elevator, leave the power to the elevator in the OFF position.

• Notify the Maintenance Department who in turn will call our elevator maintenance company to report the problem with that elevator.

No passengers trapped in the elevator

• Contact the Ocala maintenance department, the building and grounds manager or the Southern Division Operations manager to evaluate the problem. In 95% of all elevator problems, the resetting of the power to the elevator will resolve the problem.

• If the problem cannot be resolved, call GESS (General Elevator Sales & Service) @ 407-859-4340. Our account is under Park Point Medical Center – Account 41-1846-8.

2.11 Disaster Notification for Employees

This protocol shall be in place for communication with employees during a disaster. This policy will be activated during any disasters or emergencies and the Chief Executive Officer will make that determination.

The Medical Information Systems (MIS) Officer will update the SIMED Emergency Line (352-224-2212) with official (approved by the CEO or the CEO’s designee) informational bulletins as necessary. These bulletins will contain time/date information and information regarding the status of ALL SIMED locations including structure of the buildings and schedule changes.

In the event the 4343 building is damaged or has no electricity, the MIS Coordinator or MIS Officer will contact the phone company and have the Emergency phone number redirected to a working location to be determined by the MIS Coordinator or MIS Officer and approved by the CEO or the CEO’s designee.

Along with the emergency line, information will be filtered via a phone tree, with each level being responsible for contacting the level below. Phone lists with updated numbers will be distributed periodically.


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2.12 Biomedical Waste Protocols

SIMED wants to ensure that its employees, environmental-service staff, waste haulers and general public are safe from risks associated with potentially infectious biomedical waste.

SIMED has created a Biomedical Waste Plan which includes protocols on the safe handling of biomedical waste materials. This will help instruct employees on the proper management of handling and storage of biomedical waste in a manner that is in compliance with all federal, state and local laws.

The complete Biomedical Waste Protocols policy may be found by contacting the Human Resources Department or a member of the administrative team.

CHAPTER 3: INTEGRATED SERVICES POLICIES & PROCEDURES

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3 Integrated Services Policies & Procedures

3.1 Laboratory Protocols & Procedures

Our laboratory is governed by separate and specific local, federal & state regulations. A copy of these standards may be found within the Diagnostics department in the Gainesville 4343 building and the SSRT department.

3.2 Pharmacy Standards

According to Florida Rule 64B16-27.300 Standards of Practice the following Policy is implemented.

A Continuous Quality Improvement Committee comprised of staff members of the pharmacy, including Pharmacist, pharmacy technicians, Integrated Services Director and/or other personnel deemed necessary by the CEO will be formed.

This committee will meet at least every 3 months to conduct a review of Quality Related Events.

All quality events will be noted on the Quality Event Form (found in forms section of the master SSRT Manual and within the pharmacy department) and reviewed at the committee meeting.

At a minimum the review shall consider the effects on quality of the pharmacy system due to staffing levels, workflow and technological support.

Summarization of the meeting will be kept in a Continuous Quality Improvement binder for review for 2 years.

“Quality-Related Event” means the inappropriate dispensing or administration of a prescribed medication including, but not limited to:

A variation from the prescriber’s prescription order, including but not limited to: • Incorrect drug • Incorrect drug strength • Incorrect dosage form • Incorrect patient • Inadequate or incorrect packaging, labeling, or

directions. • A failure to identify and manage over-

utilization or under-utilization

• Therapeutic duplication • Drug-disease contraindications • Drug-drug interactions • Incorrect drug dosage or duration of drug

treatment • Drug-allergy interactions • Clinical abuse/misuse


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DISCOVERY OF QUALITY RELATED EVENT

All Quality-Related Events will be brought to the attention of the Pharmacist immediately.

The Pharmacist will apologize to the patient and correct the mistake immediately.

The Pharmacist may refund the customer for the medication.

The Pharmacist will contact the physician immediately if the patient has taken the medication.

The Pharmacist will then fill out a Quality Related Events Form and an internal incident report form.

This Quality Related Events form will include a description of the event that is sufficient to permit categorization until the event has been considered by the committee and incorporated into the summary.

The Internal Incident report form includes details specific to the incident and corrective action. This form once completed by the Integrated Director is submitted to the SSRT Representative for further processing.

Quarterly the Pharmacist will summarize the events for the Continuous Quality Improvement committee to review.

This summarization document shall analyze remedial measures undertaken following a Quality-Related event. This review shall consider the effects on quality of pharmacy systems due to staffing levels, workflow, and technological support. No patient name or employee name shall be included in this summarization. The summarization will be maintained for two years in the Continuous Quality Improvement Policy Manual.

Records maintained as a component of a Pharmacy Continuous Quality Improvement Program are confidential under the provisions of Section 766.101 F.S. Records are considered peer-review documents and are not subject to discovery in civil Litigation or administrative actions.

3.3 Radiology Standards

Our radiology department is governed by federal regulations and Radiation Protection Standards. A copy of these standards may be found within the diagnostics department and the SSRT department.


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3.4 Physical Therapy Standards

Southeastern Integrated Medical Physical Therapy charts are audited on a regular basis. The following is a checklist which is used when auditing the charts for compliance purposes.

• SIMED Referral Form – Information on form being followed correctly. o Number of visits o Collection of money or budget plan established o Notes for non-compliance

• PT Prescriptions – number of visits documented • Additional therapy scripts – Number of visits documented • 99% of the time treatment of proper body part will be documented. • Disclosure of ownership in chart

o Signature by patient/staff • Appropriate Forms in Chart

o HIPAA o Auto

• Documentation by Therapist of next office visit with MD • Exercise Log provided • Utilization – Goal between 9.75-10.5

o Patient was treated over/under auth visits • 99% of the time – documentation will match the billing

3.5 Sleep Center Standards

Southeastern Sleep Center has separate Quality Assurance standards for the sleep studies which are performed. The following are the QA protocols by which the Sleep Center is accountable.

The following Items will be reviewed by the scoring technologist on every Polysomnography record performed in the Sleep Center:

• Machine Calibrations • Physiologic Calibrations • Impedance Checks • Lights out • Appropriate recognition of artifact and appropriate monitoring of the artifact or

appropriate resolution of the artifact. • Appropriateness of intervention (positive pressure, and/or oxygen) • Impedance Check prior to Lights On

Results of the review will be sent with each scored report and reviewed with the Medical Director at the monthly management meeting. Results will be reviewed with the technologist


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The following items will be monitored, tracked, and reported at monthly management meetings with the Medical Director and reported on Quarterly QA reports:

1. Number of Diagnostic, Split and Positive Pressure Titration Studies 2. Number Positive Pressure Titrations with ending AHIs greater than 5.0 3. Number of Positive Pressure Titrations with ending AHIs greater than 10.0 4. Number of Positive pressure titrations with a CPAP or IPAP greater than 15 cm/H2O 5. Turn-Around-Time for Polysomnography scoring 6. Turn-Around-time for Polysomnography interpretation 7. Inter-Scorer reliability for the month

The Medical Director will determine if and when an action plan needs to be made and initiated for any of the above variables. The Medical Director will also determine when/if the variables should be changed.

CHAPTER 4: CLINICAL POLICIES & PROCEDURES

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4 Clinical Policies & Procedures 4.1 Clinic Consents and Forms

Authorization to Treat / Assignment of Benefits

When a new patient first establishes with any SIMED provider they are given the Authorization to Treat & Assignment of Benefits form to review and sign. This form outlines the permissions granted to SIMED for treating the patient, certain billing practices and provides HIPAA authorizations.

It is important for each providers and staff to read this form so that they not only understand it, but may answer any questions that patients may have about this consent. This consent must be signed by the patient in full or treatment may be declined. The agreement should not be altered in any way. Should a patient disagree with a portion or all of this agreement, the referring provider may be contacted and other arrangements for the care and treatment of this new patient may be addressed.

General Consents

Before we may begin any initial examination, treatment or medical course of action on a patient, an authorization to treat form must be signed. Additional procedures performed as part of the treatment process may also require a consent form. Our consent forms for procedures will clearly outline the potential benefits and risks associated with treatment as well as any alternative treatments. No invasive procedure should ever be administered without a signed consent form with the original scanned and kept in the patient’s medical record. Providers should document that the consent form was reviewed by the patient and the provider, signed by the patient and that the patient (and any family members or patient guests present) were given the opportunity to ask questions regarding the procedure. A review of the risks and benefits of all procedures should be performed immediately prior to the procedure along with a recap of the procedure being performed as it relates to the consent form.

Research Trials and Consents

Due to the nature of our Research and Clinical Trials program, consent forms will vary from trial to trial. Consent forms for each active and expired trial are kept with the regulatory information within the Research Department and may not necessarily appear in the patient’s official medical record.


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4.2 Prescription Pads

Prescription pads (or prescriptions for printer use with electronic prescribing) are ordered through the SIMED purchasing department. Prescriptions will contain the name of the physician, address of the SIMED facility and vendor identification number (for controlled substances) on the front of the prescription. Tamper-proof prescriptions are used for all Medicaid patients and for controlled substances. All prescriptions pads and tamper-proof prescription paper should be kept in a secure cabinet or drawer only accessible by the provider. Physicians must take responsibility for maintaining their prescription pads and should keep minimal numbers in reserve.

4.3 Time Out

At any time during the day, it is natural that a medical provider or staff member may become overwhelmed with patients and clinical duties. It is important that before a provider performs any procedure, whether it is invasive, surgical or a simple injection he or she should perform a “time out.” A time out allows the provider or staff member a moment to review some basic information about the patient to help prevent a medical error from occurring. Depending on the nature of the procedure about to be performed, some time out information may include:

• Verify patient (name and one other signifier such as date of birth) • Type of procedure about to be performed • Area of body, including side, where procedure is to be performed • Allergy information or blood thinners • Patient preparation information

This is one of the easiest and simplest, yet most effective safety tools in our kit and must be encouraged by all members of the SIMED team.

4.4 Drug Disposal Policy

Policy Purpose: In accordance with § 499.028(9) and the Florida Pharmacy Act, Southeastern Integrated Medical, PL has instituted this policy to properly dispose of samples and other prescription medications.

Agency Contact: Department of Health - Bureau of Statewide Pharmaceutical Service.

Prescription Samples: All large quantity sample medications (greater than 100 pills) should be returned to the manufacturer or distributor. The manufacturer or distributor should provide return mailing labels accordingly. Quantities less than 100 may be disposed with documentation which meets the Bureau of Statewide Pharmaceuticals Service guidelines as follows:

• The pills should be disposed of using the recommended method of flushing and a continuous log must be kept with the samples which indicate the following disposal information:


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• Date of Disposal • Name of drug disposed • Quantity of pills disposed • Method of disposal (flushing) • Signature of person disposing • Signature of witness

Narcotic/Patient Medications: It is the policy of SIMED that patients are to flush any returned prescription drugs themselves. Employees (including providers) are NOT to accept any medications for disposal from patients. The physician or the physician’s designee will accompany the patient to the rest room and observe the patient flushing the medications. The physician or physician’s designee will then document the act in the patient’s medical record with the information listed above. If the patient disposes of the bottle, the physician or designee will ensure that all protected health information is removed before it is thrown in the trash.

Southeastern Community Pharmacy is not permitted to accept unused or expired sample medications for any reason.

4.5 Drug Representative / Vendor / Referring MD Gifts

SIMED’s Healthcare Attorney has given us information regarding our relationships with Drug Representative’s (Reps) and other vendors. As in most legal situations things are not often black or white, they are gray which leads to legal interpretations and recommendations. The following is SIMED’s policy on accepting gifts, gratuities or other items from outside sources. • SIMED does not allow any staff member to receive meals, including going out for meals,

from a Drug Rep or any other vendor unless it is of modest value for a “bona fide” educational program documented in writing and retained for four years.

• A practitioner may attend a drug rep company sponsored dinner as part of an educational program. The meal must be of “modest value” and there must be a written curriculum which should be kept in your file for four years. A spouse can never accept a free meal.

• No employee is allowed to receive gifts from a Drug Rep or other vendor. • Promotional items such as pens, pads, etc are not allowed. • Educational materials for patients may be accepted so long as they are given to patients at

no charge. • If a practitioner is asked to “teach a seminar” he/she may receive payment at Fair Market

Value (FMV) for instructional time. FMV for a physician is defined as the total pay of an ER physician in our market ($125.00/hour) for 2005. Prep time may not be included. Travel time is reimbursable unless the sponsor is paying for your transportation (plane, mileage, etc...)

• Although there are no Stark or anti-kickback regulations regarding drug samples, there is always a potential malpractice concern. If there is an adverse reaction this could be an issue against you in a malpractice suit. Review all patient medications for interactions before dispensing samples and document thoroughly in the patient’s medical record. You are discouraged from giving more than one month of samples at a time.


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• “Think Tanks” or being used as a “consultant” should be approved by the Medical Director before accepting any offers. This may be permissible under the following conditions:

o The practitioner’s input is an area of his or her expertise o The practitioner’s input is documented in writing o It is reimbursed at Fair Market Value o Reimbursement for travel, hotel, and meals is necessary for the drug company or

vendor to get the value of the practitioner’s expertise. o This should be limited to one physician per group and any individual physician

should not attend more than two per year! • Drug reps are not permitted to “shadow” a clinician. • The practitioner is permitted to attend a vendor sponsored Continuing Education meeting

where the course and food are free if the practitioner pays for his own lodging. It must be an educational program documented in writing and kept for four years. The meal must be of “modest value.”

• Employees are not permitted to accept medically related items such as medical books or equipment such as a stethoscope.

• A practitioner may be paid as a “medical expert” to do chart reviews for pharmaceutical companies so long as he is paid for legitimate time at FMV.

• A practitioner may have his/her expenses paid for an out of town meeting only if he/she is a presenter and the seminar can meet all of the conditions above. If he/she is simply an attendee, he must pay his own way.

• A practitioner may not go to lunch with another physician who is looking to gain referrals from you unless you split the check or alternate paying for meals if the meeting is regular.

4.6 Employees as Patients Policy

Employees of SIMED may elect SIMED physician’s for treatment. Employees, including physicians, must take extra care in maintaining the privacy of our employee-patients. Physicians should discuss issues related to the care of employee-patients with only those for whom it is necessary.

If at any time an employee requests samples, the physician must document it in the patient’s medical record (if established) just as it would be done for any other patient. If the employee requests treatment, the physician should adhere to the “Hallway” Medicine Policy found within this manual and insist the employee schedule an appointment.

Employees do not receive discounts on fees above and beyond that of what their insurance policy allows, established SIMED fee schedules or for any other SIMED patient. Employee billing for visits or procedures will be consistent with that of all SIMED patients.


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4.7 New Injury Reporting – Workers Compensation

Often times, patients have a new problem to report during the follow-up visit for a work comp related injury. The workers compensation insurance company will only reimburse for services related to the initial injury.

If this happens, it is appropriate to document the new problem in the medical record during that visit however the patient must return to be evaluated for this new problem on a separate visit. It is during the office visit for the new problem that the clinician can write prescriptions for services to be provided etc., and to ensure reimbursement for this new problem.

To remain compliant and avoid professional courtesy, it is our responsibility to the patient to make sure we have applicable insurance coverage for this new problem. Please ask the patient “what insurance company would you like us to bill?” then update our system to match the patient’s request.

4.8 Providing Interpreters for Patients

The American’s with Disabilities Act (ADA) of 1990 prohibits discrimination on the basis of a person’s disability and applies to services rendered in private physicians’ offices among other places. The ADA has been interpreted to require physicians to provide effective means of communication to their hearing-impaired patients through auxiliary aids and services, including interpreters, notes and other written materials and telecommunication devices. The physician may not impose a surcharge on the hearing-impaired patient for the provision of such auxiliary aids and services.

Under the ADA, a physician is not required to provide an auxiliary aid or service (e.g., an interpreter) if it would cause the physician an undue burden or would financially alter the nature of the services normally provided. An undue burden is something that involves significant difficulty or expense, although cost alone is not determinative. It is not considered an undue burden if the cost of the auxiliary aid or service exceeds the amount the physician will receive for treating the patient. Physicians should be mindful that the goal is effective communication under the circumstances. With routine office matters, a pen and notepad may suffice. With more complex matters, use of a qualified interpreter may be justified.

Limited English Proficient (LEP) Patients

The US Department of Health & Human Services (HHS) issued to physicians and other recipient of HHS funding revised guidance regarding Title VI of the Civil Rights Act of 1964 which prohibits against national origin discrimination. The requirements apply to firms receiving funds from HHS, including physicians who participate in Medicare Part A, federally funded clinical trials and certain other patient categories. Although SIMED does not meet these requirements to provide interpreters and in order to provide the best customer service, we ask that staff and


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physicians try to assist the patient as much as possible to ensure that the correct medical information is being provided.

4.9 Patient Attendant and Wheelchair Use

In order to help our patients who are infirmed or need assistance while visiting a SIMED clinic, a designated SIMED employee may assist patients in:

• Getting to and from their cars and their physicians office; • Getting from their physicians office to an integrated service (i.e. Diagnostics or Lab); • General patient assistance as needed.

Within the 4343 building the designee will be the Patient Attendant. The patient attendant will be located under our main entry way (Porte cache’) and can be reached at extension 652.

If the patient attendant is unavailable it is the responsibility of the physician’s office to escort the wheelchair patient to their destination. It is the policy of SIMED that all wheelchair patients moving from one department to another department within any of our complexes will be escorted by either the patient attendant or a clinic staff member. A wheelchair patient escorted by a staff member may use back hallways as opposed to going around the outside of the building. This access is restricted to staff escorted patients only!

For clinics outside of Gainesville, we ask that patients be escorted by a SIMED employee when moving throughout the building or between buildings if they are infirmed or in need of assistance. Wheelchairs have been provided at each site for patient assistance as needed.

4.10 Transportation of Patients

In order to protect our patients, visitors, and employees, individuals who are suffering from a medical emergency should not be transported by any SIMED personnel. Employees should follow Emergency Protocols as found within the SIMED Employee Manual and call 911 immediately.

4.11 Security and Staff Identifiers

Each member of SIMED is provided with a SIMED name tag. Members of the SIMED team must encourage all SIMED employees to wear their nametags at all times. They not only allow patients to identify members of our team who can assist them, but lack of one can be used by employees as an identifier for unauthorized individuals.

Anyone entering an exam room with a patient or anyone providing any type of medical service or treatment on a patient MUST identify him/herself by way of introduction and have his/her name tag visible. No patient should ever have to ask a staff member who is providing medical care “Who are you and why are you here?”


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Make sure that you are wearing your name tag and that your staff identify themselves whenever interacting with patients.

All employees should take an active role in facility security. If you see any individual who is not wearing a nametag or if there is someone in a restricted area whom you do not recognize, introduce yourself and offer assistance in returning the person to the appropriate location.

CHAPTER 5: MEDICAL RECORDS COMMUNICATION & CONFIDENTIALITY

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5 Medical Records Communication & Confidentiality

5.1 Medical Records Rights to Access

I. Purpose This purpose of this policy is to define what constitutes a medical record and which individuals are entitled to have rights to access and amend information therein contained.

II. Definitions Medical record– A group of records maintained by a health care provider, that is:

1. The medical records and billing records about individuals maintained by or for a covered health care provider (SIMED);

2. The enrollment, payment, claims adjudication, and case or medical management record systems used in whole or in part by a health care provider (SIMED) to make decisions about individuals.

For purposes of this definition, the term record means any item, collection or grouping of information that includes protected health information (PHI) and is maintained, collected, used or disseminated by or for a health care provider. The term Medical Record may be used interchangeably with designated record set for policy purposes.

Individually identifiable health information – Information that is a subset of health information, including demographic information collected from an individual, and:

1. Is created or received by a health care provider, health plan, employer or health care clearinghouse; and

2. Relates to the past, present or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual; and

3. That identifies the individual; or

4. With respect to which there is a reasonable basis to believe the information can be used to identify the individual.

Psychotherapy notes – Notes recorded in any medium by a health care provider who is a mental health professional that document or analyze the contents of conversation during a private group, joint or family counseling session, and that are separated from the rest of the individual’s medical record. They include medication prescription and monitoring, counseling


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session start and stop times, modalities and frequencies of treatment furnished, results of clinical tests and any summary of the following items: diagnosis, functional status, treatment plan, symptoms, prognosis and progress to date.

III. Procedures Rights to Access Within the scope of the Final Privacy Act authorized by HIPAA, SIMED will provide the medical record to the following individuals with rights to access.

A. Patients - SIMED will allow any patient access to their complete medical record. Upon request by a patient SIMED will:

1. Provide an area where patients may review and inspect their complete medical record under observation of SIMED staff (to prevent removal/tampering) of the medical record and/or;

2. Provide the patient with a Medical Records Release form where a patient may request a copy of their complete medical record. Copies will be made of the entire medical record and provided within thirty days of receipt of the request.

B. Other Individuals – Non-patient individuals or entities requesting access to a patient’s medical record (in part or whole) must:

1. Provide proof of identity.

2. Provide written proof of right to access. This may include:

a) A subpoena (or court order) filed in an authorized court of law by a court officer or court appointed representative or;

b) A HIPAA or SIMED Medical Records release form signed by the patient or;

c) Proof of legal guardianship (for minor child) or personal representation in accordance with HIPAA guidelines.

Proof of right to access must be written and may not be provided to SIMED staff by the patient over the phone, via email or on a document not listed above. Access to a patient’s medical record may be granted if it falls within the scope of HIPAA (law enforcement, medical examiner’s request, etc...) but may only be granted by a member of the SIMED Administration team or Risk Manager and only after the request has been verified.

All requests for access to a chart or copies of a chart should be reviewed by the treating physician. Physicians alone have the right to deny access (see the section of this policy on Denials).

Psychotherapy notes MUST be reviewed by a physician prior to release. A physician must make the determination as to whether they are appropriate to release to the individual requesting.


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Copies

A. Any requests for copies of the medical record will be provided in the format requested by the individual if it is readily producible or such other form or format as agreed to by the covered entity and the individual.

B. Only information requested to be copied or authorized to be released shall be copied. A copy of the original records request shall be maintained with the patient’s medical record.

Rights to Amend Within the scope of the Final Privacy Act authorized by HIPAA, SIMED will allow the following individuals with rights to amend a medical record:

A. Patients – All patients have the right to request SIMED amend protected health information in a medical record for as long as SIMED maintains the record.

B. Other individuals – Only individuals previously listed as personal representatives (such as the parent of a minor child) may amend a patient’s record in accordance with HIPAA regulations.

C. Requests for an amendment to a medical record must be made in writing. All requests for amendment will be reviewed by the treating provider. If it is a correctable error (demographics, statistical, etc...) it may be corrected by the provider’s designee. If the provider does not agree with the patient’s request for amendment, the patient may submit a statement of disagreement which must be added to the patient’s record.

D. SIMED will only Amend information created or generated by SIMED providers or services. If a request for amendment is made of a record which was not generated by SIMED, the patient’s record will be noted and the patient will be instructed to contact the generating provider or entity.

Medical records The following information shall be considered part of a patient’s Medical record:

A. All information created and/or maintained by SIMED used in the diagnosis and/or treatment of a patient. This may include paper records, electronic records, X-rays or other diagnostic films, or other forms of media.

B. Financial Records such as billing reports, records of payments, patient statements, claims forms or other billing or accounting documents which may be stored in paper or electronic form.

C. Other records or documentation from outside providers or entities (including non-SIMED physicians, MRI, X-ray or other diagnostic tests) used by SIMED providers to make medical decisions.

D. Other records or documentation from outside entities related to a patient’s condition or treatment (i.e. Worker’s Compensation documentation, legal correspondences, etc...)


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E. The following information should NOT be considered a part of the Medical record and should not be included in requests for rights to access:

• Health information that is not used to make decisions about individuals.

• Quality Improvement records.

• Risk Management Records (including incident reports).

• Cancer Registry Information. Denials SIMED and its designees may deny access to protected health information as indicated below. Only physicians or their designees may make the decision to deny access as follows:

A. Psychotherapy notes;

B. Any record subject to the Privacy Act (5 U.S.C. 552a) if it meets those requirements;

C. If the information was obtained from someone other than a healthcare provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information;

D. The information released is likely to endanger the life or physical safety of the patient or another person;

E. If the individuals request is denied, in whole or in part, SIMED must provide the individual with a written denial in accordance with HIPAA.

Fees SIMED may charge patients or other entities a fee for reproducing the medical record. The fees imposed shall be the usual and customary fee schedule of SIMED for medical records and in accordance with current applicable fee schedules.

The following fee schedule shall apply for all requests for copies of medical records. This may be subject to change and the current approved SIMED medical records fee schedule shall prevail.

• All parties requesting copies of medical records for Non Worker’s Compensation cases shall be charged $1.00 per page for the first 25 pages and then $.25 per page thereafter plus postage. Any record exceeding three years in age since the patient’s last visit or in excess of one volume shall be charged a $10.00 research fee.

• Worker’s Compensation charges shall be $.50 per page or the actual direct cost to the health care provider or health care facility for x-rays, microfilm, or other non-paper records.

• Copies of records for continuity of care or transfer of care will not be charged. (Records request must indicate that they are to be sent to another healthcare provider).

Patients may request that records are held for pickup in order to eliminate a postage fee. However records should not be held for more than 30 days from completion of the request.


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Logs All requests for access or copies of medical records will be logged or documented in the patient’s Medical Record.

Any Right to Access, Right to Amend, Denial of Access or Amendment or other related to this policy and not specifically outlined above will be in compliance with all current HIPPA regulations. All SIMED employees will be instructed to see a member of the Administrative team for support or guidance with this policy when needed

5.2 Medical Records Documentation

Medical records serve to communicate essential information and provide a permanent record of diagnoses, treatment and the reasons and information pertaining to each. All SIMED medical records will contain patient histories, medication logs, examination results, diagnostic test results (lab, x-rays, MRI, etc...) reports of consultations, copies of records from other physicians (if applicable,) patient release forms and general patient demographic information.

SIMED medical records are confidential. They should remain secure and never made public. The medical record belongs to SIMED but the information belongs to the patient.

Records should be accurate and never include extraneous or subjective comments like “this patient is a jerk.” You may include direct quotations from the patient but reduce it to the least possible amount of words.

Never criticize or make derogatory comments about another healthcare professional or organization to the patient in the medical record. It can undermine patient confidence.

Be sure to document every conversation that you have with the patient, patient’s family, other providers or appropriate interested parties. Be sure to reinforce with your staff the importance of documentation.

NEVER improperly or unlawfully alter a medical record. Never use “white out”, alter or destroy documentation that is presented as part of patient care unless it has been scanned or permanently documented in the patient’s medical record. Corrections should be made to paper documentation by drawing a single line through it (never “scribble” it out,) editing the note, dating and initialing it.

Because electronic notes may sometimes need to be corrected or amended we ask that you follow these procedures when making changes to electronic notes.

• If the note has NOT been signed off by the provider then changes may be made to the note as it is in unsealed status.

• If the provider HAS signed off on the note then it has been “sealed”. No changes to the original note can occur.


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• The provider should copy/re-dictate a new note with the appropriate corrections or changes and indicate in the header of the note “Amended Note,” “Addendum” or similar.

• Division Managers can assist in indicating on the original note that there is an amended version available.

• DELETING original notes or making changes to original notes once the provider has signed off is inappropriate.

• Remember that our electronic medical record tracks changes and the users who enter them. It is important that we follow the correct protocols when doing so.

5.3 Employee Medical Records

In order to protect the privacy of our employee-patients, we require their medical records be given extra privacy measures within each division.

Upon the implementation of our electronic record, staff medical records will be flagged by a member of the IT team. Staff will have to verify they are taking responsibility for entering an employee medical record and must show necessity for any actions taken within that employee’s medical record. Intergy will track each user who accesses a record. Unauthorized individuals accessing an employee’s record may be subject to disciplinary actions.

Staff should not access employee medical records, including their own, without obtaining prior approval from their immediate supervisor or the attending physician.

5.4 Effective Communication

Due to the nature of healthcare, it is important that our Physicians, Staff Members, Administrators and members of the medical community keep the lines of communication open. SIMED requires appropriate documentation in patient medical records which may be reviewed by our Corporate Compliance Officer, Risk Manager or other administrative personnel. Physicians should feel free to communicate concerns regarding patient care with their Medical Director, Physician Team Leader or Risk Manager and should discuss operational issues with their Division Managers or other members of the administrative team, respectively.

Because SIMED is a multi-specialty healthcare organization, many of our patients see physicians in several divisions. We encourage communication regarding patient care between treating physicians to ensure our patients are receiving the best care possible.

If a patient wishes to speak with a physician, we encourage them to make an appointment to do so. However, if the physician speaks directly with the patient outside of an appointment time, regardless of length, it should be documented in the patient’s medical record.

All medically related telephone calls or messages to or from the patient will be documented in the chart. If you have a staff member return a phone call with instructions for the patient, have


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those instructions written down or entered into the patient’s electronic medical record and the phone call documented. Patient complaints, concerns or non-clinical conversations should be reviewed to see if they are appropriate for the patient’s medical record.

When speaking with a patient or family member, address and document all of their worries or concerns. Document important warnings, instructions and discussion of all possible risks and benefits you give to the patient. Doing so may help reduce patient non-compliance. Document all possible complications that are being considered. When instructing a patient and/or their caregivers on the patient’s care, be sure to utilize all means necessary and available to you to facilitate understanding. These include:

• Instructions may be verbally given with written back up given to the patient and/or patient’s family.

• Document medically related conversations and instructions in the patient’s medical record. Patient complaints or non-clinical conversations should be reviewed to see if they are appropriate for the patient’s medical record.

• Be sure to ask the patient to repeat what you have said to ensure comprehension.

• If family members or others are present who assist in the patient’s care, ask them to repeat the care instructions.

While email is a part of every-day life it should not be used as a form of patient communication unless the IT department has verified that the email is being sent securely and that the person receiving the information also has a secure connection. Medical information sent over the internet can have very negative consequences if sent to someone unintentionally.

5.5 Electronic Communications and Patient Records

As technology makes communication more efficient between providers and members of the medical staff community, as well as patients, it is important to remember that those communications are subject to both HIPAA and Medical Records policies and protocols. Any member of SIMED should be alert to electronic media which contains patient information whether it is via e-mail, text message or other form of social or electronic media.

Cell Phones, Texting and Email

If you have a Smartphone and utilize it to send text messages or check your emails please be aware of these simple but important reminders to stay both HIPAA and Medical Records compliant:

• You should avoid sending ANY patient specific data via text message, email or other electronic form which is not encrypted or protected. There is the potential for that information to be seen by an unauthorized individual should your phone become lost or stolen, hacked or simply left alone. If you aren’t sure about your level of encryption, find another way to communicate.

• Even if messages are encrypted, do not send patient specific data unless you can attach that correspondence to the patient’s medical record. Any information regarding the patient must


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be documented in the patient’s medical record. Phone calls, text messages and emails should be documented and later placed in the medical record.

• Telephones (cell phones), emails and computers are encouraged to have password protection to prevent someone from accessing your device when you are not present or if the device is lost or stolen.

• If you receive a text from a member of the medical staff regarding a patient, use that as an opportunity to call the individual. You should not respond via text message regarding patient specific instructions. Encourage those working on your team to call you verses texting or emailing you. In situations where patient specific data has been received or sent by you or to you, those messages should be immediately deleted from the electronic device.

• Do not give out your email address to patients.

• If your electronic device (cell phone, laptop, iPad, etc…) is stolen or lost, report it to the IT department, Division Manager or Risk Manager immediately so that it may be deactivated quickly to prevent unauthorized access.

5.6 What You Say and What You Write

Remember that conversations regarding patients, visitors, staff or other individuals may be overheard within the confines of the clinical area. Conversations should be held privately (not in the hallway or other “public” arenas) when regarding patient care or information. Professionalism when discussing patient care should be maintained at all times.

When documenting information regarding patient care, what you write may be seen by other staff members or people outside of SIMED. For example, referrals to non-SIMED specialists or facilities should contain only pertinent information regarding the patient and their care.

• Notes and medical record documentation should be professional and appropriate to the patient’s care.

• If a patient requests that copies of his records be sent to another provider, you must ask yourself if what was documented might be considered offensive to the patient or provider or is non-medically related.

• Only relay relevant medical information or findings as necessary.

• Never contradict another physician (“I would never have ordered that test.”) and never place the responsibility for something on another physician.

• Always document objectively what care was or was not received by the patient and then create your plan based upon what needs to be done in the best interest of the patient.


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5.7 Families of Deceased Patients

During this difficult time it is important to provide as much support as possible to those affected. It is appropriate to let your genuine concern for the patient and his/her family show.

• Listen to what the family members have to say and encourage them to express grief over their loss.

• Don’t say “I know how you feel,” or “you should be feeling better by now” and do not tell them what they should feel or do.

• Also do not make any comments that would suggest that the care given to their loved one by the medical community was inadequate or inappropriate.

• You may feel comfortable in offering advice on grief support or counseling services if the family member asks or you feel that it would be appropriate.

Remember that although the family member may be looking for “answers,” or closure, we must always respect the privacy of our patient and should not discuss specifics about the patient’s care with the family member unless authorized to do so. Our Medical Access Right to Access policy will be followed in regards to a patient’s death. Families of deceased patients do not automatically qualify to receive medical information or records access of the decedent.

5.8 Health Insurance Portability and Accountability Act (HIPAA)

Our patient’s privacy is a high priority and we take unauthorized release of our patients’ personal health information (PHI) seriously. SIMED follows the rules and guidelines as set forth by HIPAA and expects its employees to adhere to policy. If you observe or have knowledge of any unauthorized release of protected health information from Southeastern Integrated Medical, PL you must immediately report this release to your supervisor. Failure to do so may result in discipline by the Privacy Office or Corporate Compliance Officer as an accomplice to the unauthorized release.

Once the supervisor has knowledge of an alleged unauthorized use or disclosure of PHI, he or she shall immediately begin a thorough investigation of the unauthorized release of PHI. This may be performed through confidential interviews with staff members, inspection of release logs and/or access logs and any other method(s) deemed appropriate. It may also be necessary for the supervisor to ask for assistance from another staff member in conducting the investigation which he or she has concluded is not party to the alleged unauthorized release of PHI.

The supervisor, upon concluding the investigation, shall notify the Privacy Officer with recommendations for the appropriate changes to policies and the Privacy Officer will review recommendations and may make changes as follows:


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Policy Changes: The Privacy Officer shall make the necessary modifications to the practice policies by adding addendum(s) to the current policies and shall notify all staff members of the change(s) through inter-office memorandum. This shall be done as expeditiously as possible.

Personnel Changes: The supervisor reports to the Privacy Officer that one or more staff members either do not understand or refuse to abide by SIMED’s policies and procedures on maintaining the privacy and confidentiality of PHI. It may be necessary for employees to be disciplined by the Privacy Officer / Supervisor for violations of the practice policies. The Privacy Officer / Supervisor shall determine the severity of the punishment based on the severity of the unauthorized release. The following is a guide to how we may discipline the employees:

First Offense: Re-training on the practice’s policies and procedures governing privacy of PHI and verbal reprimand/counseling with a note of the reprimand filed in the staff members personnel file.

Second Offense: Written reprimand from the Privacy Officer / Supervisor, with one copy given to the employee(s) and one copy kept in the employee(s) file.

Third Offense: Suspension from duties without pay for a period to be determined by the Privacy Officer / Supervisor but not to exceed two weeks.

Fourth Offense: Termination of the employee.

In all cases the Privacy Officer / Supervisor shall document in writing the unauthorized use(s) or disclosure(s) of PHI, the perpetrator(s) and what action(s,) if any, were taken as a result of the violations.

5.9 Workstation Privacy and Confidentiality

As part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA,) we are required to inform all of our staff regarding the workstation privacy and confidentiality requirements for Southeastern Integrated Medical, PL. These requirements are used to protect the privacy of our patients and ensure the security of our information. It is critical that the employees of SIMED are careful how they use their computer workstations. Private data on the computer system must not be disclosed to unauthorized individuals. All employees must adhere to the following policies when using their computer workstation.

• Your password is for your use only. You should not reveal your password to anyone else within SIMED nor outside the organization. Your password may be used to track disclosure of information to third parties. If any other individual uses your password to disclose information to an unauthorized individual, you will be held responsible for that disclosure.

• In addition, you must not leave your password on or near your computer workstation (such as taped to your monitor); if you have difficulty remembering your password, sit down with your supervisor to create a password that is easier for you to recall.


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• If you or your supervisor believes your password has been revealed to another individual, either by accident or intentionally, the supervisor may elect to change your password at any time.

• When you leave your workstation for any reason you must logoff the system. If your monitor is still visible to you, even though you may not be sitting directly in front of it, you may exit back to a main menu instead of logging off. This will prevent any unauthorized individuals from seeing private patient information and allow you to monitor your workstation to ensure no unauthorized individuals are accessing information on it. If you do not log off the system, sensitive information may be disclosed to an unauthorized individual and you will be held fully responsible for that disclosure.

• When you sit at your workstation only you should be able to see and read your computer monitor. You should adjust the angle of your monitor to prevent other individuals from viewing and reading information. If, by adjusting the angle of your monitor, viewing it becomes uncomfortable for you, speak with your supervisor to work out an alternative.

• If you have any questions regarding these requirements or if you are unsure about a situation regarding the privacy of your workstation, please speak with your supervisor or the Medical Information Systems Officer immediately.

5.10 Confidentiality Policy

As an employee of SIMED, who is a covered entity under the Health Insurance Portability and Accountability Act of 1996 (HIPAA,) you will have access to and manage Individually Identifiable Health Information as defined in HIPAA for Southeastern Integrated Medical, PL.

During your employment and at any time thereafter you must agree to and understand that the Individually Identifiable Health Information is protected health information and therefore is confidential information. Confidential information includes but is not limited to individual member/patient demographic information, provider services agreements, pricing or salary information, business strategies, contract negotiations or any other individually identifiable health information.

Confidential information may be stored either on paper or in electronic form. This policy covers the privacy, security and confidentiality of all Individually Identifiable Health Information in any form.

As an employee you must adhere to the following:

• You will not disclose or release Individually Identifiable Health Information to any entity other than those legally authorized to receive it.

• It is your responsibility to ensure the privacy and / or security of confidential information stored, held or maintained by SIMED.

• You agree as an employee, to follow the policy and guidelines as set forth in this manual.


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• You understand that there is a copy of SIMED’s Notice of Privacy Practice within this manual and available at the Human Resources department.

• You have been made aware that the HIPAA policy is available and understand your responsibility as an employee of SIMED.

• You are responsible for notifying management of any suspected violations of company privacy and/or security policies and procedures and that you will not be harassed, discriminated or otherwise adversely treated as a result of those actions.

CHAPTER 6: PATIENT MANAGEMENT

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6 Patient Management 6.1 Patient Satisfaction & Customer Service

All things being equal, patients will choose to seek treatment with providers someone with whom they have a good physician-patient relationship. If a patient has a cold, they can receive the same basic care from any number of doctors but they will establish where it is convenient and where they feel most comfortable. Studies suggest that patients choose their medical providers by word of mouth. If a patient has a poor experience they are likely to share that with their friends and family and with the invention of social media, that experience can be shared with hundreds or thousands of followers. Patient satisfaction, or lack of it, can be one of the main reasons physicians have service recovery issues. Some of the more common complaints from patients are:

• Long wait times

• Physician’s failure to listen or interrupting patients

• Failure to answer questions or inability to speak with a physician

• Delays in receiving reports, test results or prescriptions

• Rude, unprofessional or inappropriate staff (including providers)

SIMED strives daily to work toward reducing and eliminating obstacles that may lead to patient dissatisfaction. We conduct regular Customer Service training with staff members and ask that all providers and administrators encourage positive customer service whenever possible.

In order to keep track of how we are succeeding in our approach to Customer Service, we may conduct regular Patient Satisfaction Surveys. Once the results have been reviewed and tabulated, we look for trends and consider opportunities for improvement. Patients are welcome to submit suggestions, comments or concerns at any time and may do so by speaking to the Division Manager or a member of the administrative team. We always welcome ways to improve the SIMED experience for our patients and guests.

Encourage your patients to participate during these survey times. It is important that the patients understand how valuable their feedback is to our group and that we hope to make their experience at SIMED a positive one.

Enforce with your staff the responsibility they have in making the patient feel like they are an important customer to the practice. Clinic staff are an extension of this practice and when a patient receives poor customer service it is perceived as coming directly from their provider. If you observe clinic personnel misbehaving, acting rudely, insensitively or abrupt with a patient, speak with the Division Manager immediately so the situation can be resolved. If a patient offers thanks or “kudos” for a job well done by a staff member, be sure to share it with the Division Manager or ask the patient to write a brief note which may be placed in the employee’s file. We want to take every opportunity to acknowledge staff members for a job well done!


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6.2 Patient Notification of Appointments

When a patient calls in for an appointment or upon approval/authorization from their insurance company, they will be given information regarding that appointment (such as date, time, location and treating provider). Many clinics will call the patient 24-48 hours prior to their appointment to confirm it with the patient. When calling, staff members will try to speak directly with the patient or guardian. If they have to leave a voice mail message, they will only indicate which doctor’s office they are calling from, the time and date of the appointment and call back information. They will not leave information regarding what the patient is being seen for or any information related to their visit.

6.3 Refusal to Authorize Payment

If a new patient refuses to authorize payment for services prior to treatment, SIMED can refuse to allow the patient to be seen. SIMED takes most insurance, credit card payments, cash or check for services rendered. If a patient wishes, he/she may pay cash for his office visit or procedure however payment must be made in full prior to the appointment.

SIMED cannot bill a patient directly for any established Worker’s Compensation injury unless the visit or treatment has been denied by the Worker’s Compensation carrier prior to the visit.

If a patient expresses a need for financial leniency, you should direct them to the Accounts Receivable department. SIMED will work with the patient to make alternate payment arrangements such as a payment plan to assist.

Providers should NEVER “down-code” or reduce their coding to support a lower fee in order to assist a patient. Providers should code according to the service provided.

6.4 Patient Declination of Treatment

If you deem a procedure or medical treatment for a patient necessary and the patient declines, it is important to document that refusal in the medical record. It is also recommended that you issue a letter to the patient indicating the importance of pursuing the prescribed treatment. A third option is to have the patient sign a Declination of Consent whereby the patient would indicate that knowing the risks and benefits of the procedure as well as not having the procedure or treatment, they elect not to proceed.

Offer assistance to the patient in referring him/her to another facility, physician, or the local medical society if the patient feels uncomfortable with your referral. This letter should be sent certified, return receipt with a copy scanned and kept in the medical record.

6.5 Controlled Substances and Narcotics Agreements & Contracts

Controlled Substances and Narcotics agreements are a useful tool for providers to use with patients who may be prescribed or treated with these substances. These agreements clearly


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outline the responsibilities and expectations of the patient. It also gives the physician a resource if he or she suspects that the patient has violated the agreement. These agreements should be used in situations where the patient will undergo chronic narcotic treatment or if the physician feels that the patient needs the additional support that a contract holds.

When reviewing the Controlled Substance & Narcotic Agreement with the patient, physicians should make clear to the patient that:

• The patient may be subject to drug screens regularly while under the care of the physician.

• Office visits may be required for refills and that refills will only be given to a patient in special circumstances.

• Violating the contract could result in being discharged from the Division.

While caring for a patient on a controlled substance:

• Be sure to document thoroughly in the patient medical record the history regarding the condition for which a drug is prescribed

• Document discussion of the potential for other treatments.

• Document and review with the patient both sides of the informed consent to a treatment plan involving controlled substances. Make sure it is scanned into the patient’s medical record.

• Note the dose, regimen and quantity of drugs prescribed, including total cumulative and average daily doses.

• Always review the record before authorizing a refill request.

6.6 Controlled Substance Abuse

If a physician or other staff member discovers that a patient is misusing or abusing their medications or has otherwise violated the physician’s controlled substances contract, the Division Manager or SSRT Representative should be contacted. The Manager or SSRT representative will ensure that the treating physician has been notified and the suspected misuse will be reported to the proper legal authorities. If the physician discharges the patient, a copy of the certified letter will be scanned to the patient’s medical record.

If a patient is suspected of diverting or selling the controlled substances (but there is no evidence of illegal activities) the physician may choose to discharge the patient and no further involvement of SSRT or legal authorities may be required.

When in doubt, contact SSRT/Risk Management for consultation.


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6.7 HIV Consent and Testing Policy

I. Purpose To define the requirements and recommendations by SIMED providers for all patients requesting testing for the Human Immunodeficiency Virus (HIV) and/or Acquired Immune Deficiency Syndrome (AIDS) in accordance with Florida Statute 64D.2001-6.

II. Procedures A. Risk Assessment

As part of routine health care, all SIMED providers should evaluate their patients as appropriate for their risk of HIV infection. Risk Assessment should take place without regard to age, religion, sexual orientation, gender, race/ethnicity, marital status, and economic status, social or other cultural factors. It involves asking the individual a series of open ended questions to determine behaviors which may put that patient at risk for HIV infection. It is important to assure the patient that all information will remain confidential and the questions should be asked in a professional, culturally sensitive, non-judgmental manner.

The following criteria should be used to help determine the patient’s level of risk: 1. Sexual behavior 2. Partners at risk for HIV/AIDS 3. History of sexually transmitted disease(s) 4. History of sexual assault/domestic violence 5. Sex for drugs/money 6. Substance use/abuse 7. Needle sharing 8. Blood/blood products/transplants 9. Occupational Exposure 10. Child of woman with HIV/AIDS

B. Pre Test Counseling Florida law no longer requires pre-test counseling except for any provider who attends to a pregnant woman for conditions related to her pregnancy. However, SIMED recommends that each provider use his or her own professional medical judgment on the necessity for appropriate counseling based upon the results of the patient’s Risk Assessment. C. Informed Consent While Florida law no longer requires a written consent for HIV testing within the private sector SIMED requires and/or recommends the following:

1. Consent need not be in writing but it MUST be documented in the patient’s medical record indicating the test was explained and informed consent was obtained.

2. Consent for minors will be obtained in accordance with state law (FS 64D.2004)

3. Prior to consent, the provider will review the following with the patient based on the patient’s Risk Assessment and the provider’s professional medical judgment (unless otherwise indicated):


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4. Review an explanation of the HIV test and its purpose, including indications for testing. (REQUIRED)

5. The potential uses and limitations of the test (the reliability of the results and what positive, negative or indeterminate results do and do not mean) as well as the possible need for retesting. (REQUIRED)

6. All positive test results are legally required to be reported to the local county health department and their staff may contact the patient to offer follow-up support. (REQUIRED)

7. HIV testing is voluntary and consent may be withdrawn at any time prior to testing. (REQUIRED)

8. The provider will explain the right to confidential treatment of information identifying the patient and the results of the test to the extent provided by law. (REQUIRED)

9. Information on how to avoid contracting and transmitting HIV infection. 10. Potential social, medical and economic effects of a positive test result. 11. Options for eliminating and or reducing risk behaviors. 12. Availability of support services for those awaiting test results (e.g. hotlines,

county health department, etc…). 13. Options for reviewing test results. 14. Options for anonymous testing sites.

D. Review of Test Results and Post Test Counseling Each provider must strongly consider the appropriateness of releasing test results to a patient without face-to-face counseling. If a provider chooses to release the test results to a patient without counseling, a system should be in place to ensure the confidentiality of this information. This system might include giving the results over the telephone after the patient identifies him or herself with a previously agreed upon code word or number which should be explained to the patient prior to administering the HIV test. Florida law imposes strict penalties for breaches of confidentiality. SIMED requires that HIV test results be reviewed with the patient only by a physician or physician extender (such as an ARNP or PA-C) so questions may be answered or patients may be counseled, if needed. Although Florida law no longer requires face-to-face post test counseling, it is recommended that providers conduct a session when the individual tests positive or is a high risk negative. The provider ordering the test shall ensure that all reasonable efforts are made to notify the patient of his or her test result. When the patient is given his or her test result, Florida law requires that, at a minimum, the following information is provided:

1. For Positives: a) Information on preventing transmission of HIV. b) The availability of appropriate medical and support services.


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c) The importance of notifying sex and/or needle-sharing partners who may have been exposed.

d) Providers must make a good-faith effort to ensure that spouses and former spouses (from the past ten years) of HIV-infected persons are notified that they may have been exposed to HIV infection.

2. For Negatives: a) Information on preventing the transmission of HIV, if appropriate.

E. Additional Information If the provider feels that a written consent is warranted or prefers to use a written consent to ensure understanding, SIMED has created a universal content based on the standard consent used by the Florida Department of Health. It is available in both English and Spanish and should be kept in the patient’s medical record.

6.8 Release of Test Results

Patients should always be notified of their test results. It is acceptable to ask a patient to call in for their results; however, it is the physician’s responsibility to ensure that the results have been communicated to the patient. Letters to patients for normal or non-critical results may be sent as long as a copy of the letter remains in the patient’s medical record. If the physician speaks with the patient via telephone regarding the results, that conversation should be documented appropriately. Absolutely no test results of any kind should be left on a patient’s answering machine or with any other person who has not been authorized by the patient (a copy of the signed authorization should be placed in the medical record and any results discussed with someone other than the patient should be documented.

6.9 Critical Laboratory Values Policy

All laboratory results ordered by SIMED physicians are to be reviewed by the ordering or covering physician. Once they have reviewed the results, the EMR will note this task. Providers will be responsible for determining the action needed and will be responsible for ensuring that those actions have been communicated to the patient. This may be done in person, by telephone if necessary and/or certified, return receipt letter (copy of letter and return receipt should be scanned and placed in the patient’s medical record.)

6.10 Treatment of Minors In Florida, any patient under the age of 18 is considered a minor. Any minor who is seeking treatment for services must receive permission from a parent, custodian or guardian unless they can provide proof of legal emancipation. Other persons as defined below may give consent for medical care if the person who has the power and consent cannot be contacted and actual notice to the contrary has not been given to the provider as follows:

• Person who possesses a power of attorney. • Step parent, grandparent, adult sibling, or adult uncle or aunt in accordance with

Florida Statute 743.0645.


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In an emergency situation, medical or surgical treatment may be rendered to minors without consent if, in the judgment of the physician, the minor suffers from an injury or acute illness and would be endangered by delaying treatment to secure consent. This only applies when parental consent cannot be obtained due to the patient’s inability to communicate the identity of the parent or guardian or if the parent or guardian cannot be located by telephone at the residence or business.

When Minors May Consent

• A married minor may consent to treatment for him/herself and for his/her spouse if the spouse is unable to give consent and has not designated a person other than the spouse to make healthcare decisions.

• A minor parent may consent to treatment for his/her own minor children.

• A female, regardless of age or marital status, may consent to treatments related to pregnancy, the prevention of pregnancy, childbirth and termination of pregnancy (§ 743.065).

• A minor may consent to treatment for his/her own venereal disease, drug abuse and/or illnesses which relate to venereal disease or drug abuse.

Consent may be given orally or in writing. Oral consent forms are available in our Urgent Care clinic. Consent may be implied in those cases in which the minor voluntarily submits to treatment once he or she has been fully informed of the treatment or procedure. However, a minor who has been declared incompetent cannot consent orally or otherwise to any treatment or procedure for him/herself or for any other person. All consents, regardless of how they are given must be documented in the patient’s medical record.

A parent or guardian should be present during all examinations of minors. If a parent or guardian cannot be present, SIMED may provide a chaperone to remain present during the examination.

6.11 Drug Screening of Minors

Under Florida law a parent may consent to drug screening for a minor even under the objections of the minor. Where drug screening is indicated, a physician may perform such testing upon receiving consent from either the patient or the guardian. The physician will follow the rules of general Treatment of Minors as listed above for all drug screens of minors.

6.12 Patient Exams or Diagnostic Testing Chaperones

Patients, regardless of gender have the right to request a chaperone be present for any exam or diagnostic testing. If a patient requests a chaperone, SIMED will provide one immediately or the patient may request a family member or friend be present. The provider will make the determination if it is appropriate for family or friends to be present during a procedure or exam. If it is not appropriate, a SIMED staff member will chaperone.


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Providers should remember to document the chaperoning of any exam. Many providers routinely have a medical assistant present during a particular exam or procedure, but it is important to document who that individual was for future reference.

6.13 Identifying a Difficult Patient

Difficult patients are not always apparent to physicians or staff. It is important to know the warning signs of a difficult patient or a patient who may lead to disruption or litigation. “Red Flags” that should be noted and discussed with your Division Manager or SSRT Representative are:

• Patients with unrealistic expectations of service or care. • Patients with broken agreements or promises (by a staff member or through their own

volition.) • Patients who make a “small” complaint or off-handed remark. • Patients who frequently no-show or cancel appointments. • Patients who request a copy of their medical records “out of the blue” or with no reason

given. • Patients may complain to a staff member long before it becomes known to the physician.

Staff members should be educated to report any complaints to the Division Manager immediately.

• Patients who wish to speak with the doctor only and do not indicate what is the issue. • Patients who are consistently non-compliant with their treatment or patients who violate

narcotics policies. • Patients who refuse or “forget” to make payments on a service. • Patients who “lose” prescriptions or samples.

By informing the Division Manager or SSRT Representative in a timely fashion about a concern it allows the administrators to work with the physician and patient towards a resolution.

6.14 Disruptive Patient Procedures

If a patient becomes disruptive (verbally or physically) employees should remain calm and keep their distance from the patient for their safety and the safety of others. If the individual is threatening to harm themselves or another person, the police should be called immediately, otherwise the Division Manager, supervisor, SSRT representative or member of the administrative team may be called to assist. If the situation escalates, it may be necessary to move other patients from the immediate area and escort them to an exam room, outside the clinic area or other safe location until the problem is resolved. Never try to restrain a patient.

In many situations, the disruptive individual is attempting to draw the provider into the situation. Providers should not become involved unless specifically asked by a Division Manager or Supervisor or in the absence of that person.


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6.15 Patient Discharge Policy & Letter

Please be advised that when discharging a patient from your care that you only discharge them from your DIVISION and not the healthcare system. Patients may be discharged from a division and remain under the care of another physician within the practice. For example, if a patient has been discharged for non-compliance in our Rheumatology division, it may not necessarily mean that the patient should not continue allergy injections with our Allergy division. It is also important to remember to send a copy of any discharge notices to the referring physician.

When discharging a patient, the physician should:

• Wait to withdraw care from a patient who is in the midst of a medical crisis until it has resolved otherwise you may be risking injury to the patient or a suit for abandonment.

• If it is appropriate, verbally discharge the patient in person as well as send a Certified Return Receipt letter.

• A copy of the discharge letter and the return receipt should remain in the patient’s medical record.

• Inform the Division Manager or Office Coordinator of the discharge so they can inform staff not schedule appointments after the termination date.

Each physician should tailor their discharge letter to be division and patient specific.

6.16 Prisoners Who Are Patients

At times it may be necessary to treat a patient who is currently incarcerated. Prisoners who have appointments should have their guard or escort accompany them to all areas. Staff should follow any instructions the guards or escorts may give. Prisoners should be treated respectfully but cautiously. Only the necessary staff should accompany the patient for treatment. Staff members should never be left alone with the prisoner – a guard should always be present.

6.17 Pharmaceutical Recall Policy In the event that a pharmaceutical company or other governing agency issues a recall on a drug administered or distributed by a SIMED physician the following protocol will be followed:

• All samples of the drug will be removed from storage cabinets and offices. They should be placed in a secure box, labeled and held in the Division Manager’s office.

• The SSRT Representative will instruct each clinic Division Manager upon notification from the pharmaceutical company or health official as to disposal or return of the recalled items.

• Removal and/or disposal of medication will be documented by the SSRT Representative.

• A letter should be posted at the clinic entrance informing all patients of the recall.

• Practitioners should consider an acceptable alternative to offer to patients.

CHAPTER 7: PROVIDER POLICIES

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7 Provider Policies 7.1 Compliance Plan and Code of Conduct

As providers of medical services operating several locations throughout North Central Florida, SIMED wishes to maintain an excellent standard of patient care and medical practice. In order to accomplish this, we have made a commitment to conduct our affairs in accordance with all applicable state and federal laws, rules, regulations, guidelines and policies. We have a specific focus on billing and submission of claims to ensure medical necessity which is reflected with appropriate documentation.

Our Compliance Plan and Compliance Committee strive to educate our providers, review our documentation standards and take corrective actions, when necessary. Our Compliance Plan can be found by contacting the Human Resources department or a member of the administrative team.

7.2 Basic Life Support (BLS) & Advanced Cardiac Life Support (ACLS) Training Requirements

I. Purpose To identify medical staff which SIMED requires to be trained minimally in Basic Life Support techniques and identify and define which medical providers should be trained in advanced cardiac life support techniques based on their scope of practice.

II. Policy a. Basic Life Support Training (BLS)

i. All Physicians employed with SIMED must obtain and maintain BLS certification.

ii. All Non-Physician providers (Nurse Practitioners and Physician Assistants) must obtain and maintain BLS certification.

iii. All Medical Assistants, Licensed Practical Nurses, Registered Nurses, and Radiology Technologists hired after June 1, 2012 must present and maintain BLS certification as part of their employment with SIMED.

iv. All employees will have 90 days from the initial date of hire or 90 days from the date of promotion (if promoted to a position requiring BLS certification) to complete their certification.

b. Advanced Cardiac Life Support (ACLS) i. Any medical provider responsible for supervising or performing the

following as part of their scope of practice shall be required to obtain and maintain ACLS certification.

1. Infusion therapy 2. Radiologic imaging with intravenous contrast 3. Interventional pain management procedures


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c. Certification i. BLS/ACLS training must be obtained through a course which has been

sanctioned by the AHA (American Heart Association) and/or ASHI (American Safety and Health Institute) and in accordance with the current standards of care.

ii. Providers and employees more than ninety (90) days delinquent in obtaining required BLS and/or ACLS certifications may be subject to penalties imposed by the Board of Mangers for Member physicians or by the CEO for all others. These penalties may include, but not be limited to: fines, suspensions of privileges to supervise and/or perform the above required procedures, suspension of all clinical responsibilities or placement into a non-clinical position and/or termination.

d. Exemptions i. Exemptions to this policy will be initially reviewed by the Medical

Director. ii. If the Medical Director concurs with the request for exemption he/she

will submit the request to the Chief Executive Officer for final approval. iii. Requests for exemption will be considered on a case by case basis

with scope of practice being the major determining factor.

7.3 Provider Credentialing & Licensure

Providers will be credentialed by Administration in order to participate with insurance plans with which SIMED is contracted. Administration will also work with providers to ensure they are properly credentialed at appropriate hospitals, nursing homes or other facilities with which SIMED conducts business. If a provider receives credentialing materials they should submit those to their Division Manager or a member of the Administrative team as quickly as possible to avoid delays in the process.

Should a provider have a question about credentialing with a particular insurance plan or facility they should contact their Division Manager for more information.

Providers are ultimately responsible for their licensure. Members of the administrative team will gladly assist any provider with renewing their license in a timely manner. It is important that provider remain vigilant on all educational and state mandated requirements when renewing.

To expedite the process, providers should work with their Division Managers or other members of the administrative team to ensure that copies of all necessary documents are on file.

Membership to professional societies is not a requirement of employment at SIMED but it is encouraged for all providers. These societies offer educational opportunities and may alert providers to clinical trends, legislative events and other important aspects of their specialty or practice which may be beneficial to their patients.


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7.4 Physician Evaluations

Physician performance is evaluated and reviewed through several measures. SIMED has established several Board Committees which, with the assistance of members of the Administration department, will review different aspects of patient care and general operations. These committees may also sponsor additional training or educational seminars to ensure that physicians are compliant with Federal and State Statutes and Regulations.

7.5 Disciplinary Protocols

Physicians may face disciplinary procedures for a variety of reasons. The processes for such actions are dependent upon several factors. If a physician violates an operational procedure (such as inappropriate actions or behaviors, non-compliance with policies or protocols, etc…) it may be addressed by members of Administration and/or the Board Physician Council and/or the Board of Managers. If the violation is a clinical violation, it may be addressed by the Medical or Associate Medical Director, the Compliance committee (if related to our Compliance Plan), Peer Review and/or Board Physician Council or if necessary, the Board of Managers.

Staff (Non-Member) Physicians

If a staff employee physician is reported for a violation or concern, Administration will determine if it is clinical or operational in nature. If the issue is operational members of the Executive Administrative team will determine what action, if any, is necessary. Administration will meet with the physician which may include the Division Manager, to resolve or correct the issue and document the violation accordingly.

If the violation is repeated or if the physician continues to abuse the policies set forth by SIMED he/she may be referred to the appropriate Board Committee for further action or terminated after due process.

If the physician’s violation is deemed clinical in nature or otherwise affects patient care, the violation will be reported to the Medical Director. Along with Administration, the Medical Director will determine the next course of action. They will also meet with the physician to resolve or correct the issue and document the violation accordingly.

If the violation is repeated or if the physician continues to abuse the policies set forth by SIMED, the physician may be terminated after due process. Corrective actions for either clinical or operational violations may include, but are not limited to, written documentation for the physician’s file, monetary fines, paid or unpaid leave and termination.

Member Physicians

Should a member physician be reported for a violation, the process for resolution will be similar in nature to the Employee Physicians. However, if repeated violations occur the physician will be referred to the Board for disciplinary action, up to and including termination, in accordance with


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member physician termination sections of the member physician employment agreement and the SIMED operating agreement.

7.6 Harassment

Providers must feel safe when treating patients. Should a provider feel that they are being harassed or made to feel uncomfortable by a patient or guest they should discuss it with their Division Manager immediately. The Division Manager may assign a staff member to serve as a chaperone during any visit with that patient. If harassment continues the physician can refer the patient to another physician within the division or discharge the patient from the Division.

However, it is important that the physician have a conversation with the patient (with another staff member present) to discuss the harassment and to address their inappropriate behavior face to face. A physician should never avoid or ignore a patient who has become troublesome. The behavior may be a symptom of a medical issue which the physician may need to address.

If the physician feels they are being harassed by another provider or member of the SIMED staff they should report it to their Division Manager or the Human Resources Director. The HR Department will investigate the situation and respond according to current policies which may include disciplinary actions.

7.7 Non-Retaliation

SIMED believes in a value system based on trust. It is important that every member of the SIMED team feel comfortable in reporting issues which he or she feels may be inappropriate or which could jeopardize the health, safety or privacy of our patients. We also want to make sure that every member of our organization is following appropriate business practices.

We understand that when an employee raises a concern it is in the best interest of every member of SIMED and we appreciate these matters being brought to our attention. No one should ever fear retaliation or adverse actions.

If a person suspects that they are a victim of retaliatory actions they are to report it to the Medical Director, Division Manager (if a staff member,) the Human Resources Director or other member of Executive Administration.

7.8 Clinic Cancellations

Physicians should be aware that the patient’s time is just as valuable as the physician’s. Many patients drive from rural areas or other outlying cities to receive our services. Patients should be given the respect of at least 72 hours notice before canceling a clinic except in emergency situations.

Physicians wishing to cancel clinic must inform and receive approval from the CEO or his designee. Only the SIMED CEO may authorize a clinic to close down regardless of the reason or


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circumstance. The CEO or his designee will then contact the Division Manager to begin rescheduling patients.

If a provider is in need of an extended leave of absence due to medical reasons or other emergency, he or she should contact their Division Manager, Chief Operations Officer and CEO immediately. Administration will work with the physician and his or her family to address the situation and adjust clinic schedules accordingly.

The provider should contact the Human Resources Department so that an appropriate review of benefits may begin.

7.9 New Procedures

SIMED welcomes ideas and suggestions for new patient treatments or procedures. New techniques or programs may benefit many patients within SIMED and it is important that we examine the idea thoroughly. If a physician has a treatment or procedure he/she would like to incorporate into his/her practice he/she should contact his Division Manager to begin the approval process. The following steps will be taken to insure that the idea is clinically and professionally viable.

• The physician and Division Manager will discuss the idea. The Physician Division Leader should also be included in the discussion and approve. If agreed upon, it may be added to next Division Clinical Meeting agenda.

• All division physicians should discuss and review. If all are in agreement of the general idea, the physician and Division Manager will work together to develop a written proposal.

• The physician will develop a clinical protocol and review it with the Medical Director for approval. The Division Manager will take the business proposal to a member of the Executive Administrative team for review and approval.

• Once approved by the Medical Director and the Executive Administrative team, the Division Manager will work with the Chief Financial Officer to develop an appropriate budget and obtain approval of the budget and business plan.

• Once the business plan has been approved by the Medical Director, CFO and members of the Executive Administrative team, the proposal may be delivered to the CEO for approval and recommendation to the Board for approval. If the proposal receives a majority approval from the Board members it will be implemented accordingly.

7.10 “Sidewalk” or “Hallway” Medicine Policy

Often times as a provider, you are asked to “take a quick look at something” by an employee, visitor or patient. It is against SIMED policy to perform any “sidewalk” medicine. While you may be comfortable in addressing that simple medical concern, by doing so outside of normal routine the potential for something to be missed, overlooked or undocumented is increased.


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If you are approached by someone to address a medical issue, ask that person to make an appointment with you or check in with the front desk first. An encounter form must be created on any person requesting medical treatment or evaluation and appropriate documentation of the visit must be placed in the patient’s medical record.

Samples or prescriptions should never be given to any person who is not established with your practice. You should document the reasons for giving the samples, the number given and any follow-up actions needed. Performing “sidewalk” medicine can open the door to personal and professional liability and should be taken seriously.

7.11 Proper Authorizations / Signatures

All documentation should be reviewed and signed (physically or electronically) by the physician prior to being permanently scanned into the medical record. Physicians should ensure that all forms including referrals and prescriptions are printed and signed legibly.

As SIMED moves towards complete Electronic Health Records (EHR) it is important that physicians recognize the responsibility they have in maintaining oversight when authorizing or otherwise approving dictation, labs or other medical information. Familiarize yourself with the EHR policies for organizations SIMED is affiliated with such as hospitals, nursing homes or similar. Many facilities utilizing EHR will revoke credentials if computer policies are violated.

Physicians should NEVER ask anyone else to approve or digitally sign any electronic health information using their name. Physicians should always be sure to use their OWN login to the EHR system they are accessing and they should log out any time they are not using the system. Physicians are placing themselves and SIMED at risk by having anyone else sign off on records.

SIMED also discourages signature stamps for physicians. If these stamps are stolen and used illegally, the physician is liable and the organization is at risk. If you have a signature stamp, you must ensure its safety by keeping it under lock and key at all times.

7.12 Clinical & Medical Record Reviews

As part of our Corporate Compliance Plan, Peer Review process, Risk Management or Safety & Service Recovery program, medical records may be routinely audited and/or reviewed by a member of our administrative team. Medical Records will be reviewed for various criteria relating to our compliance, patient satisfaction, quality assurance or risk management plans. Providers should be cooperative and assist during any medical records review process.

7.13 Description of Work Status

In order to remain consistent, we recommend that the following definitions be used for describing work status. Occasionally: activity exists up to 1/3 of the time. Frequently: activity exists from 1/3 to 2/3 of the time.


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Constantly: activity exists 2/3 or more of the time. Objects: any material item or the human body. Move/moving: activity that requires lifting, carrying, pushing, pulling and/or the like. Note: The constant stress and strain of maintaining a production rate pace, especially in an industrial setting, can be physically demanding of a worker even though the amount of force is negligible.

SEDENTARY WORK: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to move objects. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

LIGHT WORK: Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently and/or a negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for sedentary work. Even though the weight lifted may be only a negligible amount, a job should be rated Light Work:

• When it requires walking or standing to a significant degree; or

• When it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or

• When the job requires working at a production rate pace entailing the constant moving of materials even though the weight of those materials is negligible.

MEDIUM WORK: Exerting 20 to 50 pounds of force occasionally; and/or 10 to 20 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Physical demand requirements are in excess of those for Light Work.

HEAVY WORK: Exerting 50 to 100 pounds of force occasionally, and/or 20 to 50 pounds of force frequently, and/or negligible to 20 pounds of force constantly to move objects. Physical demand requirements are in excess of those for Medium Work.

VERY HEAVY WORK: Exerting in excess of 100 pounds of force occasionally, and/or 50 to 100 pounds of force frequently, and/or negligible to 50 pounds of force constantly to move objects. Physical demand requirements are in excess of those for Heavy Work.

CHAPTER 8: MANUAL APPROVAL & ADDENDUMS

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8 Manual Approval & Addendums

8.1 Updates

Routine updates to this manual may be found online on the SIMED website (www.simedhealth.com) or by contacting the Safety & Service Recovery Team. Additional policies, updates to policies and/or procedures may also be made and found online, through the administrative team or the Safety & Service Recovery Team.

This manual may not reflect changes in law, policy and procedures and you should always check that you have the most up to date copy available. When in doubt, check with the Safety & Service Recovery Team.

8.2 Approval

This manual has been approved for content by the Medical Director and Chief Executive Officer of Southeastern Integrated Medical, PL as indicated by signature below. All addendums to this manual from this point forward will be approved on an individual basis and appear after the signatures below.

_____________________________________________ ______________________________________ Robert A. Guskiewicz, MD Date Medical Director _____________________________________________ ______________________________________ Daniel M. Duncanson, MD, CPE Date Chief Executive Officer

http://www.simedpl.com/�

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8.3 Acknowledgement of Receipt

I acknowledge that I have received a copy of the Safety & Service Recovery Manual describing important information about Southeastern Integrated Medical, PL, and understand that I should consult the Medical Director, SSRT Representative, Chief Executive Officer, Chief Operations Officer or other member of the Administrative team if I have questions. I understand that this manual shall be used in conjunction with the policies and procedures found within my Employee Manual that I was issued upon my employment with SIMED, as well as other policies which may not have been included here. I understand that these policies and procedures are set forth by the Medical and Professional associates of SIMED. These policies are also in accordance with federal, state and county regulations and guidelines.

Since the information, policies and protocols described here are necessarily subject to change, I acknowledge that revisions to the Manual may occur. I understand that Southeastern Integrated Medical, PL may change, modify, suspend, interpret or cancel, in whole or part, any of the published or unpublished Risk Management, Safety and Service policies or practices, with or without notice, at its sole discretion with the exception of those required by law. Such revised information may supersede, modify or eliminate existing policies. Southeastern Integrated Medical, PL shall have sole authority to add, delete or adopt revisions to the policies. I understand that the complete and official version of this manual shall reside with the SSRT Representative in the Administration Department. Current copies of the manual are available upon request or may be found on our website

I understand and agree that I will read and comply with the policies contained in this Manual and any revisions, am bound by the provisions contained therein, and that my continued employment may be contingent on following those policies.

________________________________________________ __________________________________________ Name (Printed) Signature _________________________________ Date

Please sign and return to the Human Resources department for placement in your personnel file.

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