AGENDA of Board of Directors for
Regular Board Meeting
Wednesday, January 30, 2019
Location: MPUD – Fire House
5273 Highway 49 North, Mariposa
Candy O’Donel-Browne, Chair, Linda Pribyl, R.N. Secretary-Treasurer,
Philip H. De Bry, D.D.S., Joseph E.C. Rogers, M.D. and Sally Abbott Uribe, Directors
Mission – To excel in the provision of quality health care services
Vision – To be the organization of choice for community health care
Closed Session 1:00 p.m.
Regular Board Meeting 2:00 p.m.
1. Call to order and roll call
2. Open Session: disclosure regarding Closed Session items pursuant to Government Code §54957.7
3. CLOSED SESSION
A. Aimee
B. Medical Staff report to the board by attending providers
C. Medical Staff Privileges (Health & Safety Code §32155)
On recommendation from the Medical Executive Committee, the following were granted appointment privileges:
Rajwinder Bahia, MD, Internal Medicine/Hospitalist to Provisional staff
Uzoma Chukwu, MD, Internal Medicine/Hospitalist to Provisional Staff
Kevin Rudny, MD, Teleradiology, to Consulting staff
Gurjit Sivia, MD, Internal Medicine/Hospitalist, to Provisional staff
Vida Vreca-Ponnequin, FNP-BC (Family Nurse Practitioner- Board Certified) to Allied Health Staff
Anna Yaffee, MD, Emergency Medicine to Provisional staff
On recommendation from the Medical Executive Committee, the following were granted re-appointment privileges:
Ryan Frederiksen, MD, Teleradiology to Consulting Staff
Jill Furubayashi, MD, Teleradiology to Consulting Staff
Melissa Heyer, PA-C, Physician Assistant to Allied Health Staff
Shahin Laghaee, MD, Gastroenterology to Consulting Staff
D. Public Employee Evaluation (Government Code §54957(b)(2))
Title: Chief Executive Officer
4. RECONVENE PUBLIC SESSION
Disclosure on reportable action taken during closed session
5. 2:00 p.m. Call to Order Regular Scheduled Board Meeting
A. Welcome to our guests—guests may voluntarily sign in if they wish to have their name spelled correctly in the minutes of this organization.
B. Employee of the month for February, Jessica Robichaux, Referrals Coordinator
C. AirMethods, Heather Geske, Area Manager, Northern CA
6. Education
Terry Woodward, Plant Operations Manager
7. Public Comments
Persons wishing to speak on any subject not on the agenda may do so at this time. This legislative body cannot act on or discuss an item that is not on the agenda according to Government Code §54954.2(3). Persons wishing to comment on an agenda item are invited to do so when the Board considers that item and the Chair calls for comments. Thank you for your participation.
8. CONSENT AGENDA
NOTE: The Consent Agenda consists of items that are generally viewed as non-controversial and routine by JCFHD. If the Board wishes to discuss an item, it will be removed from the Consent Agenda. Consent Agenda items are generally approved in one single motion. This is the appropriate time for the public to advise the Chair of any comments to the Consent Agenda, or to request that the Board consider removing an item from the Consent Agenda.
A. Approve minutes of the Finance & Regular Board meeting of December 19, 2018
B. Approve minutes of the Policies & Procedures and Bylaws committee of January 9, 2019
C. Approve minutes of the Finance Board meeting of January 23, 2019
9. DISCUSSION/ACTION ITEMS
A. Resolution 1-19 honoring Carolyn Joan Rose, MD her retirement for JCFHD
B. Upon recommendation from Policies & Procedures and Bylaws committee – the following were recommended to be affirmed and/or adopted:
Ø Affirmation of Emergency Department P&Ps
· EMTALA-01 “Security of Psychiatric Patients”
· EMTALA-02 “EMTALA Guidelines”
· ER 21A “Advanced treatment Protocols in the ED”
Ø Adoption of Environment Services P&Ps
· EVS 1.0 “Cleanliness Inspections”
· EVS 1.1 “Daily Patient Room Cleaning (Occupied)”
· EVS 1.2 “Cleaning the Discharged Patient Room and Restroom”
· EVS 1.3 “Restroom Cleaning”
Ø Affirmation of Imaging P&Ps
· 01-1008 “Radiologist Availability”
· 02.2-2201 “MRI Safety General Requirements”
· 02.2-2202 “MR Safe or MR Conditional Equipment”
· 02.3-2301 “Preventative Maintenance”
· 02.3-2302 “CT, PET, MRI, and Nuclear Medicine Annual Equipment Testing”
· 02.3-2303 “Radiographic Equipment Care and Preventive Maintenance”
· 02.3-2304 “Trailer Preventative Maintenance”
· 02.3-2305 “Trailer Service and Repair”
· 02.3-2306 “Trailer Emergency Repair”
· 03-3001 “Certification of Technologist”
· 03-3002 “New Employee Orientation”
· 03-3003 “Department Orientation”
· 03-3004 “In-Service Program Documentation”
· 03-3005 “Dress Code”
Ø Affirmation of Infection Prevention P&Ps
· IP-100 “Health Officers”
· IP-101 “Infection Prevention and Control Plan”
· IP-102 “Infection Prevention Committee”
· IP-104 “Infection Preventionist Role and Responsibilities”
· IP-105 “Infection Control Incident Log”
· IP-106 “Infection Prevention Chairperson”
· IP-108 “Surveillance Plan”
· IP-109 “Environmental Surveillance”
· IP-110 “Mobile Auxiliary Services”
· IP-202 “Hand Hygiene”
· IP-301 “Reporting Transmissible Infections to Receiving Facility”
· IP-302a “Insertion of Central Venous Lines and PICC Lines – Bundle”
· IP-302b “Central Line Insertion Surveillance and Reporting”
· IP-302c “Central Line-Associated Blood-Stream Infection Surveillance and Reporting”
· IP-305 “Rabies”
· IP-320 “Influenza A, B Collection Technique”
· IP-400 “Protective Isolation Neutropenia Patient”
· IP-500 “Management of Accidental Exposure to Blood/Body Fluids”
· IP-600 “Antibiotic Stewardship Program”
Ø Affirmation of Laboratory P&P
· Gastroccult – Point of Care
Ø Adoption of Maintenance P&P
· MN-21 “Fire Pull, Fire Extinguisher & Emergency Exit Access”
Ø Adoption of Medical Staff P&P
· C-19 “Medical Screening Exam”
Ø Adoption of Purchasing P&Ps
· AP-3 “Purchasing/Storeroom Personnel Attire”
· AP-7 “Purchase Orders”
· AP-8 “Administration Approved Purchases”
· AP-9 “Receiving”
· AP-10 “Master Inventory File”
Ø Adoption of Skilled Nursing Facility P&Ps
· SNF-10 “Maintenance Requests”
· SNF-11 “Disaster – 1135 Waiver”
C. Contracts and Agreements — review and accept operating agreements, costs and terms on attached spreadsheet
D. Construction update
Ø Cuningham Group Architecture, Inc. on campus Thursday, January 24, 2019
E. Schedule Retreat
10. WRITTEN/VERBAL REPORTS
A. Chief Executive Officer (CEO), Matthew Matthiessen, no report at posting time
B. Chief Nursing Officer (CNO), Kristen Clayton, RN, report attached
C. Chief Human Resources Officer (CHRO), Martha Robichaux, chart attached, no report at posting time
D. Quarterly Risk Management, Laura Donahue, report attached
E. Information Technology (IT), Ginger Clark, RN, Informatics, IT Manager, no report at posting time
F. Employees Association, (EA), Kim Hopman, Secretary, report attached
G. JCFH Foundation, Melissa Takahasi, report attached
ü Minutes from December
ü Minutes from January
ü Budget FYE 2019
ü Bylaws
H. JCFH Volunteers, Phyllis Linnebur, no report at posting time
11. AGENDA ITEMS FOR FUTURE MEETINGS
Ø New Hospital Reports
ü Construction updates & discussions
ü G.L. Hicks Financial, LLC proposal
Ø Compliance Plan education, Director Uribe
Ø Brown Act “reference sheet” set to run in the Mariposa Gazette on December 20, 2018
12. INFORMATIONAL ITEM(S)
Calendar – February meeting dates and/or rescheduling
13. PUBLIC COMMENTS
Persons wishing to speak on any subject not on the agenda may do so at this time. This legislative body cannot act on or discuss an item that is not on the agenda according to Government Code §54954.2(3). Persons wishing to comment on an agenda item are invited to do so when the Board considers that item and the Chair calls for comments. Thank you for your participation.
14. ADJOURNMENT
In memory of Joan Crosby (Hospice), James Fryer (Hospice), Patrick Gerken (consultants son), Mary Haugen (Home Health), Delmer Humphrey (Hospice), Murlene Kanbe (Hospice),
In celebration of the birth of baby Elliana Scott Tucker to Sara Hatleli (employee)
Regular Meetings convene at 2:00 p.m. on the last Wednesday of each month, unless otherwise resolved at a prior meeting. Citizens wishing to schedule matters for Board consideration must contact the Clerk of the board in writing stating the action requested. Appropriate requests will be scheduled before the Board as time allows. Deadline for submission of written materials is seven days in advance of meeting. An original and five copies of all supporting materials must be submitted.
Public Presentations: The law provides the opportunity for the public to be heard on any item within the subject matter jurisdiction of the Board, before or during the consideration of that item by the Board. For all items, including items not on the agenda, the public presentation time at the start of each meeting is appropriate. The Chair may set time limits as appropriate to manage the Agenda. State law does not allow action to be taken on any item not on the Agenda. MPUD – Fire House is handicapped accessible.
This agenda shall be made available upon request in alternative formats to persons with a disability, in compliance with the Americans with Disabilities Act of 1990 (42 U.S.C. §12132) and the Ralph M. Brown Act (California Government Code §54954.2). Persons requesting special accommodations to participate in a District meeting, please contact the Board Clerk at 209-966-3631, x-9, during regular business hours, at least 48 hours prior to the time of the meeting.
Pursuant to the Brown Act as codified in Government Code §54957.5, any documents pertaining to a non-closed agenda item distributed to a majority of the Board of Directors in less than 72 hours before a Board meeting shall be available for public inspection. Said documents shall be available for inspection at the John C. Fremont Healthcare District Administrative Office located at 5189 Hospital Road, Mariposa, California, Monday through Friday, except Holidays, between the hours of 9:00 a.m. and 12:00 p.m.
