Board of Directors 
Policies & Procedures and Bylaws Committee 

Linda Pribyl, RN, Committee Chair 
Candy O’Donel-Browne, Attending Director 

Wednesday, April 10, 2019 @ 10:00 a.m. 

Location:  Board Room, 5189 Hospital Road, Mariposa 

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, Option 9, during regular business hours, at least 48 hours prior to the time of the meeting.

AGENDA

    1.         Introduction of guests

    2.         General public input for agenda and non-agenda items

    3.         Approval of previous meeting minutes was completed at the previous Board meeting

    4.         Review and discuss policies and procedures:

Ø  Adoption of Administration P&Ps

·       ADM-02 “Signature Authority”

·       ADM-09 “Travel & Expenses”

Ø  Adoption of Compliance P&P

·       100 “Request for Inspection of Public Records” & form

Ø  Adoption of District Wide P&P

·       1 “CMS Reportable Events”

·       QM-01 “Patient/Family/Staff/Other Improvement Opportunity Evaluation & Follow-up”

·       QM-02 “Quality Review Reporting”

·       QM-03 “Patient Satisfaction Surveys”

Ø  Adoption of Fiscal P&P

·       F-3 “Financial Assistance Program”

Ø  Adoption of Human Resources P&P

·       HR 4.2 (a), (b) & (c)

Ø  Affirmation of Imaging P&Ps

·       04-4001 “Infection Prevention and Control – Imaging Services”

·       05-5001 “Emergency Management”

·       07-7001 “Performance Improvement Plan”

Ø  Affirmation of Laboratory P&P

·       Miscellaneous “Technical Consultant Designation: On-Call Consultation:

Ø  Affirmation of Pharmacy P&Ps and Protocols

·       Pharm 4.22 “Ketamine”

·       Pharm 4.23 “Vancomycin Dosing”

·       Pharm 6.1 “Adverse Drug Event/Reaction and Medication Errors”

·       Pharm 6.2 “Medication Errors”

·       Pharm 6.3 “Look-Alike, Sound-Alike Medications”

    5.         Review, discuss possible action on Board Bylaws

    6.         Review DRAFT Compliance Plan, Jean Potter, Compliance Officer

    7.         Agenda item(s) for future meeting(s)

    8.         Set next meeting date

    9.         Adjourn

Source: John C. Fremont Healthcare District