BOARD OF DIRECTORS

POLICIES & PROCEDURES and

BYLAWS COMMITTEE

Wendy Ryder-Priola, Committee Chair

Nick Lambert, Attending Director

Wednesday, August 30, 2023 @ 11:00 a.m.

Location:  JCFHD Board Room, 5189 Hospital Road, Mariposa

Mission – To excel in the provision of quality health care services 
Vision – To be the organization of choice for community health care

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, extension 5101, 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 to be completed at the Regular Board meeting dated September 20, 2023

      4.        Review and discuss policies and procedures:

Ø  Affirmation of Acute P&Ps

·         N-MS-501 Blood Collection

·         N-MS-607 Care of Patients Valuables

Ø  Affirmation of COVID Protocols

·         COVID Dist Wide COVID-19 Returning to Work and Testing for Healthcare Personnel and Patients

·         COVID Dist Wide Source Control in the Healthcare Setting

Ø  Affirmation of District Wide Protocols

·         Dist Wide Nursing Reporting of Critical Lab Results

Ø  Affirmation of Emergency Department P&Ps

·         ER 001 Admission of Patients to the Emergency Department

·         ER 007 Elopement Left Without Being Seen

·         ER 008 Patient Leaving Against Medical Advice

·         ER 013 DNR

·         ER 020 Standards of Practice or Care

·         ER 021 Triage

·         ER 023 Assessment of the Trauma Patient

·         ER 024 Age Related Documentation Pediatric

·         ER 038 Patient Presenting with Amputations

·         ER 041 Administration of Blood – please see edits

·         ER 056 Extremity X Ray

·         ER 057 Standard of Care Asthma Patient

·         ER 061 Care of Patient with Stab or Puncture Wounds

·         ER 063 Standard of Care Vaginal Bleeding – please see edits

·         ER 066 Cervical Traction or CSpine Immobilization

·         ER 146 Documentation in the ED Record EMR

·         ER 163 Telephone Triage

·         ER 1012 Restraints

·         ER 2001  Safety

·         ER 2003 Security and Visitors.

·         ER 8116 Cardiac Arrest Code Blue

·         ER 8129 Defibrillation

·         ER 8130  Diarrhea

·         ER 8131  Care of Dying Patient

·         ER 8132 End of Life lssues

·         ER 8133 Emergency Delivery

·         ER 8134 Epistaxis

·         ER 8135 Eye Emergencies

·         ER 8136 Head Injury

·         ER 8138  Hypothermia

·         ER 8139 Hypovolemic Shock

·         ER 8143  Intravenous Therapy

·         ER 8144  Lacerations and or Abrasions

·         ER 8146 Assisting with Lumbar Puncture

·         ER 8152  Patient Under the Influence of Alcohol  - Immediate Intervention

·         ER 8153 Management of Patient Under the Influence of Drugs

·         ER 8155 Orthopedic Emergencies (Extremities)

·         ER 8156  Pediatric Asthma

·         ER 8157  Pediatric Fever

·         ER 8159  Poison Control  Information

·         ER 8161  CMS Reporting and  Documentation  Requirements for Death Associated with Restraint or Seclusion

·         ER 8164 Seizures - Nursing Management

·         ER 8167 Transportation of Emergency Department Patient within the Hospital

·         ER 8170 Vomiting

·         ER 9002 Patient Log

·         ER 9005 Legibility of Medical Record Documentation

·         ER 9006 Unacceptable Abbreviation and Symbol List

·         ER 11002 Blood Glucose Screening

Ø  Affirmation of Environmental Services P&P

·         EVS 2002 Cleaning of the Emergency Department

Ø  Affirmation of Infection Prevention P&P

·         IP-103 Microbiology Reports

·         IP-104 Infection Risk Assessment

·         IP-106 Infection Prevention Chairperson

·         IP-115 Infection Prevention and Control Organizaiton and Function

·         IP-206 Respiratory Hygiene Cough Etiquette

·         IP-301 Reporting Transmissable Infections to Receiving Facility

·         IP-304 Standard Precautions

·         IP-307 Patient Education

Ø  Affirmation of Imaging P&Ps

·         03-01 MRI Safety General Requirements

·         03-02 MR Safe or MR Conditional Equipment

·         03-03 Constraindictions to MRI Scanning

·         03-04 Code Blue in MRI

·         03-05 Fire in or near MRI

·         03-06 Proper Use of Hand Held MRI safe Fire Extinguisher

·         03-07Emergency Medication Box

·         08-01 Ordering Exams

·         08-02 Routine Patient Physical Safety

·         08-03 Provision of Care Treatment and Services Critical Test Results

·         08-04 Scheduling Procedures

·         08-05 patient Refusal of Exam

·         08-06 Provision of Care Treatment and Services Stat Diagnostic Radiological Procedures

·         08-07 Patient Safety

·         08-08 Patient Assessment for Imaging Procedures

·         06 01  Radiation Safety Patient and  Employee

·         06 02 Patient Safety

·         06 03 Employee Radiation Safety Guidelines

·         06 04 Radiation Safety

·         06 05 CT Radiation Safety Instructions

·         06 06 Electrical safety  and maintenance

·         06 07 Declaration of pregnancy

·         06 08 Pregnant Staff

·         06 09 Dosimetry of Pregnant Staff

·         06 10 Radiation Exposure Monitoring of Staff

·         06 11  Occupational Dose Limits

·         06 12 Radiation Monitoring Badge

·         06 13 Portable Xray

·         10 01  Annual Equipment Testing

·         10 02 Annual CT Equipment Testing

·         10 03 Lead Apron Testing

Ø  Affirmation of Laboratory P&Ps

·         ABO Grouping

·         Absolute Neutrophil Count

·         Antibody Screen

·         APINH

·         Bacterial Contamination of Platelet Packs

·         BB Alarm Check

·         BB Centrifuge Cleaning

·         BB Computer Downtime

·         Beta-Lactamase Test

·         Bleeding Time

·         Influenza A & B

·         KOH Preparation

·         Lipemic CBC Hemoglobin Correction

·         Loss of Electrical Power

·         M. Cat Butyrate Test

·         Malaria Policy

·         Manual Blood Culture

·         MedTox Drug Screen Controls

·         MedTox Drug Test

·         Advantus

·         Blood Bank Test Index

·         Blood Bank Transfusion Protocols

·         Blood Recipient Arm Band

·         Blood Release

·         Catalase

·         Cell-Dyn 26 Plus Hematology Control

·         Computer Downtime

·         Criteria for Manual Differentials

·         CSF Cell Count

·         Differential Leukocyte Count, Manual

·         Differential Validation

·         Direct Antiglobulin Test

·         Emergency Blood Release

·         Emergency Blood Type Switching

·         Gram Stain

·         H. pylori Sure-Vue

·         H. pylori

·         Hematology Back up Analyzer (Emerald)

·         Hernatology Critical Values

·         Hematology QC

·         Micro_Unexpected Results

·         Microbiology Note

·         Mono Test

·         Platelet Transfusion

·         Power Failure-BB Refrigerator

·         Refrigerator Malfunction

·         Release of Un-Crossmatched Blood

·         Rho  D Typing

·         Routine Crossmatch

·         Serofuge Quality Control

·         Therapeutic Phlebotomy

·         Transfusion Reaction Workup

·         Transfusion Service

·         Microbiology Panic Reports

Ø  Affirmation of Pharmacy P&Ps

·         4.38 Pharmacy Verification of Orders and Emergency Drug Use List

Ø  Affirmation of Physical Therapy P&Ps

·         1901 Supervision of PTA

·         1902 Budget

·         1903 District Department Orientation

·         1904 Staff Continuous Inservice Education and Training

·         1905 Contract Services

·         1907 Description of Services for Physical Therapy

·         1908 Code of Ethics

·         1910 Rehabilitation Services

·         2902 Extended Orientation

·         4901 Supply Management

·         4903 Lifting

·         4904 Therapeutic Exercise

·         4905 Gait Training

·         4906 Transcutaneous Electrical Nerve Stimulation

·         4907 Ultrasound

·         4908 Hydrocollator currently in storage

·         4909 Assistive Devices

·         5901 Designated Exercise Room

Ø  Affirmation of Skilled Nursing Facility Manuals

·         SNF-06 Theft and Loss

Ø  Affirmation of Volunteer Protocols

·         1.12 Purpose & Objectives

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

·         Medical Staff recommendation(s) of Policies & Procedures

      6.            Set next meeting date – To be determined

      7.            Adjourn

Agenda and Meeting Packets

Source: JCF