Regulatory Change / Key Requirements / Policy Name/Number/Effective Date / Action
  • Request by OIG
  • Increase in civil liability monetary penalties
/ Added
8. To report any probable violation of the False Claims Act, whether civil or criminal to the OIG as a reportable event.
Damages and Penalties
Civil penalties of not less than $11,000 and not more than $21,563 / 1028
1028.1 (NJ)]
02/01/2017 / Educate staff to policy change
Review at PAC committee
Print and place in policy binder
Responsible: All
  • Veterans administration require SAM.gov verification
/ Added:
Compliance will verify CCH entities monthly against SAM.GOV
SAM.GOV no longer required for contracted entities / 4026
07/01/2017 / Educate staff to policy change
Review at PAC committee
Print and place in policy binder
Responsible: Compliance/HR
  • Retention of Records
/ Added:
California retention rules / 5002
06/15/2017 / Educate staff to policy change
Review at PAC committee
Print and place in policy binder
Responsible: Operations
  • Restraints
/ Added:
Restraints are discontinued at the earliest possible regardless of the length of order. / 2027
07/15/2017 / Educate staff to policy change
Review at PAC committee
Print and place in policy binder
Responsible: Operations
  • In service
  • Added restraint education (per CHAP)
/ Revised:
Restraint policy education required for all clinical staff (please note there is a restraint policy and a separate one for IPU) / 4008
4008.1 GA
4008.2 NY
4008.3 MO
08/15/2017 / Educate staff to policy change
Review at PAC committee
Print and place in policy binder
Add to in service calendar
Responsible: Operations/HR
  • Disposal of Controlled Drugs (OHIO)
/ New Policy / 2029.4
02/02/2017 / Educate staff to policy change
Review at PAC committee
Print and place in policy binder
Add to in service calendar
Place policy in patient family admission packet (patient and family handbook)
Responsible: Operations
  • Bed Bug Policy
/ New Policy
Guidelines to reduce transmission
Cornell bed bug resource guide
Medline supply number spreadsheet / 3032
08/15/2017
3032.1
08/15/2017 / Educate staff to policy change
Review at PAC committee
Print and place in policy binder
Add to in service calendar (with Infection control)
Place resource guide in infection control binder
Order supplies and educate clinical team
Responsible: Operations/HR
  • Physician Compensation
/ New Policy
Physicians to be compensated FMV / 1044
02/20/2017 / Educate staff to policy change
Review at PAC committee
Print and place in policy binder
Responsible: Compliance/Operations/HR
  • Disposal of Controlled Drugs –SC
/ New Policy / 2029.5 / Educate staff to policy change
Review at PAC committee
Print and place in policy binder
Responsible: Operations
  • Emergency Preparedness Plan
/ Revised to increase patient classifications
And IPU to follow host hospital policies and procedures. / 3004 / Educate staff to policy change
Review at PAC committee
Print and place in policy binder
Responsible: Operations
  • Emergency Preparedness Drill
/ Changed title to drill / 3023.2 / Educate staff to policy change
Review at PAC committee
Print and place in policy binder
Responsible: Operations
  • Emergency Preparedness Template
/ New – template to assist in organizing plan / Not assigned / Use to formulate plan.
Responsible: Operations
Emergency Preparedness Reminder:
Complete Risk Assessment
Complete 2 drills by mid-November; one tabletop and one full scale (if you had a disaster in previous 12 months this counts as live) - but must document
  • Section 1557 Grievance Policy
/ Added revised date / 1012.1 / Print and place in policy binder
Responsible: Operations/Compliance/HR
  • Verification of Unlicensed Employee credentials (TX)
/ Updated / 4003.1 / Educate staff to policy change
Review at PAC committee
Print and place in policy binder
Responsible: HR
  • Scope of Service
/ Per CHAP –removed repetitive paragraph / 1022 / Educate staff to policy change
Review at PAC committee
Print and place in policy binder
Responsible
Responsible: Operations
  • Management and Administration of Medication
/ Removed that nurse can destroy medication (unless allowed by State) / 2015 / Educate staff to policy change
Review at PAC committee
Print and place in policy binder
Responsible: Operations
  • Medical device malfunction
/ Per CHAP – clarified that annual in- service is required for clinical staff / 3002.1 / Educate staff to policy change
Review at PAC committee
Print and place in policy binder
Responsible: Operations
  • Therapy Services Agreement
/ Per CHAP – removed qualifications of dietitian as they cannot be contracted employee / contracts / Review at PAC committee
Print and place in policy binder
Responsible: Operations
  • Organizational Charts
/ Updated / Review at PAC committee
Print from LINK and place in policy binder (when available)
Responsible: Operations
  • TOC Updated
/ Section 1
Section 2
Section 3
Section4 / Print and place in policy binder
Responsible: Operations

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