Section 1 - Introduction
1.1 Policy and Procedure Manual
1.2 Developing Policies and Procedures
1.3 Policies and Procedures - Master Book Maintenance
1.4 Policies and Procedures - Writing and Implementation
1.5 Policies and Procedures - Revision and Retirement
Section 2 - Employment and Hiring
2.1 Americans with Disabilities Act
2.2 Background Checks - General
2.3 Background Checks – Written Authorization
2.4 Base Compensation
2.5 Benefits Eligibility
2.6 Candidate Interviews
2.7 Code of Conduct
2.8 Confidentiality Agreement
2.9 Corrective Action
2.10 CPR Certification
2.11 Disciplinary Termination Policy
2.13 Employment Application
2.14 Employment Eligibility Verification
2.15 Equal Opportunity Employment
2.16 Establishing Salaries and Compensation
2.17 Medicare Provider Enrollment Process
2.18 Introductory Period for New Employees
2.19 Leave of Absence
2.20 Nature of Employment
2.21 Nepotism
2.22 No Distribution or Solicitation
2.24 Performance and Salary Reviews
2.25 Performance Bonuses
2.26 Performance Improvement: Individual Provider
2.27 Personnel Files
2.28 Personnel Records and Administration
2.29 Provider Credentialing
2.30 Provider Recredentialing
2.31 Recruitment
2.32 References and Supplemental Investigations
2.33 Suspension
2.34 Time-Keeping
2.35 Time Off, Holidays, Religious Observances, Jury Duty,
Bereavement
2.37 Work Hours
2.38 Workplace Searches
Section 3 - Workplace Conduct and Professionalism
3.1a Attendance
3.1b Attendance – Disciplinary Action
3.1c Attendance – Emergencies and Inclement Weather
3.2 Drug and Alcohol Policy
3.3 Drug and Alcohol Testing
3.4 Grievance Policy
3.5 Internet Use
3.6 Professional Appearance
3.7 Smoking Policy
3.8 Telephone and Cell Phone Policy
3.9 Violence in the Workplace
Section 4 - Clinic Operations
4.1 Audits
4.2 Building Security
4.3 Business Associate Agreements
4.4 Business Associate Inventory
4.5 Clinic Credentialing
4.6 Clinic Hours and Emergency Service
4.7 Performance Improvement Plan
4.8 Computer Workstation Protocol
4.9 Display of License
4.10 Electronic Communications Protocol
4.11 Clinic Facility Design
4.12 Firearms and Other Weapons
4.13 Identity Theft Detection and Prevention
4.14 Internet Use Protocol
4.15 Mandated Reporting of Child Abuse and Neglect
4.16 Mobile Device Protocol
Section 5 - Records and Data Management
5.1 Access Rules
5.2 Data Backup
5.3 Data From Other Facilities or the Patient
5.4 Data Integrity: Access, Audit Trail, and Security
5.5 Documentation of Privacy and Security Policies and Procedures
5.6 HIPAA and HITECH Privacy Compliance
5.7 HIPAA and HITECH Security Compliance
5.8 Legal Medical Record Standards
5.9 Legibility and Display of Entries
5.10 Meaningful Use Audits
5.11 Notice Of Privacy Practices
5.12 Patient Request for Medical Record
5.13 Performing a Billing or Coding Audit
5.14 Purging and Destruction of Paper Records
5.15 Purging ePHI
5.16 Responding to Subpoenas or Court Orders
5.17 Retention of Medical Records
5.18 Retirement of Medical Records
5.19 Safeguarding PHI in Non-Electronic Form
5.20 Storage and Retrieval of Paper Medical Records
Section 6 - Accounting, Claims, and Billing
6.1 Automobile Accident-Related Injury Claims
6.2 Fee Schedule Administration
6.3 Structuring a Compliance Plan
6.4 Conducting an Internal Audit
6.5 Internal Controls
6.6 Petty Cash
6.7 Managing Incoming Cash
6.8 Bill Paying
6.9 Charge Capture and Diagnosis Coding
6.10 Charge Capture, Encounter Forms, Data Entry
6.11 Medicare Advance Beneficiary Notice of Noncoverage (ABN)
6.12 Payment Posting
6.13 Financial Agreement for Patient Responsibility
6.14 Claim Submission to Third-Party Payers
6.15 Charge Submission Turnaround Time
6.16 Charge Corrections
6.17 Open Claims
6.18 Denied Claims
6.19 Patient Communication on Insurance Balances
6.20 Refunds to Patients
6.21 Unapplied Payments
6.23 Patient Billing Inquiries
6.24 Waiver of Patient Responsibility
6.25 Financial Hardship
6.26 Returned Checks for Insufficient Funds
6.27 Payment Plans
6.28 Turning Accounts to Collections
6.29 Collection Agencies and Patient Disputes
6.30 Small Balances
6.31 Write-Offs
6.32 Bankruptcy
Section 7 - Emergencies and Disaster Response
7.1 Emergency Equipment and Medication
7.2 Emergency Evacuation Plan
7.3 Fire Plan
7.4a Psychiatric Emergency Plan - General
7.4b Psychiatric Emergency Plan – Suicidal Crisis
Section 8 - Patient Management
8.1 Communicating Test Results and In-Office Laboratory Reports
8.2 Marketing, Fundraising, Sale of PHI Under HIPAA
8.3 Marketing Policy
8.4 Patient Education
8.5 Patient Grievances
8.7 Patient Satisfaction
8.8 Prescription Ordering and Documentation
8.9 Prescription Refills
8.10 Procedure for Follow-Up
8.11 Procedure for Patient Scheduling
8.12 Steps to Terminate Patient Relationship
8.13 Tracking System for Diagnostic Reports
8.14 Video Monitoring Policy
8.15 Website and Social Media Marketing
Section 9 - Ketamine
9.1 Ketamine Protocol – Administration Procedures
9.1a IV Access – Pre-Insertion Care
9.1b IV Access - Peripheral Venous Cannula
9.1c IV Access – Midline Venous Catheters
9.1d IV Access - Central Venous Catheter
9.1e Central Port Access and Care
9.2 Ketamine Protocol - Backgroud and Drug Info
9.3 Ketamine Protocol – Equipment and Adjuvant Medications
9.4 Ketamine Protocol – Preparation Notes
9.5 Ketamine Protocol – Required Monitoring
9.6 Management of Allergic and Anaphylactic Reactions
9.7 Patient Distress
9.8 Ketamine Protocol
9.9 Ketamine Protocol - Oral Administration
9.10 Ketamine Protocol – Intranasal (racemic)
9.11 Spravato (esketamine) Clinic Policy
Section 10 - Workplace Safety
10.1 Sharps Disposal
10.2 Engineering and Work Practice Controls
10.3a OSHA Compliance Committee
10.3b OSHA Compliance Committee - Duties
10.4 Clinic Exposure Control Plan
10.5 Exposure Control Plan Administration
10.6 Exposure Determination
10.7 Universal Exposure Control Practices
10.8 Exposure Control Plan Review & Availability
10.9a Post-Exposure Evaluation and Follow-Up - Administration
10.9b Post-Exposure Evaluation and Follow-Up – Plan of Action When
Exposure Incident Occurs
10.9c Post-Exposure Evaluation and Follow-Up – Plan of Action When
an Exposure Incident Occurs
10.10a Biohazardous Waste
10.11a Infection Control Competency Training
10.11b Infection Control Competency Training – Bloodborne Pathogen
Training
10.12 Injection Safety
10.13 Injury Prevention
10.14 Housekeeping
10.15 Recordkeeping
10.16 Hepatitis B Virus (HBV) Vaccination
Section 11 - Drugs, Chemicals, and Controlled Substances
11.1 Controlled Substances
11.2 Inventory Rotation
11.3 Recall Response Plan
11.4 Use of Single-Dose and Multiple-Dose Containers
Section 12 - Equipment, Supplies, and Inventory
12.1 Infusion Equipment Requirements
12.2 Supply Procurement, Receipt, and Inspection
12.3 Purchasing Policy and Procedure
12.4 Request for Proposal
12.5 Vendor Accounts
