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VERIFICATION OF OTHER HEALTH CARE PROVIDERS (OHP)

Effective Date: 
Sun, 07/01/2012
Revised: 
Wed, 11/01/2017
Policy: 

To assure that patients receive care by qualified staff, each  Other Healthcare Provider (OHP) (Certified Medical Assistant, Certified Optician, Certified Pharmacy Technician, Certified Phlebotomy Technician, Certified Radiology Technician, Clinical Laboratory Scientist, Licensed Vocational Nurse, Registered Dietitian, Registered Nurse) is verified  prior to being hired.  The verification process by the Credentials Verification Organization (CVO) includes verification of current licensure/certification in good standing, NPDB and OIG.

Procedure: 

Initial Verification Prior to Hiring:

Candidate Applies—Hiring Supervisor receives and reviews applications and selects candidates for Interview

Interview, References and Livescan—Hiring Supervisor completes reference checks, employment verification, interview and refers select applicants for Livescan background check.

After successful Livescan is returned to Hiring Supervisor and all references are deemed acceptable, Hiring Supervisor notifies Credentialing Specialist to initiate the verification process.

Begin Verification Process—Credentialing Specialist contacts selected applicant and starts them on the online  application process with Medversant CVO. The CVO will verify the following: Current license/certification (except Registered Dietitian, Certified Medical Assistant and Certified Optician which are not State of California issued), NPDB and OIG.

      All license/certifications serve as primary source verification for applicable education, with the exception of Registered Nurse (RN). The CVO will do primary source verification of Registered Nurse education/training.  Certified Medical Assistant, Certified Optician and Registered Dietitian, will provide verification of their registration from their applicable certifying agencies.

Once verified profile is completed and returned by the CVO— Credentialing Specialist reviews and audits all pertinent paperwork. If additional information is required, Credentialing Specialist will obtain prior to presenting to the Medical Director for sign off.  If there are any discrepancies or other information the Credentialing Specialist will discuss with the Medical Director and hiring supervisor as applicable.

Medical Director reviews the audited file and if acceptable and clear signs off on the applicants file.  This is the approval  to proceed with hiring.

Credential Specialist notifies Health Center HR staff member and hiring supervisor that applicant has been approved and the final steps can be taken to move forward to Staff HR for the formal job offer.

SHR On-boarding—after formal offer is accepted, SHR sets up the date  for Campus SHR                       On-boarding.

SHS Orientation—New hire comes to SHC for Orientation. Confidentiality, HIPAA and other topics are covered. Staff must provide copy of CPR card and other credentials as required.

 

Maintaining Licenses/Certifications and Other Credentials

All state issued licenses/certifications are monitored monthly by the CVO for expiration dates and any adverse actions. The Credentialing Specialist uses this report in conjunction with other reports to track license/certification, CPR and other trainings for expiration.

It is each staff member’s responsibility to renew their license/certifications/CPR in a timely manner and give a copy to the Credentialing Specialist prior to the expiration of the old one.No staff member may work with an expired license/certification.Current California license/certification in good standing is required as a special condition of employment for all OHP staff.

Every 3 years, OHP staff members, at the discretion of the Credentialing Committee/Governing Board, will complete the online application through the CVOfor DisclosureQuestions and Attestation.

Key Points:

The Student Health Center is required to verify Initial and Continued licensure/certification of OHP staff.

It is the employee’s responsibility to provide copies of current licensure/certification and CPR as applicable.

 

CREDENTIALING OF ALLIED HEALTH PROFESSIONALS (AHP) - PA, NP, RPh, LMFT, LCSW, OD

Effective Date: 
Sun, 07/01/2012
Revised: 
Wed, 11/01/2017
Policy: 

In order to ensure patients/clients receive care by qualified clinical staff, all Allied Health Professionals (PA, NP, RPh, LMFT, LCSW, OD ) must meet the credentialing requirements of the Student Health Services prior to hiring and approval of clinical privileges. The credentialing process includes, but is not limited to, verification of applicable education, training, licensure, certification, reference checks, background checks and other required verifications per UCOP regulations.

 

Procedure: 

Initial Credentialing Procedure prior to hiring:

Candidate Applies—Hiring Supervisor receives and reviews applications and selects candidates for Interview

Interview, References and Livescan—Hiring Supervisor completes 3 reference checks, interviews and refers select applicants for Livescan background check.

After successful Livescan is returned to Hiring Supervisor and all references are deemed acceptable, Hiring Supervisor notifies Credentialing Specialist to initiate the Credentialing Process.

Begin Credentialing Process—Credentialing Specialist contacts selected applicant and starts them on the onlineapplication process with Medversant CVO.Once application is completed and submitted, the CVO will verify the following:

Education, training and experience:Relevant education and training are verified, the applicant’s experience is reviewed for continuity, relevance and documentation of any interruptions in that experience.

Three (3) Peer References:Current competence is verified and documented.

Board Certification, if applicable.

Current hospital affiliation, if applicable.

Employment history.

State license(s): The primary and California state licenses held during the past five (5) years shall be verified and documented at the time of credentialing including current, unrestricted California license

Drug Enforcement Administration (DEA) registration, if applicable, for location address.

Proof of current medical liability coverage meeting Governing Body requirements, if any.

Information obtained from the National Practitioner Data Bank (NPDB).

Information obtained from the Office of Inspector General (OIG).

Once verified profile is completed and returned by the CVO— Credentialing Specialist reviews, audits and analyzes all pertinent reports. If adverse actions or incomplete information is received, the Credentialing Specialist will consult with the Credentialing Committee/Governing Boardprior to convening them for approval.Once the file is in order and all information has been satisfactorily verified, the Credentialing Specialist will convene the Credentialing Committee/Governing Board.The Credentialing Specialist will then present the applicant’s file for review, discussion and approval/denial.The Credentialing Committee/Governing Body may at their discretion provisionally approve the applicant pending specific follow up as will be documented in the file.In this event, the Credentialing Specialist will track follow up requirements and reconvene the Credentialing Committee/Governing Body when they have been completed.

 

Credential Specialist notifies Health Center HR staff member and hiring supervisor that applicant has been approved and the final steps can be taken to move forward to Staff HR for the formal job offer.

SHR On-boarding—after formal offer is accepted, SHR sets up the datefor Campus SHROn-boarding.

SHS Orientation—New hire comes to SHC for Orientation to include: Confidentiality, HIPAA, I2P2and other relevant topics. Staff must provide copy of CPR card, Immunization records and other credentials as required. Physicians Assistants and Nurse Practitioners will sign the Statement of Approval for theSHC Standardized Procedures and Protocols for Midlevel Providers.

      New hire will complete the request for specific privileges at this time.  The Credentialing Specialist will convene the Credentialing Committee/Governing Body to meet, discuss and approve/deny the request for specific privileges.  A copy of the privilege form will be given to the provider for reference. New privileges may be granted by the Credentialing Committee/Governing Body upon written request documenting satisfactory training and experience. The copy of the updated privilege form will be given to provider for their records.

For Physicians Assistants and Nurse Practitioners, initial review of clinical work is done on a minimum of 30 cases within the first 30 days of the initial assumption of duties.  Additional chart review may be deemed appropriate at the discretion of the Medical Director or Psychiatry Director.  The Medical Director or designees will use the standard peer review format in reviewing cases.  Results of this initial review are evaluated by the Medical Director or Psychiatry Director, who will hold a conference with the staff member regarding the results.

Documentation pertaining to the AHP credentialing is maintained in confidential files in the Credentialing Specialist office.It is the responsibility of the AHP staff to notify the Credentialing Specialistof any changes or updates in credentials or licensure.

Appointment and privileges for AHP staff are granted for a maximum of 3 years.

 

Procedure for Re-Credentialing

All state issued licenses/certifications are monitored monthly by the CVO for expiration dates and any adverse actions. The Credentialing Specialist uses this report in conjunction with other reports to track license, certifications, CPR and other trainings for expiration.

It is each staff member’s responsibility to renew their license/certifications/CPR in a timely manner and give a copy to the Credentialing Specialist prior to the expiration of the old one.No staff member may work with an expired license/certification.Current California license in good standing is required as a special condition of employment for all AHP staff.

Every 3 years, the AHP staff members will go through re-credentialing which consists of updating their online application through the CVO (verifying demographics, expiration dates, hospital affiliation if applicable, liability coverage, disclosure questions and attesting and signing) and completing a new privilege form.

Once the credential profile is completed and returned from the CVO— the Credentialing Specialist reviews and audits all pertinent paperwork. The file is presented along with updated privilege form to the Medical Director, Psychiatry Director or CAPS Director, as applicable, to review prior to committee.

The Medical Director, Psychiatry Director and CAPS Director will evaluate the  AHP staff’s professional performance, judgment, patterns of patient/client care, and when appropriate, technical skill (through direct observation or consultation with other UCSC Student Health Center practitioners  who have observed the candidate). The evaluation shall also include the AHP’s specific performance improvement and patient/client safety data (peer review). They will sign a form recommending or not-recommending the staff member for reappointment.

Credential Committee/Governing Body convenes to review re-credential packet (credential file, updated privilege form and recommendation from Medical, Psychiatry or CAPS Director) and discuss any relevant issues as applicable. After any discussions, the Credentialing Committee/Governing Bodythen approves the file, or if applicable defer or place conditionspending further information before final approval. The Credentialing Committee/Governing Body signs off and approves

re-appointment for 3 more years.

Credential Specialist sends letter to staff members with copy of updated Privilege form and notice of re-appointment.

 

 

 

CREDENTIALING OF LICENSED INDEPENDENT PRACTITIONERS (LIP) - MD, DO & PhD/PsyD

Effective Date: 
Sun, 07/01/2012
Revised: 
Wed, 11/01/2017
Policy: 

In order to ensure patients/clients receive care by qualified clinical staff, all Licensed Independent Practitioners (MD, DO and PhD/PsyD) must meet the credentialing requirements of the Student Health Services prior to hiring and approval of clinical privileges. The credentialing process includes, but is not limited to, verification of applicable education, training, licensure, certification, reference checks, background checks and other required verifications per UCOP regulations.

 

Procedure: 

Initial Credentialing Procedure prior to hiring:

Candidate Applies—Hiring Supervisor receives and reviews applications and selects candidates for Interview

Interview, References and Livescan—Hiring Supervisor completes 3 reference checks, interviews and refers select applicants for Livescan background check.

After successful Livescan is returned to Hiring Supervisor and all references are deemed acceptable, Hiring Supervisor notifies Credentialing Specialist to initiate the Credentialing Process.

Begin Credentialing Process—Credentialing Specialist contacts selected applicant and starts them on the onlineapplication process with Medversant CVO. Once application is completed and submitted, the CVO will verify the following:

Education, training and experience:Relevant education and training are verified, the applicant’s experience is reviewed for continuity, relevance and documentation of any interruptions in that experience.

Three (3) Peer References:Current competence is verified and documented.

Board Certification, if applicable.

Current hospital affiliation, if applicable.

Employment history.

State license(s): The primary and California state licenses held during the past five (5) years shall be verified and documented at the time of credentialing including current, unrestricted California license

Drug Enforcement Administration (DEA) registration, if applicable, for location address.

Proof of current medical liability coverage meeting Governing Body requirements, if any.

Information obtained from the National Practitioner Data Bank (NPDB).

Information obtained from the Office of Inspector General (OIG).

Once verified profile is completed and returned by the CVO— Credentialing Specialist reviews, audits and analyzes all pertinent reports. If adverse actions or incomplete information is received, the Credentialing Specialist will consult with the Credentialing Committee/Governing Board prior to convening them for approval.Once the file is in order and all information has been satisfactorily verified, the Credentialing Specialist will convene the Credentialing Committee/Governing Board.The Credentialing Specialist will then present the applicant’s file for review, discussion and approval/denial.The Credentialing Committee/Governing Body may at their discretion provisionally approve the applicant pending specific follow up as will be documented in the file.In this event, the Credentialing Specialist will track follow up requirements and reconvene the Credentialing Committee/Governing Body when they have been completed.

 

Credential Specialist notifies Health Center HR staff member and hiring supervisor that applicant has been approved and the final steps can be taken to move forward to Staff HR for the formal job offer.

SHR On-boarding—after formal offer is accepted, SHR sets up the datefor Campus SHROn-boarding.

SHS Orientation—New hire comes to SHC for Orientation to include: Confidentiality, HIPAA, I2P2and other relevant topics. Staff must provide copy of CPR card, Immunization records and other credentials as required. Physicians will sign the Statement of Approval for theSHC Standardized Procedures and Protocols for Midlevel Providers.

      New hire will complete the request for specific privileges at this time.  The Credentialing Specialist will convene the Credentialing Committee/Governing Body to meet, discuss and approve/deny the request for specific privileges.  A copy of the privilege form will be given to the provider for reference. New privileges may be granted by the Credentialing Committee/Governing Body upon written request documenting satisfactory training and experience. The copy of the updated privilege form will be given to provider for their records.

For physicians, initial review of clinical work is done on a minimum of 30 cases within the first 30 days of the initial assumption of duties.  Additional chart review may be deemed appropriate at the discretion of the Medical or Psychiatry Director.  The Medical or Psychiatry Director or designees will use the standard peer review format in reviewing cases.  Results of this initial review are evaluated by the Medical or Psychiatry Director, who will hold a conference with the staff member regarding the results.

Documentation pertaining to the LIP credentialing is maintained in confidential files in the Credentialing Specialist office.It is the responsibility of the LIP staff to notify the Credentialing Specialist of any changes or updates in credentials or licensure.

Appointment and privileges for LIP staff are granted for a maximum of 3 years.

 

Procedure for Re-Credentialing

All state issued licenses/certifications are monitored monthly by the CVO for expiration dates and any adverse actions. The Credentialing Specialist uses this report in conjunction with other reports to track license, certifications, CPR and other trainings for expiration.

It is each staff member’s responsibility to renew their license/certifications/CPR in a timely manner and give a copy to the Credentialing Specialist prior to the expiration of the old one.No staff member may work with an expired license/certification.Current California license in good standing is required as a special condition of employment for all LIP staff.

Every 3 years, the LIP staff members will go through re-credentialing which consists of updating their online application through the CVO (verifying demographics, expiration dates, hospital affiliation if applicable, liability coverage, disclosure questions and attesting and signing) and completing a new privilege form.

Once the credential profile is completed and returned from the CVO— the Credentialing Specialist reviews and audits all pertinent paperwork. The file is presented along with updated privilege form to the Medical Director , Psychiatry Director or CAPS Director, as applicable, to review prior to committee.

The Medical Director, Psychiatry Director and CAPS Director will evaluate their LIP staff’s professional performance, judgment, patterns of patient/client care, and when appropriate, technical skill (through direct observation or consultation with other UCSC Student Health Center practitioners  who have observed the candidate). The evaluation shall also include the practitioner’s practitioner specific performance improvement and patient/client safety data (peer review). They will sign a form recommending or not-recommending the staff member for reappointment.

Credential Committee/Governing Body convenes to review re-credential packet (credential file, updated privilege form and recommendation from Medical, Psychaitry or CAPS Director) and discuss any relevant issues as applicable. After any discussions, the Credentialing Committee/Governing Bodythen approves the file, or if applicable defer or place conditionspending further information before final approval. The Credentialing Committee/Governing Body signs off and approves re-appointment for 3 more years.

Credential Specialist sends letter to staff members with copy of updated Privilege form and notice of re-appointment.

 

 

MANAGEMENT OF THE AGITATED OR COMBATIVE PATIENT

Effective Date: 
Wed, 06/03/2015
Revised: 
Fri, 08/25/2017
Policy: 

When a patient is combative or agitated and staff are concerned for the safety of themselves or others there is a procedure in place to manage the situation and try to protect staff and patients while we await the arrival and assistance of police.

Procedure: 
  • Declare the situation early.Use your intuition. Do what is necessary to be safe as the first priority.
  • Dial 44, remove, remove headset, and page "Dr. Slug to (and give Location)" three times. Call police. If the situation prevents you from calling 911 either use a panic alarm or clearly request this of another person in the area.
  • Move other people out of the immediate area.
  • Dr. Slug responders: all available managers plus Behavioral Health Consultant. Do not storm the area. First manager assesses and takes command. Additional responders are sent away as soon as situation assessed.
  • Move the patient to a quieter location as quickly as possible.
  • Minimize the number of people interacting with the patient to:
    • A support person.
    • A provider
    • Someone from CAPS or the BHC
    • Manager on hand to observe and coordinate.
  • Try not to confine the patient more than necessary:
    • Use a holding room.
    • Keep observation window open.
    • Keep doorway open.
    • Allow patient to wander and, if necessary, to leave the building.
    • Attempt to check bag/backpack/jacket for sharps/weapons/drugs.

At the call for Dr. Slug – Specific Job Responsibilities

  • Manager : Assumes lead for situation.
  • Manager: Determines that police/EMS has been alerted.
  • Nursing/MAs: Move other patients out of the area
  • Charge RN/Triage/Reception: Divert patient care to other locations or reschedule non-urgent visits.
  • MA in Impacted Area: Close doorways to waiting areas front and back. Provide support and observation.
  • South Wing Staff: Close doorways to West Wing.
  • Reception: Consider evacuating waiting areas to outside or mural room. Put people at doorways to avoid more people entering building/area.
  • Lab/X-ray: Prepare to meet and guide Emergency Responders. Prepare for stat labs if necessary.
  • Manager in Charge pages when Dr. Slug event is concluded.

Arrange for de-brief/review within 72 hours of situation. Revise policies as indicated.

PRIVACY & SECURITY OF HEALTH INFORMATION

Effective Date: 
Tue, 05/19/2015

RISK MANAGEMENT: PUBLIC HEALTH

Effective Date: 
Tue, 05/19/2015
Policy: 

The Student Health Services actively mitigates risk to our community through communicable disease (CD) prevention, identification and response and through on-going community emergency preparedness and response.    The chair of the Quality management committee is responsible for oversight of these risk reduction activities.  The SHS works with campus colleagues and our local community for disease prevention and response.  The SHS works closely with local, state and national health agencies to mitigate risk.  The SHS works with campus counsel and with the University of California Office of the President Risk management services on risk mitigation and response.

Procedure: 

The Quality Management Committee will hear an annual report of disease occurences, emergency preparedness activities, risk mitigation activities and incidence rates for influenza, gastroenteritis, STIs, and other CDs as indicated.

The communicable disease identification and response policy outlines specific CD management policies and procedures.
The Emergency Preparedness policy outlines on-going emergency preparedness policies and procedures.

PHARMACY SALES OF PARKING CARDS

Effective Date: 
Fri, 04/24/2015
Policy: 

To assist students and others who need to pay for parking, the Pharmacy will sell UCSC ParkCards for use at meters on the UCSC Campus.

Procedure: 

PARKCards are acquired by the Pharmacy via Operations staff. 

Students and others who need to pay for parking meters or paystations on campus may purchase a UCSC PARKCard from the Pharmacy.

Pharmacy staff will charge for each UCSC PARKCard in the Point of Sale system.  Each card is $25 and is preloaded with $20 worth of parking meter time.  The pharmacy staff will provide the purchaser with a card, a TAPS receipt specific to the PARKCard as well as a pharmacy receipt.  A duplicate TAPS receipt for that specific PARKCard will be kept by the Pharmacy with the Student Identification Number (SID) for students, documented on the receipt.  Students may charge the UCSC PARKCard on their student account.

PARKCards and receipts will be stored in the cash register, under the drawer.

The Pharmacy will not refill current empty or low PARKCards.

If acquisition of additional PARKCards is needed, pharmacy staff with request them through the SHS Operations staff.

UCSC PARKCard Facts

  • No need for coins
  • Quicker than credit cards at paystations
  • Retrieve your unused time on meters
  • $25 ($5 for refillable card, $20 of value)
  • No expiration date
  • Purchase and refill at TAPS Sales Office

OPTOMETRY - END OF DAY CLEANING

Effective Date: 
Fri, 04/24/2015
Policy: 

The Optometry Department performs daily cleaning.  See the procedure.

Procedure: 

Certol ProSpray wipes (yellow top canister):

  • Exam chair
  • Stool

**Remove filmy build-up by wiping surfaces with plain water and paper towel as needed**

Sani-Cloth wipes (black top canister):

**Use a minimum of 2 cloths to properly wipe down all the following items**

  • Counter top and area around sink
  • Faucet handles
  • Cupboard and drawer handles
  • Keyboard and mouse
  • Inner and outer door handles
  • Retinoscope handle
  • Lamp arm

 

70% isopropyl alcohol wipes:

**To be performed in front of patient at start of every exam**

  • Phoropter forehead and nose rest
  • Slit lamp chin and forehead rest
  • Cover paddle
  • FDT forehead and nose rest

OPTOMETRY OPENING PROCEDURES

Effective Date: 
Thu, 04/23/2015
Revised: 
Mon, 02/29/2016
Policy: 

See the Opening Procedures for Optometry below.

Procedure: 
  • Turn on main desk computer and exam lane computers. Log in to Windows and open and log in to Point and Click (PnC) EMR.
  • Open Google Chrome with the following tab: Eyemed. Log in to site so that insurance authorizations can be checked at each patient visit.
  • Check phone messages.
  • Open Updated Format Master Excel log (found under Desktop, Optometry).
  • Open CL Log and Frame Log (found in Desktop, pub.optometry, My Documents).
  • Organize any glasses or contact lens orders from Optometry Technician that have been left on the desk. Bill appropriately if not yet billed. Add to Updated Format Master Excel log spreadsheet. Add to Frame Log the frame that was sold, and to CL Log the CL order that was made, with the date and number of boxes.
  • In PnC, make a brief chart note for each Optometry Technician order that was left on the desk, indicating that the patient came in with the Optometry Technician and ordered glasses or CL, etc on which date. The Optometry Technician is not able to make entries in PnC as they are not licensed.
  • Respond to Instant Messages in PnC.
  • Pick up CL or frame shipments in the Pharmacy.
  • Leave CL boxes in Pharmacy under pt’s name.
  • Place all glasses in appropriate cases with lens cloths and leave in Pharmacy under pt’s name.
  • Send secure messages to pts using PnC indicating their glasses and/or CL are ready for pickup in the pharmacy.
  • Uncover and turn on exam lane equipment.
  • Retrieve/unlock ophthalmic meds from locked cabinet and prepare for exam use.
  • Unpack any frame shipments and label with prices and stock the displays (see top desk drawer folder labeled Glasses Inventory, has inventory and price list).
  • Restock contact lens solution starter kits in upper cabinets (back exam room).

OPTOMETRY APPOINTMENT MAKING

Effective Date: 
Thu, 04/23/2015
Policy: 

Optometry appointments need special consideration and are performed by Insurance staff.

Documentation of vision insurance is required.

Attached File: 
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