FQHC Policies, Procedures & Documentation
  • Home
  • Table of Contents
  • FQHC Policy & Procedures
  • Contact us

FQHC Polices, Procedures & Documentation

​Table of Contents

Here is a detailed Table of Contents.  Just click on the Tab to take you to the TOC of each category.

​

We have added Covid-19 Protocols for immediate download

  • Open/Close Tabs
  • Personnel
  • Clinical
  • Environment of Care
  • P.I.
<
>

​Click on a Tab above or below to open the TOC for the section.​

Personnel Policies & Procedures (71 Policies in 4 Sections)
​

General Employment (29 Policies) 

1A -   Employment Standards                                   
2A -   Job Classification                                 
3A -   Position Descriptions
4A -   Orientation of New Employees           
5A -   Standard Work Hours             
6A -   Employee Compensation         
7A -   Recruitment for Vacant Positions       
8A -   Employee Evaluations                         
9A -   Competencies
10A – Lay-Offs                                             
11A - Salary Information                               
12A - Grievance Procedures
13A – Probation                                             
14A – Separation of Employment     
15A – Temporary Privileges                          
16A – Credentialing                                      
17A – Nepotism                                             
19A – Tardiness                     
20A - Travel Expenses                                   
21A - Personnel Records                               
23A – Disaster Privileges
24A – Students
25A – Basic Cardiac Life Support
26A – Office Environment Policy
27A – Time Reporting
28A – Reference Policy
29A – Signatory Authority
30A - Lockers
31A – Peer Review Policy

​
Employment Benefits (18 Policies)

1B – Jury Duty                
2B – Bereavement Leave            
3B – Vacation Leave                
4B – Sick Leave
5B – Provider Recruitment Incentive        
6B – Holiday Leave    
8B – Unpaid Leave            
9B – Pregnancy, Childbirth and Related Medical Conditions Leave                
10B – Family Medical Leave Act        
11B – Continuing Education            
12B – Tuition Reimbursement        
13B – Insurance                
14B – Retirement Benefits            
15B – Employee Health Care Benefit
16B – Volunteer Leave
17B – Break Time For Nursing Mothers
18B - Overtime
20B – Workers Compensation 
Employee Conduct (19 Policies)

1C – Conduct of Employees            
2C – Confidential Information        
3C – Conflict of Interest            
4C – Cell Phones and Electronic Devices
5C – Use of organization Computer Systems        
6C – Tobacco and Smoking Related Products
7C – Drug-Free Workplace            
8C – Garnishments, Attachments, and Judgments                
9C – Employee Identification Badges
10C – Public/Media Information 
12C – Solicitation of Goods and Services
13C – Dress Code                
14C – Transportation of Patients        
15C – Use of organization Vehicles        
16C – Harassment                
17C – Disciplinary Action            
18C – Focused Review            
19C – Impaired or Dysfunctional Provider
20C - Social Networking Policy    

    

Safety Policies (5 Policies)

1D – Bomb Threat                            
2D – Inclement Weather                                
3D – Concealed Weapon
4D – Tornado Warning
5D – Fire Regulations

Go to the Personnel section for download
Clinical (30 Policies)

*All Clinical (30 files)​
1.Abuse/Neglect Management 
2.Acquisition of Supplies and Medications 
3.Aerosol Treatment 
4.Application of Ice Pack 
5.Crash Cart 
6.Ear Irrigation 
7.EKG 
8.Emergency Action 
9.Eye Examination 
10.Fingersticks 
11.Hearing Screen 
12.Immunizations – Administration of
 
               12A.  Immunizations – Nurse Visit Administration of
               12B.  Immunizations – Provider Visit Administration of
 
13.Mantoux Skin Test 
14.Medication Administration - Intramuscular 
15.Medication Administration – Oral 
16.Medication Administration – Subcutaneous 
17.Medication Administration – Z-Track 
18.Nurse Visits 
19.Oxygen Therapy 
20.Pain Management 
21.Pap Smears – Preparation of 
22.STD Cultures – Preparing 
23.Specimen Collection – Occult Blood 
24.Specimen Collection – Throat 
25.Specimen Collection – Urine 
26.Time Out Procedures 
27.Vital Signs – Orthostatic 
28.Provider Ordered – Patient Obtained Medication 
29.Critical Value Notifications


Go to the Clinical Policies section for download
Environment of Care (36 Policies)

*All Environment of Care (36 files)
Hazard Materials and Waste Management
 
1.Hazard Surveillance / Risk Assessment 
2.Hazardous Materials & Waste Management Program 
3.Infectious Hazards / Universal Precautions Education 
4.Infectious Waste, Segregation, and Collection of 
5.Infectious Waste, Shipping of 
6.Infectious Waste Spills: Clean-Up 
7.Personal Protective Equipment 
8.Hazard Communication Plan
 
Safety Management Policy
 
1.Safety Management Program
  
Security Management Policy
 
  1. Protection Of Property
  2. Robbery
  3. Pharmacy Security
  4. Visitor/Student Badges
  5. Escalating Behavior
  6. Weapon Protocol
 
Utilities Management Program Policy
 
  1. Utilities Management Program
 
Equipment Management Policy
 
  1. Equipment Management Program
 
 
Emergency Preparedness Policy
 
  1. Emergency Preparedness
 
Life Safety Policy
 
  1. Fire Regulations
  2. Tornado Warning (Code Gray)
  3. Gas Leak (Code Green)
  4. Code STAT
  5. Sentinel Event
 
Infection Control Policy
 
  1. Communicable Disease, Reporting Of
  2. Contagious Diseases – Handing Of
  3. Post-Exposure Follow-Up
  4. Employee Exposure to Communicable Diseases
  5. Hand Hygiene
  6. Hepatitis B Vaccine Program
  7. Illness or Injury On-Duty
  8. Sterilization Techniques
  9. TB Patients – Care Of
  10. TB Testing & Follow-Up – Employee
  11. Influenza Vaccine Program
  12. Exposure Control Plan
SonicleanTM  Ultrasonic Cleaner Monitoring Policy
Go to the Environment of Care Section for Download
Performance Improvement (9 Policies)

*All Performance Improvement (9 files)
1.   No Show Appointment Policy
1A. Risk Management Plan
2.   Patient Discharge Policy
2A. Emergency Preparedness Plan
3.  Patient Grievance Policy
4.  Needs Assessment
5.  Incidents Report
6.  Suicidal/Homicidal Threats
​7.  Policy Review


Go to the Performance Improvement Section for Download
  • Open/Close Tabs
  • Dental
  • Pharmacy
  • 340b
  • Behavior Health
<
>

​Click on a Tab above or below to open the TOC for the section.

Dental (16 Policies)

*All Dental (16 files)
1.Back-Up testing of Sterilizers 
2.Butane Burner and Torch 
3.Dental Laundry 
4.Dental Radiology Safety 
5.Dental Instrument Sterilization 
6.Hazardous Material Spill clean-up 
7.Mercury Spill Clean-Up 
8.Permissible Duties of Dental Hygienists and Dental Assistants 
9.Radiation Quality Controls, Frequencies, and Responsible party 
10.Radiation Exposure Monitoring 
11.Radiation Quality Assurance and Control 
12.Radiation Quality Control Test 
13.Safe Operating Procedures for Radiation 
14.NOMAD Portable X-Ray Safe Operating Procedures 
15.Safe Operating Procedures for Radiation - Gendex Orthoralix 8500 DDE – Panoramic 
16.Sterilizer Spore Testing
Go to the Dental Section for download
Pharmacy (13 Policies, 1 additional file)

*All Pharmacy (14 Policies)
1. Pharmacy
2. Formulary
3. Medication Inventory
4. Medication Disposal
5. Patient Assistance Medication Pickup for Patients
6. Transcription for Medication Log out
7. Pharmaceutical Salesmen
8. Look Alike/Sound Like, High Alert & Hazardous Medication
9. Product Recall Notification
10. Vaccine Ordering, Storage & Handling
11. Medication handling during power outages
12. Vaccine related reactions - Reporting of
13. Vivitrol Program
Soundalike Listing


​
Go to the Pharmacy section for download
340b (6 Policies)

*All 340b Policies (6 files)
1 – 340B Compliance
2 – 340B Responsible Staff
3 – 340B Enrollment, Recertification and Change Requests
4 – 340B Procurement, Inventory Management and Dispensing
5 – 340B Monitoring and Reporting
6 – 340B Contract Pharmacy Compliance Elements


Go to 340b section for download
Behavior Health (8 Policies)

*All Behavior Files (8 files)​
1 – Behavioral Health Utilization
2 – Continuity Of Care
3 – Screening and Assessment
4 – Care Plan
5 – Education
6 – Behavioral Health Records
7 – Abuse/Neglect Management
8 – Application for Emergency Admission (Pink Slip)
Go to the Behavior Health Section for Download
  • Open/Close Tabs
  • Outreach & Enrollment
  • Finance
  • Info Tech (IT)
  • Sub Recipient
<
>

Click on a Tab above or below to open the TOC for the section.

Outreach & Enrollment (4 Policies)

*All Outreach and Enrollment (4 files)
1 – Certified Application (CAC) Certification and Recertification 
2 – Certified Designated Organization Renewal of CMS Agreement 
3 – Certified Application Counselor Activities 
4 – Certified Application Counselor (CAC) Training

​
Go to the outreach & Enrollment section For Download
Finance (40 Policies)

All Finance Polices (40 files)
General
1A - Fiscal Year Cycle
2A - External Reporting
3A - Internal Reporting, Monthly
4A - Monthly Bank Reconciliation
5A - Journal Entries
6A - Annual Audit
7A - Federal Draw Down
8A - Fixed Asset Inventory
9A - Capitalization/Depreciation
10A - Investment
11A - Electronic Funds Transfer (EFT)
12A - Bond Insurance
13A - Check Signatures
14A - Fiscal Record Retention
 
Payroll 
1B - Payroll
2B - Payroll Overtime Payment
3B - Direct Deposit
4B - Payroll Statement Distribution
 
Accounts Payable 
1C - Accounts Payable
2C - Expense Reimbursement
3C - Credit Cards
4C - Petty Cash
5C - Procurement
6C - Purchase Orders
7C - Receipt of Deliveries
 
Accounts Receivable 
1D – Counterfeit Notes
2D – Encounter/Charge Passing Process
3D - Fee Schedule
4D - Account Adjustment
5D - Billing Cycles
6D - Collections
7D - Sliding Fee Scale
8D - Dental Service Treatment Estimates
9D - Cash Boxes
10D - A/R - Deposit of Receipts
11D - Refunding Overpayments and Incorrect Payments
12D - Returned Checks
13D - Medicare Credit Balance
14D - Credit/Debit Card Payment
15D - Check Payment
Go to the Finance Section for Download
Information Technology - (11 Policies)

*Total Information Technology (IT) - (11 Files)
1 – Laptop Deployment
2 – Authenticate Electronic Personal Health Information / Record Revision
3 – Business Associates Agreements - Security Breaches
4 – System Unavailability Contingency Plan
5 – Emergency Access to EHR
6 – Information Technology (IT) Security
7 – Document Scanning/Indexing and Disposal
8 – Password Management
9 – Data Backups
10 – Social Networking
11 – Acceptable Use of IT Resources
Go to the IT section for Download

Sub-Recipient/Public Agency ​(1 File)
​

*All Sub-Recipient/Public Agency Files (2 Files)
Co-Applicant Agreement Template

​

Go to the Sub Recipient/Public Agency Category For Download
  • Open/Close Tabs
  • Governance
  • Health Records (HIPAA)
  • Additional Documents
  • Emergency Preparedness Plan
<
>

Click on a Tab above to open the TOC for the section.

Governance  (8 Files)
​

*All Governance Files (8 Files)
Articles of Incorporation Template
Board Agenda Template
Board Meeting Minutes Agenda 
Corporate Bylaws Agenda
Board Self Assessment Tool Template
Strategic Plan Template
CEO Self Assessment Template


​

Go to the Governance category for Download

Health Records ​(12 Files)
​

*All Health Records Policies (12 Files)
Health Records Policy 1 - Amendment of Health Records
Health Records Policy 2 - Consent
Health Records Policy 3 - Consent of Minor
Health Records Policy 4 - Patient Requests to Amend Health Record
Health Records Policy 5 - Patient Requests to Review Health Record
Health Records Policy 6 - Record Retention
Health Records Policy 7 - Release of Information
Health Records Policy 8 - Shredding
Health Records Policy 9 - Core Elements of an Authorization
Health Records Policy 10 - Privacy Breach Risk Assessment and Notification
Health Records Policy 11 - Invalid Authorizations
Health Records Policy 12 - Non-Residential Parents and Step-Parents




Go to the Health Records Policies for Download

Additional Documentation ​(6 Files)

*All Additional Documentation (6 Files)
Hospitalist & In-Patient Care Template
Pharmacy Agreement Template
Radiology Agreement Template 
Dental Agreement Template
Affiliation Agreement - Mental Health Template
Letter of Support Template
Go to the additional Documents Category For Download

Emergency Preparedness Plan & Documentation (8 Files)

Emergency Preparedness Plan
Emergency Preparedness Plan Policy
Emergency Preparedness Plan Diagram
Emergency Preparedness Plan Organization Chart
Emergency Preparedness Plan Evaluation
Emergency Preparedness Plan Supplies & Equipment List
Emergency Preparedness Plan Leadership Job Descriptions
Emergency Preparedness Plan Public Information Officer JAC
Go to the Emergency Preparedness Plan Section for Download
  • Open/Close Tabs
  • Covid-19 Protocols
<
>

Click on a Tab above to open the TOC for the section.

Covid-19 Protocols  (5 Files)
​

*All Covid-19 Protocols (5 Files)
Protocol 1 - Employee Symptom Screening 
Protocol 2 - In-office Coronavirus Protocol
Protocol 3 - Minimum Personal Protective Equipment
Protocol 4 - Patient Entrance Screening Protocol
Protocol 5 - Phone - Coronavirus Triage

Go to the Governance category for Download
FQHCmd Consulting updates the Policies, Procedures and Documentation on a regular basis to insure that they meet and/or exceed HRSA requirements and expectations.  Input for all documentation is through FQHC CEO's, CFO's, and other personnel throughout the country, HRSA auditors, FQHC Associations, etc. and all documentation has been reviewed by our legal department.
FQHC Documentation is a service of FQHCmd Consulting Group.
Please direct any questions to info@FQHCmd.com
New Access Point (NAP) Applications  |  FQHC Look Alike Applications  |  Service Area Competition (SAC)/Budget Period Progress Reports  |  FQHC Management Support  |  Monthly Financial Statement Preparation  |  Grant Writing for New Access Points (NAP) & Service Area Competition Applications (SAC)  |  UDS Reports  |  Change In Scope Support  |  OSV "Mock" Surveys  |  Community Health Needs Assessments  |  Dashboard Reporting  |  HRSA Site Visit Preparation  |  FQHC Budget Development  |  FQHC Staff/Board Education  |  FQHC Strategic Planning  |  340B Pharmacy Development  |  FQHC Financial Management Training
Privacy Policy  |   ​Terms of Service  |  Email  |   © Copyright 2008-2022, FQHCmd Consulting 

  • Home
  • Table of Contents
  • FQHC Policy & Procedures
  • Contact us