Employee Handbook
The Employee Handbook is offered to each new employee upon hire. It is the complete listing of BPWC policies and a complete guide to how BPWC operates in any given situation. It is important for you to read through this Handbook as soon as possible, so that you are familiar with and understand the policies that are currently in place.
Communications All communications equipment is the property of Bridgeport Laser. Telephones, computer systems, internet access, etc. are all company issued and will be monitored. Personal use of company property is prohibited.
BRIDGEPORT LASER & WELLNESS IS DEDICATED TO THE HIGHEST QUALITY CUSTOMER SERVICE.
IN ORDER TO ENSURE THAT OUR COMPANY’S MISSION : TO PROVIDE EXCELLENCE IN ALL AREAS OF PATIENT CARE AND THAT WE ARE TREATING EACH PATIENT LIKE FAMILY, PHONE LINES MAY BE RECORDED AND REGULARLY MONITORED FOR TRAINING AND REVIEW PURPOSES.
Phone Etiquette – these minimum standards should be followed during each call
1. The caller is aware that they have called the right location and whom they are speaking with.
2. That we are addressing the caller by the name they have provided to us.
3. That we are listening to the callers request, meeting their needs, and remembering what they have said.
4. That we are engaging with them. (Responding to what they have said, asking questions, showing an interest in them. Social graces)
5. That we do not interrupt our callers while they are speaking.
6. That we are showing courtesy by using the words Please, Thank You and May I.
7. That we are showing compassion, empathy, concern, and apologizing when appropriate.
8. That our voices reflect Energy and Enthusiasm!
9. That we are not placing barriers. (Saying what we CAN DO instead of what we can’t do)
10. That we are avoiding Long Silences.
11. That we are polite, efficient and appropriate.
12. That we use proper grammar, business language, avoiding company terms and jargon.
13. That we are using POSITIVE words,
14. That if we need to place a caller on hold we wait for them to acknowledge and agree to our request/ we thank them for holding/and provide updates during long holds,
15. That if we need to transfer their call, we let them know who they are being transferred to /the reason and instructions should they receive voicemail.
16. That we are waiting for the caller to disconnect the call before placing our receiver down
17. That we are not tying up the lines by making (non emergent) personal calls .When our callers can not get through we are not providing excellence in customer service.
Thank you, please feel free to contact your Office Manager with any questions.
Use of Cell Phones Employees can check cell phone messages during unpaid breaks or at lunch times when they are away from their work area.
PURPOSE: To establish a procedure to provide a consistent process for personnel who may have cell phones at work.
POLICY: The policy applies to all management, staff and Provider positions at Bridgeport Laser. Employees may have their cell phones hidden in a desk or locker while at work for use in emergency purposes only. However, they must be off or on vibrate. Personal texting will not be permitted during working hours; texting off the clock on BPWC property is permitted. Exceptions would apply to Managers in positions that are required to use their cell phones to conduct business. Managers should try to utilize office phones and computers before having to access a cell phone. If you have been approved to conduct business on a cell phone, please be sure to utilize the cell phone for business purposes only and to not disrupt employees or patients.
RESPONSIBILITY: It is an employee’s responsibility to focus on work related projects during working hours. We ask that all employees’ respect the work environment and adhere to this policy.
PROCEDURE:.
1. Personal texting and phone calls are not permitted while on the clock.
2. If there is an emergency and you need to take or make a call, please notify your supervisor of such and step outside.
3. Cell Phones must be left in desk or locker.
4. Cell phones must be kept out of patient view at all times.
Webclock Hourly BPWC employees record their time online with Orchid. You must clock in and out for lunch daily. If you should decide to leave the building during work hours, you must clock out if the absence is for personal reasons.
• It is the employee’s responsibility to report any/all absences as well as issues clocking in/out to his/her immediate supervisor prior to payroll deadlines.
• Overtime should not be accrued unless your supervisor has specifically authorized it for you.
Payroll
Payroll is done on a monthly basis. This means that there are 12 pay periods in a year. Your supervisor will review your timesheet for accuracy and add any PTO that has been requested. Please review your hours weekly. Should any corrections need to be made, please correct, making notes as appropriate. There may be times in which you may not have access or time to make changes. In this event supervisor may make the changes on behalf of the employee.
Lunches
Please see your supervisor to determine your lunch schedule. Lunch breaks for hourly employees are 30-60 minutes; salaried employees are allotted up to 1 hour. Please be sure to take your lunch break. Please do not try to work through your lunch break. You will have a much better day!
Parking
Please park in the middle lot spaces to allow the best available parking for patients. Front row parking during work hours is not allowed.
Break Room
Each employee has designated cabinet space in the kitchen area for food and personal belongings. Coffee, tea, water, microwave, refrigerator and freezer are all available for your use. Be respectful of others’ personal items and ask before taking/using. Please be kind and keep these areas & items tidy. Bulletin Boards are located in the kitchen. Federally mandated postings, such as EEO guidelines, minimum wage statements, etc. are posted in the back office. Another bulletin board exists specifically for informational postings that employees need to see. Newsletters, date changes for meetings, information on upcoming meetings or events, and sometimes an occasional community event will be posted.
Terms of Endearment
Please take care when speaking with other employees, patients, and physicians. There are those that take offense to being called anything other than their real names. When you call someone “honey” or “dear” or “sweetie” you may be offending them and it really is best, and more professional, to use the person’s name when addressing them.
Evaluations
BPWC hourly employees will be evaluated at the 90 day mark and annually thereafter. It is your responsibility to let Practice Manager know throughout the year of ideas for business growth, patient retention, ease of work flow, or of supplies/equipment needed to perform your job.
Facility
BPWC employees are responsible for cleaning their work area or work rooms daily. This includes emptying their garbage, wiping down all equipment, sweeping the floor, wiping down doors, wiping down countertops & sink, sanitizing tools, restocking supplies, and preparing for the next day’s appointments. Failure to contribute in this way will be addressed with a verbal warning then written warning. If you must leave urgently prior to cleaning your work space please notify Practice Manager. It is imperative that all employees work together to keep common areas clean (bathroom, hallways, lobby, front walkway, kitchen)
Benefits Benefits offered at BPWC include:
All Full Time employees are eligible to participate in the insurance plans the first day of the month after they were hired. Human Resources will contact you prior to your eligibility date to review costs, plan options, complete forms, etc.
BPWC benefits include:
Medical, Dental – Plan options and details will be provided to you upon eligibility. Should you wish to review the benefit options with BPWC prior to then, please request a copy of our Enrollment Guide from HR.
401K Plan – BPWC employees must complete 1 year of service before they become eligible to participate in the BPWC 401(k) Plan. Entry dates will be January 1st & July 1st of each year. Part Time employees may participate in the plan, but only after completing 1 year of service. There is currently not an employer match, employee contributions only.
HRA Plan – BPWC offers a HRA (Health Reimbursement Account) plan through GNSA to save on healthcare expenses that are not covered by your medical, dental and vision insurance plans. Plan details and further information will be provided to you upon benefit eligibility.
Paid Time Off (PTO) – PTO Time is accrued beginning on your 1st day of work. You may not request/use PTO time until you have successfully completed your 90 day introductory period.
Full Time employees working a 160 hour pay period will accrue :
0 -12 months = 5 Days (per year)
13 – 48 months = 10.00 Days (per year)
49 – 120 months = 15.00 Days (per year)
120 months – 10 Years = 20.00 Days (per year)
Those employees working less than 160 hours will accrue PTO according to the number of hours worked in that particular pay period. Seasonal, Part Time and PRN (on call) employees are not eligible for this benefit. Once introductory period has been satisfied, you must request PTO time from your supervisor via a PTO Request Form.
Please follow this process when requesting PTO time.
Paid Holidays – The Practice recognizes seven (4) paid holidays for all employees during each calendar year. Hours will be paid in 6 or 8 hour increments, depends on if employee is full time or part time.
The holidays that the Practice recognizes as paid holidays are as follows:
New Year’s Day
Independence Day (July 4)
Thanksgiving Day
Christmas Day
NOTE: Holidays falling on Sunday will be observed the following Monday.
Employee Discounts & Services
PURPOSE: It is the purpose of this policy to establish guidelines for a program which offers discounts on products and services to BPWC staff and family.
POLICY: It is the policy of the Bridgeport Laser & Wellness to offer discounts on products and services to Employees and Family. No discount is to be given on the purchase of a gift card.
Employee discounts should be considered a perk/benefit for exemplary employees and is not part of the regular Bridgeport Laser benefit package. Any and all exceptions to this policy can be made only by Dr. Norcom and/or Practice Administrator.
As costs increase, the costs listed in this policy will also increase. This policy and all discounts listed within are subject to change without notice. BPWC has the right to discontinue this program at anytime or discontinue a provider’s participation in the program without advance notice.
DEFINITION: For the purposes of this policy: Full Time Employees who have been working for BPWC at least 90 days are eligible for discounts that may be available. Part Time Employees who have been working for BPWC at least one full year are eligible for discounts that may be available.
Relatives are defined to include immediate family members specifically, but not limited to spouses, parents, children, brothers, sisters, brothers and sisters-in-law, fathers and mothers-in-law.
PROCEDURES:
For Cosmetic Services: The employee must first schedule a consultation with the Practice Administrator to discuss procedure and cost, if applicable. Should the employee want to proceed with the services discussed during the consult, the employee will complete the discount services form in this policy return form to Practice Administrator to coordinate the Cosmetic Services based on provider availability.
• The Discount Services Form does not need to be filled out for basic aesthetic services including facials, chemical peels.
• No consults or procedures will be done during lunch breaks unless approved first.
• The employee must remain off the clock during any consult or procedure.
• Patients come first, so the employee may be rescheduled to prioritize patient requests.
• All procedures must be entered on the schedule and the proper paperwork/consents filled out.
• Payment for services must be made on the day of services.
• Aestheticians cannot go into overtime when performing services for employees.
Aesthicians need to be mindful of their schedule. Should they be close to earning over time hours, they should reschedule the employee for another time and day, when not earning over time hours, but regular hours.
Employee Discounts
Eligible Employee
Eligible Employee**
Immediate Family
Hcg Weight Loss
Cost
20% off
Aesthetic Services****
50% off / no charge if self-treating
15% off
Skin Care Products
Cost
20% off
Laser Services
75% off
50% off
Botox/Dysport
Cost (free if product provided by vendor)
10% off
Juvederm/ Restylane
Cost (free if product provided by vendor)
10% off
Other injectables
Cost (free if product provided by vendor)
10% off
ThermiVA
Cost
10% off
Ultherapy
Cost – .89 cents per line
10% off
Hormone Therapy
Free – Lab work at cost
10% off
It is important to remember the following: **Cost rates are subject to change at any time without notice. **No discount is to be given on the purchase of a Gift Card. **Should be noted as employee or employee family purchase on ticket. **All Employee Services must be performed in times that do not affect workflow. **Employees’ services may be moved at any time for a paying patient.**Must have supervisor’s approval for any needed time off. **Supervisor must be aware of elective procedure. ****The Discount Services Form does not need to be filled out for basic aesthetic services including facials, peels & dermaplaning.
1. For Skincare Services or Procedures: Please complete the discount services form in this policy and provide to Practice Manager. Should the employee want to proceed with the services at the rate noted on the form, the Practice Manager will schedule their office visit with the Provider when the employee is off the clock. Once scheduled the employee will copy their approval from the Practice Manager and bring it with them to their scheduled appointment.
• No visits or procedures will be done during lunch breaks unless approved first.
• The employee must remain off the clock during any visit or procedure.
• Patients come first, so the employee may be rescheduled to prioritize patient requests.
• All procedures must be entered on the schedule and the proper paperwork/consents filled out.
• Payment for services must be made on the day of services unless prior arrangements have been made.
• Be sure that your Practice Manager is aware of your family’s appointments with a provider.
1. For product: Any employee purchasing product will be entitled to a discount as follows: Employee will receive the product at Cost unless other vendor discounts are available.
1. Roles: Find your role listed below and adhere to as noted.
• Employee/Family: review this policy and adhere to all areas of this policy. Be sure to do exactly as this policy states when requesting services, whether cosmetic or wellness services. The form enclosed in this policy is required and mandatory. It is the sole responsibility of the employee to adhere to this policy and rates may change without notice, no matter what any other BPWC team member may tell you, this includes any information a Provider may provide you. Before employee can schedule any services as noted in this policy, all signatures on the discount services form must be signed by all parties as requested on the form. Non adherence of this policy will result in a formal warning, up to termination.
• Practice Manager: will adhere to all areas of this policy, while ensuring staff are in compliance with this policy. Practice Manager will be sure to collect the payment noted on the discount services form, then sign and date the form. Once payment has been collected and services have been rendered, the “Employee Eligibility for Discounts Services” Form must be sent to Human Resources for filing.
Employee Eligibility for Discount Services
Download Here
Sick Calls If you should find yourself ill and need to miss work, please be sure to call in and let the scheduling desk and Practice Manager know. Use Practice Manager’s cell phone number to call and/or text as well as calling the office number. Be sure to continue to call until you reach someone if you are ill or need to miss work for some reason. Emails are not acceptable ways to contact your co-workers or Practice Manager when/if you need to call in. Please be aware that BPWC does have a policy that states that 2 “no show-no calls” (or unexcused absences) in a row equals immediate termination. As always, it is important to call in as early as possible, to allow your Practice Manager to find someone to cover you for the the day.
• In addition, please be mindful of Attendance Policy on Absenteeism & Tardiness. (Below)
Absenteeism/Tardiness
Punctual and regular attendance is an essential responsibility of each employee at Bridgeport Laser & Wellness. Any tardiness or absence causes problems for fellow employees and supervisors. When an employee is absent, others must perform the work, which diminishes the smooth functioning of Bridgeport Laser. Employees are expected to report to work as scheduled, on time and prepared to start work. Employees also are expected to remain at work for their entire work schedule. Late arrival, early departure, or other absences from scheduled hours are disruptive and must be avoided. The purpose of this policy is to promote the efficient operation of the company and minimize unscheduled absences. In the rare instances when employees cannot avoid being late to work or unable to work as scheduled, they must notify their supervisor as soon as possible via a phone call. Texting only is not allowed. When possible, please call at least 1 hour prior to your shift beginning. If your Practice Manager cannot be reached, contact the front desk staff.
Sufficient Notice
To be considered an excused absence, sufficient notice must be given to the supervisor. Sufficient notice is:
1. For a scheduled absence of 8 hours or more, employees must give a notice of 2 weeks.
2. For a scheduled absence of less than 8 hours, employees must also give at least notice of 2 weeks.
3. For a serious emergency where proof can be provided occurring a) at the beginning of the employee’s shift, employees must notify their supervisor at least one hour before the beginning of their shift and b) during the employee’s shift, employees must notify their supervisor prior to leaving the premises.
4. Your Practice Manager must approve any exceptions to this provision or any conflicts in scheduling.
Absence Defined: Absence is the failure of an employee to report to work when the employee is scheduled to work.
1. Excused Absence occurs when all three of the following conditions are met: i) the employee provides sufficient notice to his or her supervisor ii) the reason is found credible or acceptable by his supervisor, and iii) such absence request is approved by his or her supervisor.
2. Unexcused Absence occurs when any of the items listed under Sufficient Notice are not met. If it is necessary for you to be absent or late for work because of illness or an emergency, you must notify your supervisor at least one hour before your scheduled starting time on that same day. If you are unable to call, have someone make the call on your behalf. Texting is not allowed.
Tardiness
You are expected to report to work on time. If you cannot report to work as scheduled, you should notify your supervisor at least one hour before your regular starting time. This notification does not excuse the tardiness, but simply notifies your supervisor that a schedule change may be necessary.
Job Abandonment
If an employee is absent three days without proper notice to their supervisor, he/she is considered to have “voluntarily quit without notice”. The employee will not be eligible for rehire.
Attendance Standards
Human Resources and Practice Manager will administer the attendance standards and procedures outlined below, regardless of employee position, length of service, etc. Practice Manager will work with Human Resources to administer warning per the below. The following Attendance Matrix demonstrates how points will be assessed and the types of corrective actions that may be issued. The employee will be given one point for arriving 5 to 15 minutes after their scheduled starting time or for leaving 5 to 15 minutes early from their scheduled end time; and three points for arriving between sixteen minutes and two hours late or for leaving 16 minutes to 2 hours early from their scheduled end time. Employees who are more than two hours late in reporting to work or who are leaving more than 2 hours early from their scheduled end time will accumulate 5 points. Employees calling out for a full day absence will accumulate 7 points.
Absence Time Frame
Points
5-15 minutes – tardy or left early
1
16 minutes – 2 hours – tardy or left early
3
Over 2 hours – tardy or left early
5
Full Day Absence
7
Employees will be subject to disciplinary action when the total points accumulated from unauthorized absence and tardiness reaches the following levels during any six month period.
Points
Corrective Action to be issued
10 Points
Verbal Warning
21 Points
Written Warning
30 Points
Termination
Family Medical Leave Act (FMLA) – IMPORTANT!!! There have been sweeping changes to the Federal FMLA laws in the last few years. Request forms have changed and now have VERY SHORT TIME LIMITS for completion. Please see your Practice Manager or HR as soon as possible for any FMLA leave you may be considering, in order to understand approval and reporting requirements. If you are approved for FMLA leave or an approved intermittent FMLA leave, there are very specific requirements regarding calling in to report your status. If you are on an approved intermittent FMLA leave, IT IS NOW A REQUIREMENT THAT YOU CALL IN EACH AND EVERY TIME YOU ARE GOING TO MISS WORK. Please see your Practice Manager or HR to discuss this new change to the federal law and to discuss how/to whom you are to call in. Failure to call in could result in an interruption of your FMLA benefits.
DIVERSITY
Diversity is the fact or quality of being diverse; or difference. A point of respect in which things differ. Finding common ground between people who are culturally different is most important. – Finding common ground means finding attributes, concerns, and goals you have in common with another person. It is a necessary part of building a relationship of any kind. Respect is one way of finding common ground between people. – One example of demonstrating respect is being tolerant of someone else’s approach and ideas. – Each of us is different culturally, emotionally, and historically. Stereotyping is one way that people close off the growth of diversity in the workplace. – When we stereotype, we apply our biases and experiences to an entire group of people. – Biases are grown out of life experiences, values, and beliefs. We accept biases all through our lives, and fuel our biases out of fear – without taking time to give the individual a chance. BPWC strives to promote a workplace that is respectful of all people, regardless of culture. – It is important that we, as a group, recognize the importance of acceptance of our co-workers as individuals.
SEXUAL HARASSMENT:
IMAGES +
It is the policy of Bridgeport Laser & Wellness to: – Investigate all complaints of sexual harassment immediately and thoroughly. – Take corrective action promptly – Follow through with communication
If you believe that you have been harassed on the job, or if you are aware of harassment, you should provide a written or verbal complaint to the Practice Administrator or Dr. Norcom as soon as possible. Be as detailed as possible, including names of individuals involved and witnesses, and direct quotations when relevant.
Any employee of BPWC, whether a co-worker or supervisor, who is found to have engaged in harassment, is subject to disciplinary action, up to and including termination from employment. Any employee who engages in harassment, including any supervisor who knew about the harassment but took no action to stop it or failed to report the harassment to Practice Administrator, may also be subject to discipline up to and including discharge.
CORPORATE COMPLIANCE:
After reviewing the Standards below, print and sign the acknowledgement and return to HR.
STANDARDS OF CORPORATE COMPLIANCE
October 2015
Dear Bridgeport Laser & Wellness Colleague:
Our patients and the communities we serve rely on us for quality care and trust us to conduct ourselves with integrity in everything we do. We will strive to provide an ethical and compassionate approach to health care, including safeguarding against actions that could damage our reputation. Our employees have been and will be a critical factor in this process.
The purpose of the Standards of Corporate Compliance is to let all employees and appropriate third parties know that Bridgeport Laser & Wellness is fully dedicated to conducting all of its activities, especially compliance with laws and regulations, in an ethical manner. Since everyone at Bridgeport Laser & Wellness has a personal stake in this important program, I strongly urge each of you to review this information thoroughly.
Compliance with laws, regulations and our policies requires the full commitment of every employee. Each of us is personally and professionally responsible for understanding and adhering to this Standards of Corporate Compliance and supporting compliance policies and procedures, including those areas covering your specific job responsibilities. The Standards of Corporate Compliance are meant to provide you with guidance on ethical and compliance issues. At the same time, we recognize that it is impossible to cover every issue you may encounter. If you have a question or encounter a situation which concerns you, you should ask for assistance through your supervisor or Compliance Officer. These resources are available to you and I encourage you to use them without concern for reprisal. You will always find we have an “open door” when it comes to business ethics and compliance issues.
Bridgeport Laser & Wellness is a health care leader. We must also be a leader in demonstrating sound ethical and compliance practices. We know that focusing our efforts on ethics and compliance is the right thing to do and we know that a sound compliance program will be the basis for a stronger organization. I encourage you to join in our commitment to these goals so that we can continue to be proud of our organization and be a role model for our industry.
Showing empathy to others is the backbone of everything we do. Please watch the 10 minute video below prior to proceeding:
Empathy vs. Sympathy
Dr. Derek & Alina Norcom
Owners
Bridgeport Laser & Wellness
CONTENTS
INTRODUCTION
I. PATIENTS
1. Patient Care
2. Patient Information
II. PHYSICIAN RELATIONSHIPS
1. Patient Referrals
2. Physician Recruitment
III. THIRD PARTY PAYORS
1. Coding and Billing for Services
2. Auditing & Monitoring
3. Training & Education
IV. COMPLIANCE FOR ALL EMPLOYEES
1. Conflicts of Interest
2. Controlled Substances
3. Confidential Information
4. Antitrust
5. Communications Systems
6. Employment Practices
7. Substance Abuse
8. Workplace Violence
9. Health and Safety
10. Environmental Compliance
11. Marketing and Advertising
12. Financial Reporting and Records
13. Record Retention
14. Government Inquiries
V. USING THE COMPLIANCE PROGRAM
1. Personal Obligation to Report
2. Internal Investigations of Violations
3. Media Inquiries
VI. ACKNOWLEDGMENT
INTRODUCTION
At Bridgeport Laser & Wellness, we recognize the importance of maintaining an environment of integrity, honesty and respect. It is our goal and a high priority to provide such an atmosphere, where patients feel valued and cared for, and employees are oriented, trained, and educated to positively influence our center. Together we can work to foster this environment of ethical and compliance responsibility and achieve our mission:
MISSION STATEMENT
Bridgeport Laser & Wellness is committed to providing outstanding healthcare services to our patients. Our patients are like family, and as such, we have created an atmosphere of welcome, caring and comfort. Our providers and staff work as a team driven by work ethic, mutual respect, open communication and a desire for continuous improvement.
CORE VALUES
• Greet each patient, visitor, and each other with a smile
• Treat all patients like important family members
• Use eye contact when speaking with patients and visitors to the Practice
• Learn to recognize patients by name. Everyone likes to be remembered
• Treat all personal and health related information with utmost confidentiality
• Know and understand the importance of your role within the Practice
• Choose words carefully. While the words may be forgotten, the power of how they made someone feel may not
• Take pride in personal appearance. You represent Bridgeport Laser & Wellness
• Always arrive on time ready to perform your job to the best of your ability.
• Commit yourself to maintaining a positive attitude always
• If you perceive a problem, take ownership of the solution.
Our Standards of Corporate Compliance (“Standards”) provide guidance to all employees of Bridgeport Laser & Wellness (“BPWC”). The Standards are meant to assist you in carrying out your day to day activities within appropriate ethical and legal standards.
The Standards are a critical component of our overall Compliance Program. We have developed the Standards to assist us in providing quality care, meeting our ethical standards, and complying with applicable laws and regulations. Since it is not possible to describe all instances of improper conduct, these Standards provide a framework defining some of expectations. If you ever have a question regarding BPWC practices, you should contact your supervisor or HR. It is your responsibility to understand and comply with the rules, regulations and laws that pertain to your jobs. If you are responsible for managing or supervising other employees, it is your responsibility to reinforce periodically with each person under your supervision compliance with the Standards. You are responsible for reporting compliance issues which come to your attention to your supervisor, or HR.
Positive commitment to compliance and ethics will be considered in our hiring practices and performance evaluations. If you violate the principles contained in these Standards, you will be subject to disciplinary action, up to and including termination.
I. PATIENTS
1. Patient Care
Our mission is to provide quality health care to all of our patients. This means we treat all patients with respect and dignity and provide care that is both necessary and appropriate, without regard to race, color, age, gender, national origin, disability, marital status or sexual orientation. Our commitment to quality care involves the patients and their families in decision making regarding care as much as possible.
Compassion and care are part of our commitment to the communities we serve. We will not withhold medically necessary treatment for any reason. If you have any questions or concerns about this policy, contact the Practice Manager.
2. Patient Information
We collect information about the patient’s medical condition, history, medication and family illnesses to assist us in providing an appropriate level of care. We consider this information confidential and do not release or discuss such information with others unless it is necessary to serve the patient and within HIPAA guidelines. We should never disclose confidential information that violates the privacy rights of our patients. All employees must follow the HIPAA guidelines.
Patients are entitled to expect both the protection of confidentiality and the release of information only to authorized parties who have obtained the patient’s written consent to inspect their medical records. In an emergency situation, when requested by a physician or hospital, a fax request will be acceptable.
If you have any questions or concerns about this policy, contact Practice Manager.
II. PHYSICIAN RELATIONSHIPS
1. Patient Referrals
We Do Not Pay For Referrals. We accept patient referrals solely based on the patient’s clinical needs and our ability to render the needed services. We do not, however, pay or offer to pay anyone – employees, physicians or other persons – for referrals of patients. No employee or other person acting on behalf of BPWC is permitted to enter into any agreements (especially with physicians) that are intended, directly or indirectly, to induce the referral of patients.
We Do Not Accept Payments For Referrals That We Make. No employee or any other person acting on behalf of BPWC is permitted to solicit or receive anything of value, directly or indirectly, in exchange for the referral of patients. Similarly, when making patient referrals to another health care provider, we do not take into account the volume or value of referrals that the provider has made (or may make) to BPWC.
We Do Not Allow Personal Interests To Influence Referrals. Our policy is to inform patients of their options, regardless of ownership, as to durable medical equipment, and other ancillary health care services and to promote patient freedom of choice in selecting these services.
We Do Not Pay Patients. We do not waive service fees or otherwise provide financial benefits to patients, unless directed by the Administration. Under certain circumstances, BPWC may provide for appropriate financial arrangements (such as allowing monthly payments over time) to patients based purely on their documented financial need.
2. Physician Recruitment
BPWC shall exercise reasonable and good faith efforts to comply with all applicable state and federal laws and regulations, including the IRS Code, pertaining to physician or other staff recruitment. All physician recruitment shall be conducted under the guidance and direction of Dr. Norcom.
III. THIRD PARTY PAYORS
1. Coding and Billing for Services
BPWC will bill the patient, not their insurance carrier, which may be the government, for the medical services we provide. We are committed to preparing accurate and complete billing claims that comply with the law when requested by a patient for insurance reimbursement purposes.
BPWC is committed to compliance with all applicable rules and regulations of government health care programs, including Medicare, as well as managed care entities participating in these government programs. All claim forms provided to patients for reimbursement shall have adequate supporting documentation in the patient’s medical record. It is our policy to apply the correct Current Procedural Terminology (CPT-4), HCPCS (HCFA Common Procedure Coding System) and International Classification of Disease (ICD-10-CM) coding principles and guidelines and any other regulations that apply when analyzing medical record documentation.
We do not:
Bill insurance directly for items and services rendered;
Misrepresent the type or level of service rendered;
Inappropriately unbundle services;
Misrepresent the diagnosis in order to obtain payment;
For questions concerning billing issues, you should contact the Book keeper and/or Practice Manager.
If you have any questions or concerns about this policy, contact the Practice Manager.
2. Auditing & Monitoring
BPWC will conduct periodic self-audits at least once each year to determine that procedures are accurately documented and accurately reflect the services provided and that documentation is being completed correctly. This is done on order to ensure that written standards and procedures are being followed, to help reduce the prospect of fraudulent activity, to identify risk areas for the practice and establish tighter internal controls to counter those risks, and to help identify any aberrant practices.
3. Training & Education
BPWC recognizes that education is an important part of any compliance program, and as such, strives to accomplish two goals when conducting training: (1) That all employees will receive training on how to perform their jobs in compliance with the standards of the practice and any applicable regulations; and (2) that each employee will understand that compliance is a condition of continued employment. Additional education and training will be determined by the practice’s needs as well as individual job duties, and the type of training will be accomplished through a variety of means, including in-person training sessions, in-service training, self study, distribution of newsletters, etc.
4. Bidding, Negotiation and Contract Performance
It is the policy of BPWC to use its best efforts in complying with all laws, rules and regulations regarding the acquisition of goods and services. No employee shall submit or concur in the submission of any claim, invoice, bid, proposal or other document that is false, fictitious or fraudulent.
If you have any questions or concerns regarding this, contact the Practice Administrator.
IV. COMPLIANCE FOR ALL EMPLOYEES
1. Conflicts of Interest
All employees of BPWC carry with them a requirement of loyalty and fidelity. It is the responsibility of such employees to administer the affairs of BPWC honestly and economically, and to exercise their best care, skill, and judgment for the benefit of BPWC. They shall not use their positions, or knowledge gained there from, in such a way that a conflict of interest might arise.
A conflict of interest may occur if your outside activities or personal interests influence your ability to make objective decisions in the course of your job responsibilities. A conflict of interest may also exist if the demands of any outside activities hinder or distract you from the performance of your job or cause you to use BPWC resources (i.e. time, computers, facilities, supplies) for non-BPWC purposes. This policy applies to all employees of BPWC. It is important that while on the job that you think about BPWC first.
Some examples of potential conflict situations:
Acting as a director, partner, consultant or employee of a firm which either provides services, supplies or equipment to BPWC, or is a competitor of BPWC. This generally means you should not have a business relationship with suppliers and competitors.
Material ownership by you or members of your family of a financial interest in a firm that is either a competitor, or vendor of BPWC.
Purchase or lease of real estate which may increase in value because it is known that BPWC may have an interest in the property.
Gifts and entertainment represent a sensitive area since these activities may create a potential conflict of interest or be interpreted by others as an attempt to influence a situation.
All questions regarding conflicts of interest should go to the Practice Manager.
2. Controlled Substances
As part of their job responsibilities for BPWC, many employees routinely have access to prescription drugs, controlled substances and other medical supplies such as drug samples and hypodermic needles. Many of these substances are governed and monitored by specific regulatory organizations and should be administered by authorized personnel pursuant to a physician’s order only. It is extremely important that these items be handled properly and only by authorized individuals (pharmacists, nurses, and doctors) to minimize risks to ourselves and the patients. Under no circumstances should such items be used for personal use or administered unless there has been an appropriate determination of medical necessity and/or you have obtained a valid physician order.
If you have any questions or concerns about this policy, contact Dr. Norcom.
3. Confidential Business Information
Every organization develops or owns information that it wants to protect. Although you may use BPWC’s confidential information to perform your job, it is not public information and should not be shared with others. Some examples of this type of information include personnel data, patient lists, financial data, research data, clinical information, strategic plans, marketing strategies, processes, techniques, computer software and any information with a copyright.
In the course of employment, you may become aware of non-public information about BPWC and its plans for mergers, marketing strategy, financial results or other business dealings. Generally, you may not discuss this type of information with anyone outside of BPWC. Within BPWC, you should discuss this information on a strictly “need to know” basis only with other employees who require this information to perform their jobs.
If you have any questions regarding what constitutes “Confidential Information,” please contact Practice Manager.
4. Antitrust
It is our policy to fully comply with antitrust laws. Antitrust laws are designed to create a level playing field in the marketplace and to promote fair competition. Our competitors are other health centers and business entities in markets where we operate. Antitrust laws could be violated by discussing BPWC business with a competitor, such as how our rates are set, disclosing the terms of supplier relationships, allocating markets amongst competitors or agreeing with a competitor to refuse to deal with a supplier. The following standards will be observed relative to compliance with the antitrust laws, specifically with respect to activities, negotiations and interactions with competitors.
No employee, director or agent of BPWC has the authority to enter into any activity, agreement or contract that would have the effect of reducing or eliminating competition, controlling prices, allocating markets or excluding competitors. This includes not only formal written agreements but also so-called “gentlemen’s agreements” or understandings.
Examples of potentially anti competitive arrangements include but are not limited to those that limit capacity, allocate patients, markets or territories, boycott or refuse to deal with third party payors, restricting of advertising or marketing efforts, or suppressing technological developments.
No employee, director or agent of BPWC may enter into any discussion, communication, or agreement with any representative of any other organization providing the same services concerning prices or charges, pricing policies, discounts or allowances, other pricing terms and conditions, or wage and salary information. Requests for such information in the form of third party surveys or questionnaires shall be reviewed by the Practice Administrator.
Any agreement with any other organization that provides the same services of this organization must be reviewed by legal counsel and approved by Dr. Norcom.
Any employee or director who suspects that a particular activity, communication agreement or situation involving employees, directors or agents of BPWC violates these standards or state or federal antitrust laws, or appears to do so, should report those concerns to his or her supervisor or the Practice Manager.
5. Communications Systems
All communications systems, electronic mail, Internet access, voice mail, intranet, intellectual property or paper is the property of BPWC and is to be primarily used for BPWC business purposes. Reasonable personal use of BPWC communications systems is permitted, however, you should assume that these communications are not private. Generally, patient or confidential information should not be sent through the Internet since its confidentiality cannot be guaranteed.
BPWC may review E-mail and voice messages periodically if we have a business reason or are conducting reviews for quality control purposes. If you abuse our communications systems or use them excessively for non-business purposes, you may lose these privileges and/or be subject to disciplinary action which may include termination.
You may not use BPWC communications to:
Send harassing, threatening or obscene messages;
Send chain letters;
Access non-business information on the Internet (refer to our Internet Policy);
Send copyrighted documents that are not authorized for reproduction;
Conduct a job search;
Sell items of a personal nature or conduct any business other than the official business of BPWC.
6. Employment Practices
We are committed to providing a fair and equal opportunity work environment where every employee, subcontractor, vendor and visitor is treated with respect and courtesy. We will not tolerate any unlawful harassment or discrimination for any reason. We expect the same from all of our contractors, vendors and visitors to BPWC. This means that:
We provide equal opportunity for employment and advancement.
We provide equitable benefits to all employees.
Harassment of any type will not be tolerated.
No employee shall discriminate against any individual with a disability with respect to any offer, term or condition of employment. We will make reasonable accommodations to the known physical and mental limitations of otherwise qualified individuals with disabilities.
For further information in this area, refer to the Employee Handbook. If you have any questions or concerns about this policy, contact the Practice Administrator.
7. Substance Abuse
To protect the interests of our employees and patients, we are committed to an alcohol and drug-free work environment. All employees must report for work free of the influence of alcohol and illegal drugs. Anyone who reports to work while under the influence of alcohol or illegal drugs will be disciplined, which may include termination.
If you have any questions or concerns about this policy, contact the Human Resources department.
8. Workplace Violence
Our concern for others also prohibits threatening, aggressive or abusive behavior, as well as carrying weapons. Violence in the workplace will not be tolerated and this behavior will result in disciplinary action which may include termination.
If you have any questions or concerns about this policy, contact Human Resources department.
9. Health and Safety
We are committed to providing a healthy and safe workplace. BPWC and each of its affiliated facilities must comply with the federal, state and local laws, regulations and rules that promote the protection of health and safety. Our policies have been developed to protect you and your co-worker from potential workplace hazards and all employees are expected to abide by them. You should understand how these requirements apply to your specific job responsibilities and seek advice from your supervisor or HR whenever you have a question or concern.
It is important for you to advise your supervisor, Practice Manager or Human Resources of any serious workplace injury or any situation presenting a danger of injury. This information will help us prevent these incidents either from happening or from happening again.
10. Environmental Compliance
It is our policy to comply with all environmental laws and regulations as they relate to our business. It is your responsibility to understand how your job responsibilities may impact the environment and make sure you follow BPWC policy. If you have questions about environmental regulations or the proper handling of hazardous materials, ask your supervisor for assistance. This includes advising the Clinical Director immediately should you see discharge of what may be hazardous substances or potential danger of discharge.
If you have any questions or concerns about this policy, contact the Practice Administrator.
11. Marketing and Advertising
BPWC uses marketing and advertising to educate the public, report to the community, increase awareness of our services, and to recruit employees. We will not make any false or misleading statements about BPWC, our services or other organizations.
If you have any questions or concerns about this policy, contact the Marketing Manager.
12. Financial Reporting and Records
We have established and maintain our financial records in an accurate and complete fashion. These records serve as a basis for managing our business and are important in meeting our obligations to patients, employees, directors, suppliers and others; as well as for compliance with tax and financial reporting requirements. It is our policy to comply with the reporting requirements of applicable laws and established financial standards and generally accepted accounting principles.
If you have any questions or concerns about this policy, contact the Bookkeeper.
13. Record Retention
We maintain certain types of medical and business records, in accordance with our record retention policy. Records may be defined as hard copies, computer files on tape, disk, etc., and electronic systems. It is important to retain and destroy records appropriately according to BPWC policy. You should not tamper with records, or remove or destroy them prior to the specified date.
If you have any questions or concerns about this policy, contact the Practice Administrator.
14. Government Inquiries
It is the policy of BPWC to cooperate with all government inquiries and investigations. In so doing, it is important that the legal rights of our employees be protected. If any employee receives an inquiry, subpoena, or other legal document regarding BPWC business, whether at home or in the workplace, they should immediately notify their supervisor. If an employee is contacted at home by a governmental agency regarding BPWC, the employee should instruct the agent to call or return at a later time then immediately contact their Dr. Norcom and the Practice Manager.
If you have any questions regarding this, contact the Practice Manager.
V. USING THE COMPLIANCE PROGRAM
1. Personal Obligation to Report
We are committed to ethical and legal conduct that is compliant with all relevant laws and regulations. We are also committed to correcting wrongdoing wherever it may occur in BPWC. Each employee has an individual responsibility for monitoring and reporting any activity by any employee, subcontractor or vendor that appears to violate applicable laws, rules, regulations or these Standards.
If you suspect that anything improper has occurred, we expect you to bring that information immediately to the attention of your supervisor or HR, the Corporate Compliance can serve as a resource to employees for asking questions, seeking advice, clarifying issues, raising concerns and reporting suspected violations. Your anonymity will be protected if desired. We do not tolerate retribution against anyone who acts in good faith to bring to light a potential violation of these Standards.
If an employee is aware of a violation of the Standards and does not report that knowledge, it could be interpreted as approving of the action, and could result in disciplinary action. Supervisors who receive a report of a potential Standards violation must immediately advise HR.
If you have any questions or concerns about this policy, contact Practice Manager.
2. Internal Investigations of Violations
We are committed to investigate all reported violations promptly and confidentially to the extent possible. All investigations will be directed by the Practice Manager and may be assisted by the other personnel as appropriate. The Practice Manager will coordinate any findings from the investigations and immediately implement corrections or changes that need to be made. We require all employees to cooperate with investigation efforts for the well being of BPWC.
If you have any questions or concerns about this policy, contact the Practice Manager.
3. Media Inquiries
BPWC’s Marketing Manager is responsible for all contact with the media. Unless you are specifically authorized to represent BPWC in the media, please do not respond to inquiries or requests for information. This includes newspapers, magazines, trade publications, radio, television, as well as any other external source who is looking for information concerning or involving BPWC.
If the media contacts you about any topic, you should refer them to BPWC’s Marketing Manager.
VI. ACKNOWLEDGMENT
BPWC requires each employee to sign an acknowledgment confirming that you have received and read these Standards, understand them and will abide by them. New employees will be required to sign this acknowledgment as a condition of employment. Compliance functions and participation will be considered in decisions regarding hiring, promotion and compensation for all candidates and employees. It is BPWC’s policy not to hire, contract or otherwise deal with sanctioned individuals.
EMPLOYESS HEALTH SAFETY:
Protected: Employee Health & Safety
Search this website Search
Employee Health & Safety
Bridgeport Laser & Wellness serves to deliver high-quality health care and dependability from all employees, therefore prompt attendance at scheduled work hours is expected of all employees. Continued tardiness or absence becomes unfair to providers, fellow employees, as well as patients.
In case of illness, you are to contact your supervisor or relay means by which you can be contacted by your supervisor as soon as you know you will not be at work, so that adjustments can be made.
It is your responsibility to notify management every day during your absence, as to the status of your illness, and approximate day of return. A doctor’s note is requested for time away from work for more than three days.
If a staff member is absent two days without proper notice to their supervisor he/she is considered to have “voluntarily quit without notice,” and the employee will not be eligible for rehire.
Remember: Texting is not a proper form of communication for calling in sick!
Workers compensation/claims management
Fear and uncertainty are primary reasons for injured employees to delay reporting injuries and to seek assistance from attorneys. This may be due to concern over medical bills, lost income or even the loss of employment. The following procedure will be utilized to alleviate these fears and ensure that workers’ compensation claims will be handled in a fair and expeditious manner.
The Company provides a comprehensive workers’ compensation insurance program at no cost to employees. This program provides coverage for certain injuries or illnesses sustained in the course of employment. Subject to applicable legal requirements, workers’ compensation insurance provides benefits after a short waiting period or, if the employee is hospitalized, immediately.
Employees who sustain work-related injuries or illnesses should inform their supervisor and Human Resources immediately. No matter how minor an on-the-job injury may appear, it is important that it be reported immediately. This will enable an eligible employee to qualify for coverage as quickly as possible.
Procedures:
Employees who are injured on the job and need immediate medical assistance need to dial 911 or head to the nearest hospital for treatment. For those that do not need medical assistance, please head to the nearest Worker’s Compensation Clinic. For those that are injured at work and refuse medical assistance, please see or contact your supervisor within 24 hours of the injury taking place. All accidents/injuries must also be called into Human Resources ASAP by the supervisor of the injured employee or by the injured employee.
All injuries require the employee to complete an Accident/Incident Form. This form must be completed within 24 hours from the time of the injury or accident and must be turned into the employee’s supervisor. Supervisor will then this form to Human Resources ASAP.
Once the accident has been reported to Human Resources or once the form as mentioned above is turned in, Human Resources will report the injury to the Workers Compensation Carrier.
If any witnesses were present at the time of accident or injury, they need to also complete the witness portion of an accident/incident form stating the events they witnessed. Please make sure that the witnesses include the following information: date, time, place, and others that were present. The witnesses must sign and date this document and the document should be turned in to Human Resources or their supervisor within 24 hours from the time the accident or injury took place.
Once the accident/incident has been reported the Workers Compensation Carrier will send the injured employee an explanation of the workers’ compensation system and the benefits it will provide. In the event of a work-related injury or illness, the injured employee must report it to his/her immediate supervisor or Practice Manager before the end of the work shift.
An accident investigation will be conducted following all work-related injuries. The supervisor or Practice Manager will be responsible for interviewing the injured employee and all witnesses.
If the incident involved an employee death or a catastrophe (three or more employees admitted to the hospital), OSHA must be notified within eight hours.
The Safety Officer will use information from the accident investigation to identify changes that may help prevent future incidents.
Modified duty procedures will be as follows:
• The medical restrictions will be evaluated by the employee’s supervisor who will determine if the employee can return to his/her regular job duties.
•
If the employee is unable to return to normal job duties, the supervisor will determine if the employee’s position can be temporarily modified to accommodate the restrictions.
•
If the job cannot be modified, the safety coordinator will evaluate other tasks or positions the employee may be able to perform until the medical restrictions are lifted.
•
If the employee is unable to return safely to a modified position, the medical restrictions will be re-evaluated after each doctor’s visit to ensure the employee is returned to work as soon as possible.
Accurate records will be kept for all workers’ compensation claims.
Bridgeport Employee Health & Safety Facts
Please be aware of the details listed below. These details are noted to provide you with additional BPWC information.
Existing Hazards:
• Chemicals
• Biohazardous Waste liquid/solid
• Contaminated Sharps
• Fire Hazards. Ex: boxes in the way of hallways
• Trips and Falls
Site Inspections
• Weekly & Daily
• Clinical Coordinators – Checklist utilized
Hazard Controls
• Protective Protection Equipment (PPE)
• Universal precautions
• GHS/MSDS
• Spill Kits
• Eye glasses available at all offices and at sinks
• Sharps Containers
HazCom
• Biowaste Symbols
• Lab Doors
• Door to rooms that Biowaste is kept for pick up
MSDS available in all offices
Formalin stickers on all drawers containing formalin
Safety storage cabinets for all lab chemicals with HazCom symbols depicting chemicals inside
Nearest Hospitals
Tualatin — Meridian Park
Portland — Providence St. Vincent’s
Worksite Analysis for Hazards
Practice Manager- Spot Check
Providers- Daily/Weekly Checklist
Office Supervisor – Spot Checks and completes a list weekly for the non clinical work areas
Fire & Safety
Every BPWC office has a floor plan of all emergency exits, as well as an emergency plan. If you do not know your exit route, please see your supervisor or the office supervisor.
Electrical training
BPWC Electrical Items to be careful with
• Computers/Printers/Phones plugged into surge protectors all over the offices
• Hyfrecators
• Laser / RF Equipment
Risk Management
Patient Incident report must be completed and signed by patient prior to leaving the office. The incident report must then be reviewed and signed by Human Resources or Practice Administrator prior to patient leaving.
IMAGES
Fire & Safety Procedures
PURPOSE:
To provide and establish procedures for a safe, calm response in the event of fire.
POLICY:
All BPWC staff will be prepared to calmly and efficiently respond to a fire emergency.
Evacuation plans are posted throughout all locations.
Fire extinguishers are located throughout the center.
Exit lights are lighted and checked regularly.
Elevators are NOT used during a fire alarm situation.
RESPONSIBILITY:
The Administrator shall be responsible for establishing the protocol, initiating the evacuation order and communicating with the fire department and media.
Human Resources are responsible for staff orientation and annual retraining.
PROCEDURE:
The following instructions are presented as a plan of action should a fire or smoke situation develop:
1. Remain calm
2. Remember your Acronym
R Remove / Rescue all persons from the area of smoke or fire
A Alarm . Activate the fire alarm system using the nearest pull station.
C Confine smoke by closing all doors/windows, leave room lights on.
E Extinguish a very small fire if possible using a fire extinguisher or evacuate the immediate fire/smoke area and wait for further instructions.
3. The employee who locates the fire will directly alert other employees.
4. Fire Extinguishers Acronym
Are multi-purpose ABC extinguishers that can be used on live electrical equipment, grease, oil, paper and wood fires. Are inspected monthly and certified annually. Service tags are not removed.
P Pull the Pin
A Aim at the base of the fire
S Squeeze the Handle
S Sweep from side to side
5. Evacuation Routes:
Patients will be removed from a danger zone to a point of temporary refuge. Attention should be given to evacuation from a hazardous area to a safe area. Lateral evacuation, followed by exit from the building, using designated evacuation routes.
6. Order of Evacuation:
Those nearest the fire
Helpless patients
Semi-ambulatory patients who can be assisted.
Ambulatory patients or visitors who can be led to safety
Reporting successful evacuation:
Employees, patients and visitors will be directed to the front parking lot.
Administrative staff shall assess and begin accounting for all those known to be in the building at the time of evacuation.
General Instructions:
Upon hearing the word Fire, everyone should stop assess the situation.
Close all doors.
Leave room lights on.
Turn off all electrical equipment which is not being used for patient care.
Telephones are used for emergency only
Reassure patients and visitors. Inform visitor of fire alarm situation, directing them to avoid walking through fire/smoke doors and elevator use.
Stand by to assist with evacuation if ordered.
Evacuation Routes:
Refer to evacuation routes and make your way safely out of the building.
RISK MANAGEMENT
The Purpose of a Risk Management Program
• To eliminate harm to patients, staff and the organization.
• To reduce financial loss associated with harmful situations.
• To fulfill requirements by insurance companies.
• To identify and investigate undesirable events leading to potential lawsuits.
• To comply with Federal and Oregon State law.
Risk Management Principles
Risk Management is about recognizing risks and taking steps to prevent them. Risk management covers every facet of a medical practice, but the main principles include:
1. Communication involves the effective and consistent transfer of information between all office staff and the patient to ensure that all patients understand all facets of care and treatment, as well as experience a positive encounter with BPWC from beginning to end.
2. Documentation involves accurate, complete and consistent recording of services provided. This includes providing patients with forms that are clear and understandable, documenting the care that is rendered and the rationale for it, documenting the informed consent, and documenting tests or treatments that are performed, the return of results, and conveying the results to the patient.
3. Office policies and risk management procedures involve the assurance that all systems in the office work effectively to facilitate safe and effective patient care.
Incident Reporting Procedures
Overview
An incident is an unplanned occurrence that resulted or could have resulted in injury to people; damage to property, equipment, or the environment. These events may affect any person on the premises, including patients, employees, providers, visitors, etc. When an incident is reported promptly, injured persons receive timely medical care and unsafe conditions are quickly corrected. All injuries, no matter how small must be reported.
Reporting responsibilities
Employees must report any and all work related injury or incident to their supervisor immediately upon occurrence. Depending upon the severity of the injury, employees may need to seek immediate medical attention. Employees should forward all relevant Worker’s Compensation paperwork to Human Resources to ensure proper and expedient processing of their claim.
Supervisors are responsible for ensuring that an Incident Report and/or Employee Occupational Exposure Report is completed and received by the Safety Officer. In addition, any medical information received by the supervisor subsequent to the incident should be forward to Human Resources.
If involving a patient, the Incident Report is NOT placed in the patient’s medical record nor are references made to it. A progress note is entered in the chart, however, describing what occurred, the results of evaluation, and treatment provided. No names or excuses should be given.
Who should complete an Incident Report?
The first priority is to ensure the wellness and safety of the person(s) involved.
An Incident Report should be completed in a timely manner by the person who first witnessed or discovered the event or by the person most closely involved in the occurrence, even if this person did not commit or contribute to the occurrence.
Completing the Incident Report
Documentation should consist only of facts stated in a clear, concise, objective and comprehensive manner. The report should be completed as soon as possible after the incident. Accurate, detailed, and complete information is the most effective tool in the incident report. Opinions, assumptions, and hearsay should be put aside. The five W’s are a useful guide in completing the report.
• What? Describe what happened in detail
• When? Give the date and time of the incident
• Where? Describe the incident’s location
• Who? Tell who did what to whom and who witnessed the incident
• Why? Did equipment fail?
The Incident Report is signed by the person who completed the report, witnesses (if any), the Safety Officer and Administrator. The data is used to help identify potential and actual risks for quality assurance improvement and risk management purposes.
Summary
Incident Reports:
• Used for an unplanned or unusual occurrence, whether or not there was an injury.
• Essential tool for data collection.
• Confidential, never part of a patient’s record.
• Never a punitive measure.
• Accurate, concise and objective.
• Who, What, When, Where, Why.
• Degree of injury. (If any)
• Who is responsible for the follow-up.
Completed incident reports must be to the Safety Officer (Satomi) within 24 hours.
ERGONOMICS
INFECTION CIONTROL
BIOMEDICAL WASTE
BLOODBORNE PATHOGENS
HIPPA PRIVACA SECURTY
Bridgeport Laser & Wellness Protocol Regarding Emailing PHI (Protected Health Information)
The purpose of this policy is to guide Bridgeport Laser & Wellness staff in the use of electronic mail (e-mail) which contains Protected Health Information (PHI).
Definitions
1) Protected Health Information (PHI) is individually identifiable health information. Health information means any information, whether oral or recorded in any medium, that: is created or received by Bridgeport Laser & Wellness; and relates to the past, present, or future physical or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual
2) Patient-Healthcare provider electronic mail is computer based communication between clinicians and patients for treatment.
3) Individual-Healthcare provider electronic mail is computer based communication between healthcare providers and individuals who are not known to the healthcare provider.
Procedure
1) Whenever an email is sent, verify the “to” field prior to sending the message.
2) Email sent by Bridgeport Laser & Wellness Email applications are scanned by a tool which will encrypt the message.
3) A confidentiality statement is automatically added to the footer of all outbound email from the Bridgeport Laser & Wellness practice email servers.
4) Upon receipt the patient/provider or Bridgeport Laser & Wellness staff member will be required to create a password before email is viewable. All future correspondence with the patient or health care provider will require the same password to be used. An option is available to the recipient if needed to reset the password on the login screen.
5) Once the encrypted message is sent, all future correspondence related to that individual email message between Bridgeport Laser & Wellness offices to the patient or health care provider office will continue within the encryption email window of that message.
3. E-mail communication may occur between Bridgeport Laser & Wellness and two categories of individuals:
1) Established Bridgeport Laser & Wellness patients known to the healthcare provider, designee, or covering provider. (4.1)
2) Individuals unknown to the healthcare provider. (4.2)
As with any verbal or written communication, Bridgeport Laser & Wellness staff are advised to be extremely cautious and use their professional judgment in what they say as this is a written form of communication.
3,1) Established Bridgeport Laser & Wellness patients
3.1.1) Documentation of email communication between Bridgeport Laser & Wellness staff and patients must be included in the medical record to ensure continuity of care. Documentation comparable to documentation of a telephone call should be included in the record
3.1.2) If you wish to send a group mailing, do not send a group mailing where recipients are visible to each other. Use the blind copy feature of the e-mail software.
3.1.3) Health care providers may forward a patient’s message or patient identifiable information for treatment purposes.
3.1.4) If the health care provider has reason to suspect that the email has been initiated by someone other than the patient, a response may be given indicating that the email will not receive a response.
3.1.5) The subject line of the email should not contain the patient name the medical record number, patient account number and/or date of service.
3,2) Individuals unknown to Bridgeport Laser & Wellness
3.2.1) The healthcare provider must ensure that the individual clearly understands that the communication is for educational purposes and not be construed as establishing a patient-health care provider relationship.
3.2.2) Based on your professional judgment, if it appears individual is seeking treatment, direct individual to call office for an appointment or to see their health care provider.
3.2.3) Only general information should be communicated. This information is to be viewed as “educational”.
priv1
priv2
priv3
priv4
priv5
priv6
priv7
priv8
priv9
priv10
priv11
priv12
priv13
priv14
priv15
priv16
priv17
priv18
priv19
priv20
priv21
priv22
priv23
priv24
priv25
priv26
priv27
priv29
HIPAA Violations and Enforcement
Civil Penalties
Type of Offense Minimum Maximum
Person did not know (and by exercising reasonable diligence would have known) that a person violated HIPAA $100 per violation, with an annual maximum of $25,000 for repeat violations. $50,000 per violation, with an annual maximum of $1.5 Million
Violation due to reasonable cause and not willful neglect. $1000 per violation, with an annual maximum of $100,000 for repeat violations. $50,000 per violation, with an annual maximum of $1.5 million.
Violation due to willful neglect but violation is corrected within the required time period. $10,000 per violation, with an annual maximum of $250,000 for repeat violations. $50,000 per violation, with an annual maximum of $1.5 million.
Violation is due to willful neglect and is not corrected. $50,000 per violation, with an annual maximum of $1.5 million. $50,000 per violation, with an annual maximum of $1.5 million.
Criminal Penalties
In June 2005, the U.S. Department of Justice (DOJ) clarified who can be held criminally liable under HIPAA. Covered entities and specified individuals, as explained below, whom “knowingly” obtain or disclose individually identifiable health information in violation of the Administrative Simplification Regulations face a fine of up to $50,000, as well as imprisonment up to one year. Offenses committed under false pretenses allow penalties to be increased to a $100,000 fine, with up to five years in prison. Finally, offenses committed with the intent to sell, transfer, or use individually identifiable health information for commercial advantage, personal gain or malicious harm permit fines of $250,000, and imprisonment for up to ten years.
