Policy and Procedure Manual

The

Policies and Procedures

of

Wound Care Treatment and Prevention Program

 

 

Table of Contents

 

 

 

 

Health and Medical Division
Wound Care Treatment and Prevention Program

SUBJECT: Dress Code

PURPOSE: To ensure professional appearance of staff.

STAFF GOVERNED BY THIS POLICY: WCTP staff

EFFECTIVE DATE: 12/11/04

DATE REVIEWED OR REVISED: 6/8/04

DISTRIBUTION: HMD

POLICY:

It is the policy of the WCTP to adhere to the HMD dress code in addition to the following requirements:

Fingernails must be clean; appropriate nail polish is allowed. Nails must be at a length that does not interfere with duties or endanger the patient.
Hair must be clean and neat, and of a length and style that will not interfere with duties.
Clothing must be in good repair and clean. Skirts may be two inches above the knee for the office setting but down to the knee in the field to allow for bending and stooping.
No denim jeans or shorts are allowed with the exception of times of bad winter weather.
No crop tops or low necklines are allowed.
Shoes should be clean and protect the foot. Nylons or socks must be worn.

In addition, field staff must adhere to the following requirements:

No sandals, clog or high-heeled pumps.
Jewelry should be kept at a minimum and safe for patient care.
Rings that do not tear gloves may be worn.
Three WCTP shirts will be provided to field staff to be worn with pants, scrub pants, skirts, or shorts that reach the top of the knees. Replacement of shirts will the responsibility of the employee.
No mini-skirts should be worn.
Sweatshirts in good taste may be worn in periods of severe cold.

 

 

 

 

 

Health and Medical Division
Wound Care Treatment and Prevention Program

SUBJECT: Nurse Aide II tasks performed by Nurse Aide I personnel

PURPOSE: To define the Nurse Aide I staff that may perform Nurse Aide II tasks

STAFF GOVERNED BY THIS POLICY: All Nurse Aide I staff

EFFECTIVE DATE: 12/11/01

DATE REVIEWED OR REVISED: 6/8/04

DISTRIBUTION: WCTP wide

POLICY:

It is the policy of the WCTP program, that Nurse Aide I staff may perform Nurse Aide II tasks that have been approved by the North Carolina Board of Nursing, in the execution of their duties.

PROCEDURE:

  1. The Manager will obtain the NA II modules for wound care and sterile technique and update the modules as directed by the North Carolina Board of Nursing (NCBON).
  2. The NA I will participate in the inservice provided by the manager, using the NCBON approved training modules.
  3. The NA I will be evaluated using the NCBON competency evaluation and a record of successful completion will be kept in the NA I’s personnel file.
  4. NA II staff will be given the choice of whether or not to take the inservice, but must pass the competency evaluation or participation in the inservice will be mandatory.
  5. All NA’s will be required to pass the competency evaluation once every year with record of evaluation to be kept in the personnel file.

 

 

 

 

 

Health and Medical Division
Wound Care Treatment and Prevention Program

Protocol for Wound Evaluation

Conducting the wound evaluation:

The provider will consider the following:

  1. History-Does the patient have DM? Date of diagnosis. Years of DM. Does patient have HTN or BP > 130/85? Is BP controlled? Tobacco and or ETOH use. Where was the patient referred from and on what date? When was initial presentation?
  2. Subjective-Date wound started. Cause of wound. Any prior treatment?
  3. Objective-Wound location, side, monofilament sensation. Pulses-right and left DP and PT, right and left ABI’s. Wound dimensions in cm. Measurements should be taken usually on a weekly basis. Any drainage, erythema, temperature.
  4. Documentation-wound evaluations will be documented on the I.H.S.- 803 PCC that is pre-printed for wound evaluations and will be completed by COB on the day of evaluation.

 

 

 

 

Health and Medical Division
Wound Care Treatment and Prevention Program

SUBJECT: Referral of Patients to Other Medical Clinics or Providers

PURPOSE: To define the process for referral of patients to other providers

STAFF GOVERNED BY THIS POLICY: WCTP staff

EFFECTIVE DATE: 12/11/04

DATE REVIEWED OR REVISED: 6/8/04

DISTRIBUTION: HMD

POLICY:

It is the policy of the WCTP to provide excellent health care to its patients. As situations may arise that fall outside of the scope of work for the program, referrals will be made to the appropriate health care clinic/provider.

PROCEDURE:

  1. After the determination is made that an issue exists that is out side the scope of work, the provider is responsible for initial coordination of services. An appointment will be made with the appropriate clinic/provider.
  2. An appointment slip will be given to the patient and the appointment will be documented in the patient’s chart.
  3. A patient referral form I.H.S. 199-1 will be completed and sent to the clinic/provider.


 

Health and Medical Division
Wound Care Treatment and Prevention Program

SUBJECT: Release of Confidential Patient Information

PURPOSE: Define process for releasing patient information to other agencies or persons

STAFF GOVERNED BY THIS POLICY: WCTP staff

EFFECTIVE DATE: 12/11/01

DATE REVIEWED OR REVISED: 6/8/04

DISTRIBUTION: HMD

POLICY:

It is the policy of WCTP to adhere to the I.H.S. and EBCI policies and procedures re: release of information/disclosure of medical records. (See attached confidentiality policy and procedures) Since WCTP records are copies of originals stored in the Medical Records at CIH, the following procedures will be followed:

PROCEDURE:

  1. The patient or their representative makes a request for information/records to WCTP staff.
  2. The WCTP staff member refers the patient to the Medical Records Department at CIH.
  3. If the patient is unable to go to CIH to make the request, WCTP staff may have the patient complete and sign request form I.H.S.-810 and deliver it to Medical Records.
  4. WCTP staff may not deliver medical records/information to the patient or their representative.


 

 

 

Health and Medical Division
Wound Care Treatment and Prevention Program

SUBJECT: Replacement of monofilaments

PURPOSE: To define method and responsibility of replacement of monofilaments.

STAFF GOVERNED BY THIS POLICY: WCTP staff

EFFECTIVE DATE: 12/11/01

DATE REVIEWED OR REVISED: 6/8/04

DISTRIBUTION: HMD

POLICY:

It is the policy of WCTP to provide each employee with a 10 g monofilament for performing foot exams. The monofilament will be replaced by the program when needed if monofilament is worn out or damaged. It will be the responsibility of the employee to replace the monofilament if lost. When a monofilament needs to be replaced, the CC in the clinic will be notified by clinic staff and the Manager will be notified by the Outreach staff for re-ordering.

 

 

 

Health and Medical Division
Wound Care Treatment and Prevention Program

SUBJECT: Rescheduling of patients

PURPOSE: To define the process for rescheduling patients at the WCTP Program

STAFF GOVERNED BY THIS POLICY: WCTP staff

EFFECTIVE DATE: 12/11/01

DATE REVIEWED OR REVISED: 6/8/04

DISTRIBUTION: HMD

POLICY:

Patient appointments may be rescheduled due to absence of provider, emergency closure, patient request, or circumstances beyond control. Patients will be given as much advance notice of appointment change as possible and will be rescheduled at the next available time. If patient must be seen that day, they will be referred to the CIH OPD or ED as appropriate.

PROCEDURE:

  1. If it is determined that patients need to be rescheduled for a HOW, the manager will ascertain if coverage can be provided by another HOW or the manager and assignments made accordingly.
  2. If coverage cannot be provided, the manager will contact patients to cancel their appointments.
  3. It will be the responsibility of the HOW to make rescheduled appointments upon return to work.
  4. If the Manager must reschedule personal patients, an HOW will be assigned to notify patients of canceled appointment and the manager will reschedule the patients upon return to work.
  5. In the WCTP clinic at CIH the CC will be responsible for notifying and rescheduling patients.
  6. In all instances, the person notifying the patient of the need to reschedule will advise patient to seek medical care at the CIH OPD or ED if appropriate.

 

 

Health and Medical Division
Wound Care Treatment and Prevention Program

SUBJECT: Safety During Community/Home Visits

PURPOSE: To define the measures to be taken to ensure the safety of WCTP staff

STAFF GOVERNED BY THIS POLICY: WCTP staff

EFFECTIVE DATE: 12/11/04

DATE REVIEWED OR REVISED: 6/8/04

DISTRIBUTION: HMD

POLICY:

The safety and security of the WCTP staff is essential for providing quality patient care. It is the responsibility of the patient to provide a safe work environment when WCTP staff is in their homes. The WCTP staff will not tolerate being exposed to threats of and/or actual physical/verbal abuse. The WCTP staff will not tolerate being exposed to threat of or actual harm from animals at the patient’s residence.

PROCEDURE:

  1. Staff in the WCTP clinic will be covered by the CIH policy on staff safety.
  2. If WCTP staff experience threats of and/or actual physical/verbal abuse, they will remove themselves from the situation, using the assistance of the police if needed.
  3. A written incident report will be turned in to the Manager within 2 working days of the incident.
  4. The Manager will obtain any police reports if the police were involved.
  5. The Manager will decide if WCTP services should be terminated. The staff member involved will decide if any criminal charges should be evoked.
  6. If the patient was not the abuser, but it was a family member/guest, the patient must ensure that the abuser will not be present on any subsequent visits if services are not terminated. The patient also has the option of receiving services in the office if it is not possible to remove the abuser.
  7. If WCTP staff feels that there is a threat of harm from an animal at the patient’s residence, the staff members will remove themselves from the situation. They do not have to leave the safety of their vehicle if the animal is not properly restrained.
  8. The patient will be notified in writing that services will be discontinued if the animal is not properly restrained.
  9. If a WCTP staff member is attacked or bitten by an animal at a patient’s residence, they will remove themselves from the situation and take any fist aid measures necessary. They will notify the manager of the situation and report to CIH for any necessary medical attention.
  10. A written incident report will be turned in to the Manager within 2 working days of the incident.
  11. The Manager will notify the patient that services will be discontinued at their residence, but the patient has the option of receiving services at the WCTP office.

 

 

Health and Medical Division
Wound Care Treatment and Prevention Program

SUBJECT: Supply Inventory

PURPOSE: To safeguard supply stock

STAFF GOVERNED BY THIS POLICY: WCTP

EFFECTIVE DATE: 6/4/04

DATE REVIEWED OR REVISED:

DISTRIBUTION: WCTP

POLICY:

WCTP staff will perform a monthly inventory of wound care supplies.

PROCEDURE:

The assigned HOW will conduct monthly inventory by the last day of each month for the supplies stored at the GLWWC offices. The PTA will conduct monthly inventory by the last day of each month for the supplies stored at the CIHA offices. Each assigned HOW and PTA will perform the inventory using a prepared inventory control log. The inventory control log will be kept in the supply area.

 

 

 

Health and Medical Division
Wound Care Treatment and Prevention Program

SUBJECT: Telephone Log

PURPOSE: To ensure that long distance telephone charges are for business matters only.

STAFF GOVERNED BY THIS POLICY: WCTP

EFFECTIVE DATE: 12/11/01

DATE REVIEWED OR REVISED: 6/8/04

DISTRIBUTION: HMD

POLICY:

It is the policy of the WCTP to only make long distance calls that are business related and to keep a log of these calls as a means of safeguarding tribal funds.

PROCEDURE:

  1. Each employee in the outreach program will have a phone log at their desk in which to record long distance calls.
  2. Each employee will write any long distance calls in the log when the call is placed.
  3. The Manager will gather logs monthly and compare them to the pending phone bill.
  4. Any charge not accounted for will be investigated by the manager and the charge must be paid by the employee who made the call, if it is determined to be a personal call.

 

 

 

Health and Medical Division
Wound Care Treatment and Prevention Program

SUBJECT: Travel and Training

PURPOSE: To provide funds to support the professional growth of employees in a fair and equitable manner.

STAFF GOVERNED BY THIS POLICY: WCTP

EFFECTIVE DATE: 12/11/01

DATE REVIEWED OR REVISED: 6/8/04

DISTRIBUTION: HMD

POLICY:

It is the policy of WCTP to follow the Travel Policy (Article XI) of the EBCI. It is also the policy of the WCTP to provide funding for at least one training per year, per employee. (As funds allow) This training may be at the employee’s request or at the recommendation of the supervisor. Training/travel may be mandatory or may be denied based on an employee’s performance evaluation, at the discretion of the supervisor.

PROCEDURE:

  1. The employee (or supervisor) will access information pertaining to appropriate training opportunities.
  2. The employee (or supervisor) will submit a training and travel authorization form to the appropriate supervisor (along with all supporting documentation) at least two weeks in advance of the training.
  3. After approval, the Manager will determine if funding is available and forward the request through the appropriate channels as outlined in EBCI policy, Article XI.
  4. Once final approval has been obtained, the employee may then make travel and training arrangements.
  5. Expense/trip reports are due to the manager within 5 days of return from travel/training. No further travel/training will be allowed if the employee has an outstanding expense/trip report.

 

 

 

Health and Medical Division
Wound Care Treatment and Prevention Program

WCTP ADVISORY BOARD FUNCTIONS


1. To review policies and procedures and make pertinent recommendations, at least annually and more often if necessary.

2. To promote the WCTP Program on the Cherokee Indian Reservation.

3. To serve in an advisory capacity to the WCTP Program and provide leadership for the Program.

4. To provide input to the WCTP Program concerning needs and demands of the community.

5. To assist with integration of other related health care resources.

6. To assist with seeking ways of obtaining needed services for the WCTP Program.

7. To assist with an annual evaluation of the WCTP Program.

 

Health and Medical Division
Wound Care Treatment and Prevention Program

SUBJECT: Wound Evaluations

PURPOSE: To define the method by which wounds are to be evaluated and documented.

STAFF GOVERNED BY THIS POLICY: WCTP staff

EFFECTIVE DATE 12/11/01:

DATE REVIEWED OR REVISED: 6/8/04

DISTRIBUTION: HMD

POLICY:

It is the policy of WCTP to have wound evaluations performed by the WCS, Manager/RN, or PT. PTA’s and C.N.A.’s may not perform evaluations, but will refer patients to the appropriate provider if new wounds or deterioration is noted in present wounds, i.e. increased erythema, edema, drainage, size, temperature or odor. Wound evaluations will be documented on I.H.S. –803 PCC for wound evaluation by the COB of day of evaluation.