Public Health Department Policy & Procedure Manual Example



Download 1.45 Mb.
Page1/18
Date conversion03.05.2018
Size1.45 Mb.
  1   2   3   4   5   6   7   8   9   ...   18

Public Health Department Policy & Procedure Manual Example











Policy & Procedure

Effective

Revised/Reviewed




1. Administration




 

A.

Accident/ Injury (Employee or Client)

10/01/03

07/18/12




 

B.

Administrative Policy

01/05/10

06/15/12




 

C.

Background Checks for Employees

12/03/03


06/15/12




 

D.

Board of Health

07/02/12

07/02/12




 

E.

Civil Rights Compliance

06/29/12

06/29/12




 

F.

Conflict Resolution

07/16/12

07/16/12




 

G.

Cultural and Linguistic Assurance Policy

06/29/12

06/29/12


 


H.

Delegation of Authority

06/28/12

06/28/12




 

I.

Employee Safety

7/2/2012

07/02/12




 

J.

Fee Policy for Public Health Services

01/01/07

07/02/12




 

K.

Flexible Schedule

07/16/12

07/16/12




 

M.

Medical Advisor

05/25/06


06/29/12




 

N.

Orientation

12/11/03

07/23/12




 

O.

Policy and Procedure Access and Annual Review

06/29/12

06/29/12




 

P.

Professional Staff Licensure

01/13/10

06/26/12




 

Q.

Public Health Supply Ordering

01/01/00

07/23/12


 


R.

County Vehicle for Work-Related Travel

10/05/07

07/17/12




 

S.

Workforce Development

07/17/12

07/16/12




2. Adult Health

 

 

 

 




 

A.

Blood Pressure Screening for Adults

11/10/03

07/12/12




 

B.

Cholestech: Lipid and Glucose Screening and Testing

07/16/12

07/16/12





 

C.

Cholestech: Optics Check

07/16/12

07/16/12




 

D.

Cholestech: Quality Control Testing

07/16/12

07/16/12




 

E.

Jail Health (See Jail Health Policy and Procedure Manual)

 

 




 

F.

Public Health Clinic

7/20/12

7/25/12




 

G.


Wisconsin Well Woman Program (WWWP)

05/31/07

06/20/12




3. Communicable Disease




 

 

 




 

A.

Communicable Disease Investigation and Control

12/19/07

07/02/12




 

B.

Infection Control and Prevention

07/16/09

07/02/12




 

C.

Rabies Prevention and Control

01/05/10

07/02/12





 

D.

TB – Accessing Services

09/30/09

07/16/12




 

E.

TB Confinement

03/30/09

07/16/12




 

F.

TB – Directly Observed Therapy

09/19/03

07/16/12




 

G.

TB – Isolation

09/19/12

07/16/12




 

H.

TB – Sputum Testing


07/16/12

07/16/12




4. Emergency Preparedness

 

 

 

 




 

A.

Response to Public Health Emergencies

05/31/08

07/18/12




 

B.

Personal Protective Equipment (PPE)

01/18/07

07/23/12




 

C.

Public Health Emergency Plan (See PHEP Manual)

 

 


 


D.

Respiratory Protection Program

03/26/08

07/23/12




5. Environmental Health

 

 

 

 




 

A.

Blood Lead Level (BLL) Results and Follow-Up

07/05/06

07/06/12




 

B.

Environmental Health Complaint Investigation

08/01/03

06/28/12




 

C.

Environmental Health Fee Exempt Testing

07/16/12

07/16/12





 

D.

Foodborne and Waterborne Outbreak Investigation

07/02/12

07/02/12




 

E.

Home Visitation: Elimination of Second Hand Smoke Exposure

09/05/08

06/28/12




 

F.

Human Health Hazards

05/25/06

07/06/12




 

G.

Medical Waste Disposal

11/07/03

06/15/12




 

H.

Methamphetamine Lab Follow-up

01/13/04

07/13/12




 

I.

Radon Outreach and Testing

07/02/12

07/02/12




 

J.

Recreational Water: Restricted Use/Closure

08/01/03

07/20/12




 

K.

Well Water Testing

01/13/10

07/19/12




6. Health Information

 

 


 

 




 

A.

Access to Vital Records

10/01/03

07/13/12




 

B.

Birth Records Use and Retention Policy

07/16/12

07/16/12




 

C.

Confidentiality of Client Information

08/01/03

06/26/12




 

D.

Correction of Errors in Client Records

11/01/03

07/16/12


 

E.

Interpreter / Translator Services

02/20/09

06/18/12




 

F.

Public Records Availability for Inspection and Copying

06/01/04

07/02/12




 

G.

Record Retention

10/01/03

7/2/12




7. Immunization

 

 

 

 




 

A.

Amish Health Education Screening and Immunization

07/16/12

07/16/12





 

B.

Emergency Vaccine Retrieval and Storage Plan

07/07/10

06/26/12




 

C.

Immunization Program (See Immunization Policy and Procedure Manual)

 

 




 

D.

Immunizations: General Procedure for Adults and Children

06/23/06

04/14/12




 

E.

Seasonal Influenza Vaccine Administration

07/17/12

07/17/12




 

F.

Testing vaccine alarm system


07/16/10

06/26/12




 

G.

Vaccine Receiving and Shipment Unpacking

07/07/10

06/26/12




8. Miscellaneous

 

 










 

A.

Client Transfers and Referrals

10/01/03

06/15/12




 










06/15/12

 

B.

Emergency Administration of Epinephrine


07/01/07

07/25/12




 

C.

Facebook Page

07/13/12

07/13/12




 

D.

Media Communications

12/18/07

06/22/12




 

E.

Social Media

09/09/10

06/19/12




9. Oral Health

 

 

 

 




 

A.

Fluoride Rinse Program

12/22/03


06/21/12




 

B.

Fluoride Sealant Program

01/04/10

07/12/12




 

C.

Fluoride Supplement Program

12/22/03

06/21/12




 

D.

Fluoride Varnish Program

05/29/07

06/21/12




10. Reproductive Health

 

 

 

 




 

A.


Chlamydia and Gonorrhea

06/15/12

06/15/12




 

B.

Completing a Urinalysis

08/27/03

07/23/12




 

C.

Family Planning Only Services Program

06/14/12

06/14/12




 

D.

Hemoglobin Testing

08/27/03

07/23/12




 

E.

Emergency Contraception Response Line Lock Box

06/14/12


06/14/12




 

F.

Packaging and Transport of Laboratory Specimens

06/14/12

06/14/12




 

G.

STI Follow-Up

07/16/12

07/16/12




11. Parent/Child Health

 

 










 

A.

Blood Lead Screening for Children

07/05/06

07/23/12




 

B.


Buffalo County/Pepin County WIC

07/23/12

07/23/12




 

C.

Child Abuse or Neglect Reporting

07/16/12

07/16/12




07/23/12

 

D.

Childhood Lead Poisoning Prevention

11/12/03

07/19/12




 

E.

Children and Youth with Special Health Care Needs (SCYHCN)

02/08/05

06/20/12




 

F.

Child Passenger Safety


01/15/10

06/15/12




 

G.

Head Lice Prevention and Control

01/27/11

07/16/12




 

H.

Health Check Screenings and Referrals

01/02/04

06/26/12




 

I.

Home Births – Third Party Corroboration of Birth Facts

12/27/07

07/16/12




 

J.

Lazy Eye Screening

05/26/06

06/20/12





 

K.

Maternal and Child Health Services (MCH)

01/02/04

07/25/12




 

L.

Prenatal Care Coordination (PNCC)

01/02/04

06/26/12







M.

Postpartum/Newborn Follow-up

01/02/04

06/26/12





POLICY TITLE: Accident/ Injury (Employee or Client)

EFFECTIVE DATE: 10/1/03

DATE REVIEWED/REVISED: 7/18/12

AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director

PURPOSE STATEMENT:

To protect the safety and well being of employees and clients. To provide a means of

tracking incidents and evaluating the safety of agency practices.


POLICY:
Pepin County Health Department strives to provide high quality services in a safe manner

to the residents of Pepin County. The health department is committed to maintaining

client and employee safety and preventing injuries. All client and employee

accidents/injuries will be reviewed thoroughly to facilitate necessary changes in program

policies to assure quality public health services.
PROCEDURE:
Client Accidents/Incidents


  1. All accidents/incidents involving clients are to be reported to the director immediately. The Incident Report Form is to be completed and signed by the employee witnessing or discovering the incident. The incident report form can be found in the Personnel Office. Objective descriptions of the facts are to be documented and any witnesses are to be identified. The involved employee is to notify the client’s health care provider of the incident, if appropriate.

  2. The director will review the report, investigate the circumstances, and determine any corrective action or changes in agency policies and procedures that are needed to prevent the same situation from happening in the future.

  3. The Incident Report will be maintained in a confidential file in the director’s office.


Employee Accidents/Incidents

  1. An employee who has sustained an injury that requires medical care is to seek medical attention immediately and notify his/her supervisor.

  2. The employee is to complete an Employer’s First Report of Injury or Disease form as soon as possible following the accident/incident.
  3. The employee injury report can be found here: Accident and Injury Forms\employee incident report form.pdf


  4. The completed form is to be submitted to the director for review as soon as possible.

  5. The director will conduct an investigation into the circumstances of the accident/incident to determine if procedural changes are necessary to prevent the event from occurring again in the future.

  6. Employee training will be offered as appropriate to prevent similar circumstances from happening again.

  7. All reports are kept in a confidential file in the director’s office.

  8. If the accident/incident involves exposure to blood or other potentially infections body fluids, follow the procedure in the Blood borne Pathogens Policy and Procedure and the Exposure Control Plan.


EVALUATION:

REFERENCES/LEGAL AUTHORITY:
POLICY TITLE: Administrative Policy

EFFECTIVE DATE: 1/5/10

DATE REVIEWED/REVISED: 6/15/12

AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director
PURPOSE STATEMENT:
To define staff areas of responsibility concerning the delivery of public health services.
POLICY:
The administrative staff maintains administrative control and establishes lines of authority for the

delegation of responsibility concerning the delivery of care services.


PROCEDURE:


  1. The public health agency’s governing body assumes overall legal authority and responsibility for operation of the agency.
  2. The Director of Pepin County Health Department assumes overall responsibility and authority for administrative and supervisory functions and operations of the agency.


  3. The public health agency’s Medical Advisor assumes overall responsibility for review and evaluation of the agency’s delivery of care services.

  4. Public Health staff members report directly to the Director.

  5. In the absence of the Director, a designated Public Health Nurse carries out the delegated responsibilities of the Director.

  6. All agency policies and procedures are annually reviewed by the Professional Advisory Committee or the Medical Advisor.

  7. All agency policies and procedures are annually reviewed and approved by the Director.

  8. All revised agency policies and procedures are communicated to staff at staff meetings.

  9. All aspects of the development and continuation of the program shall be in consultation with a representative of the Division of Health.

  10. Selection of employees shall not be influenced by their race, color, creed or national origin.

  11. Attempts will be made to select employees to be utilized more effectively and economically for the geographic area to be served.

  12. Office space needed for the public health program shall be charged to the Pepin County Health Department.

  13. Salaries of all personnel will be established to the Salary Schedule as it pertains to the individual approval of the Pepin County Board of Health.


GOVERNING BODY:

Pepin County Board of Health consists of seven members. Four members are members of the County Board of Supervisors who are elected to represent their respective districts. Three members are not elected officials or employees of the governing body. They are persons who have demonstrated interest and/or competence in the field of public and community health. All members are voting members.


FUNCTIONS:
  1. Board of Health governs the Pepin County Health Department and assures the enforcement of state public health statutes 251.04 and rules of the department.


  2. The board appoints a qualified Director for Pepin County Health Department and authorizes in writing a qualified person to act in the absence of the Director.

  3. Establishes a budget to initiate and maintain a public health program and oversees the management and fiscal affairs of the agency.

  4. Reviews and approves policies to provide for effective operation of the Public Health Program.

  5. Supports, advertises, and explains the program to the Board of Supervisors and to the community.

  6. Meets at least four times yearly or more often if necessary to review, evaluate, support and regulate the Public Health Program.

  7. Appoints a chairman, vice chairman, and secretary of the committee every two years after total County Board reorganization. The chairman is to conduct the meetings, the vice chairman is to act in absence of the chairman and the secretary is to record the minutes of all meetings. Minutes of the meetings are kept in the Public Health Office.

  8. Reviews and renews contracts annually for contract personnel employed for the Public Health Program.

  9. Establishes fiscal policies regulating fees, grants, etc.

  10. Assess public health needs and advocate for the provision of reasonable and necessary public health services.

  11. Shall assure that measures are taken to provide an environment in which individuals can be healthy.

Organizational Chart for Pepin County Health Department can be found here:



S:\PUBLIC HEALTH\Misc\Forms-Letters\ORGANIZATIONAL STRUCTURE.doc
EVALUATION:

REFERENCES/LEGAL AUTHORITY:



  • Pepin County Personnel Code

POLICY TITLE: Background Checks for Employees


EFFECTIVE DATE: 12/3/03


DATE REVIEWED/REVISED: 6/15/12

AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director
PURPOSE STATEMENT:
To assure compliance with HFS Chapter 12 – Caregiver Background Checks.
POLICY:
The employees of Pepin County Health Department who have direct client contact will undergo a

background check upon hiring and then every four years after that.




PROCEDURE:
1. All new employees who work directly with clients will complete Form HFS-0064 Background Information Disclosure found at: http://www.dhs.wisconsin.gov/forms/F8/F82064.pdf

  1. The health officer will complete the background check via the State of Wisconsin Department of Justice online at http://wi-recordcheck.org. The criminal history and the caregiver checks will be completed.

  2. The health officer will assure that background checks are completed every four years on all employees who have direct client contact.

  3. The health officer will obtain detailed information as needed from other states, clerks of court, military and tribal courts, or other sources in order to have sufficient facts to evaluate employees who work directly with clients.

  4. The health officer will determine whether individuals are eligible to be/remain employed with the health department. This decision will require analysis of any and all criminal acts to determine whether the identified crime(s), act(s) or offense(s) are related to the job the employee performs.

  5. An employee who is determined to be ineligible for employment may request a rehabilitation review unless the crime is defined as a permanent bar from employment/licensure.


EVALUATION:

REFERENCES/LEGAL AUTHORITY:


  • Wisconsin Department of Justice

POLICY TITLE: Board of Health



EFFECTIVE DATE: 7/02/12

DATE REVIEWED/REVISED: 7/02/12

AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director
PURPOSE STATEMENT:
To assure that measures are taken to provide an environment in which individuals can be healthy.
POLICY:
The local Board of Health (BOH) shall assess public health needs and advocate for the provision of reasonable and necessary public health services; develop policy and provide leadership that fosters local involvement and commitment, that emphasizes public health needs and that advocates for equitable distribution of health services.
PROCEDURE:

1. The Board of Health regularly reviews and approves public health related policies and procedures.

2. The Board of Health incorporates public health enforcement into agency policies and procedures including ordering abatement/removal of human health hazards, ordering removal of a person to quarantine as necessary, and to employ persons to execute orders.

3. Enforcement activities are regularly reviewed at Board of Health meetings.

4. Board of Health minutes demonstrate board involvement in the community health assessment and community health improvement plan, policy work including resolutions to support public health efforts, and advocacy for public health programs.

5. Board of Health minutes reflect time spent on public health education.

6. The Health Officer and Board of Health are responsible for conducting a community health needs assessment, developing a plan with partners and overseeing the implementation of the plan with partners.

7. The Health Officer and Board of Health are responsible for conducting a public health nursing program.

8. The Health Officer and Board of Health are responsible for assuring a confidentiality of records.

EVALUATION:
The Board of Health is evaluated during DHS Chapter 140 Reviews, which are conducted every 5 years.

REFERENCES/LEGAL AUTHORITY:


  • Wis. Stats 250.01, 250.042, and 251.04

  • HFS 140

  • DHS 140.06

POLICY TITLE: Civil Rights Compliance



EFFECTIVE DATE: 6/29/12

DATE REVIEWED/REVISED: 6/29/12

AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director
PURPOSE STATEMENT:
To comply with all State and Federal Civil Rights Compliance regulations and service as a supplement to other related policies and procedures.
POLICY:
Pepin County Health Department receives federal financial assistance and is required to be in compliance with all State and Federal Civil Rights laws and regulations. Title VI of the Civil Rights Act of 1964 prohibits discrimination on the basis of race, color, or national origin in programs and activities receiving federal financial assistance. Pepin County Health Department will:

  • Provide Training to employees

  • Assist Pepin County as a whole in complying with submission requirements of the Civil Rights Letter of Assurance and Civil Rights Compliance Plan

  • Work with the Pepin County Finance Personnel to insure equal opportunity in employment and service delivery to all individuals.


PROCEDURE:

Completion of a county-wide Civil Rights Compliance Plan and Letter of Assurance will be facilitated by the Finance Personnel Department. The Health Department Director will participate in this process and provide all necessary information and data as requested.

1. The Health Department Director will receive civil rights training annually and such training will be documented.

2. All other staff will receive civil rights training at least every three years and such training will be documented.

3. The following information will be prominently displayed in the health department:


  1. Equal Opportunity in Employment and Service Delivery Policy Statement (English, Spanish, Hmong, and posted on the Intranet)

  2. Limited English Proficiency Policy Statement (English, Spanish, Hmong, and posted on the Intranet)

  3. Service Delivery of Employment Discrimination Complaint (English, Spanish, Hmong, and posted on Intranet)

  4. USDA “And Justice for All” poster

  5. “I Speak” language poster

  6. WI Fair Employment Law poster

  7. Non-discrimination statement

4. If any sub-contracts are established, the Health Department will assure that the agency is in compliance with all civil rights laws

5. The Pepin County Maintenance Department will be reasonable for assuring all Americans with Disabilities Act regulations are met.

6. The Finance Director is designated as the Equal Opportunity Coordinator and the Limited English Proficiency Coordinator. This individual has the following responsibilities:


  1. Handling service delivery, employment discrimination, and language access complaints;

  2. Disseminating equal opportunity and language access information to provider staff and interested persons;

  3. Preparing equal opportunity and language access plans and reports;

  4. Acting as a liaison between the provider, DHS, federal agencies and the community;

  5. Monitoring, reviewing and evaluating equal opportunity and language access activities;

  6. Arranging training regarding civil rights, cultural awareness, disability sensitivity, language needs, and other relevant topics

  7. Assuring any sub-contractees are compliant with laws and regulations

Compliant/Grievance Procedures

Pepin County uses the DHS model Discrimination Compliant Forms and Process. The Health Department will assure the following:


  1. the complaint procedures are posted.

  2. All written investigation documents are held confidential.

  3. All participants in complaint investigations are advised and protected from retaliation.

  4. Complaints received will be acknowledged within five calendar days and appeals rights are provided. If an extension is needed, the complainant will be notified.

  5. Results of the complaint investigation will be provided to complainant within 90 days of receipt of the complaint

  6. Corrective action is taken when evidence of discrimination has been found.

  7. Translators, interpreters and/or readers, who meet the communication needs of customers, are provided by the agency during the complaint process.

  8. Customers are permitted to have representatives of their choice during the complaint process.

  9. Complainants and employees are made aware of other venues or redress.

  10. Complainants are informed that the complaint must be filed within 180 days from alleged discriminatory act.

.
EVALUATION:
Director will review for any concerns or complaints.
REFERENCES/LEGAL AUTHORITY:


  • Equal Opportunity in Employment and Service Delivery Policy Statement,

  • Limited English Proficiency Policy Statement

  • Service Delivery or Employment Discrimination Complaint

POLICY TITLE: Conflict Resolution



EFFECTIVE DATE: 7/16/12

DATE REVIEWED/REVISED: 7/16/12

AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director

PURPOSE STATEMENT:



  1. To resolve internal conflicts quickly and to the satisfaction of all parties involved.

  2. To implement a consistent and understood procedure for addressing conflict.



POLICY:
There are several “norms” that are important for resolving workplace conflicts. These norms can be summarized as follows:


  • Address conflict early

  • Respect for both parties

  • Honest and direct communication

  • Emphasis on active listening

  • Problem vs. personality focus

  • Focus on one issue

  • Seek a common goal

  • Talk directly to the other party

Our staff understand the importance of these “norms” and agree to follow the guidelines below when dealing with conflict within the department




PROCEDURE:
Stage One Conflict

A “live and let live” attitude; a high level of respect and trust and a willingness to work toward solutions; conflict is limited to the two people/parties involved.



  1. Participants will talk directly to each other. Face-to-face communication is critical for resolving conflicts. If the people involved in a conflict are reluctant to meet, others will remind them they have an obligation to the well-being of the department and other employees to meet and resolve their differences.

  2. Choose a time and place that works for both people. Find a time when those involved can focus on the issues at hand and an environment that supports effective discussion and problem solving.
  3. Take a listening stance into the discussion. The most effective way for each person to have their concerns heard is to demonstrate their ability to hear the concerns of the other person. Paraphrase what you hear the other person saying before speaking yourself.


  4. Use “I messages” that are clear and specific. “I messages” (like “I felt _____ when you _____ and it resulted in ____.) express how you felt and how you were impacted by the actions of the other person. They are the best way to foster honesty and empathy in a relationship.

  5. Talk it all through. Don’t avoid the big issues. While we may feel more comfortable trying to “patch up” small issues, it is critical that the central issues in the relationship be addressed. Get to the core of the problem.

  6. Identify mutually agreeable solutions. Keep talking until you find solutions that work for both parties. Seek collaborative “win/win” solutions if possible, but settle for compromise if you cannot find a solution where both parties win.

  7. Follow-through is essential. Stay in touch and be sure to implement your agreement. Evaluate how things are working out and stay in dialog so changes can be made, if necessary.




  1   2   3   4   5   6   7   8   9   ...   18


The database is protected by copyright ©hestories.info 2017
send message

    Main page