RESIDENT/FELLOW MANUAL 2012-2013 docx

-1- Table of Contents Introduction Section Purpose of This Manual 1.1 Acknowledgment 1.2 Family Medicine Asheville Residents 1.3 Geriatric Medicine Fellows 1.3 Hospice and Palliative Medicine Fellows 1.3 General Practice Dental Residents 1.4 Family Medicine Hendersonville Residents 1.5 Obstetrics and Gynecology Residents .1.6 Faculty 1.7 Institutional Organization Section History of the NC Area Health Education Program 2.1 NC AHEC Map 2.2 History of MAHEC 2.3 Mission Statement 2.4 Diversity Statement 2.5 Strategic Plan 2.6 Organizational Chart 2.7 Facility Locations / Information .2.8 Division of Administration .2.9 Department of Fiscal Services .2.10 Department of Human Resources 2.11 Division of Dentistry 2.12 Division of Family Medicine 2.13 Division of Obstetrics and Gynecology 2.14 Division of Regional Services .2.15 Graduate Medical & Dental Education Policies Section Institutional Commitment to Graduate Medical & Dental Education 3.1 Graduate Medical and Dental Education Committee(s) 3.2 Institutional Master Affiliation and Program Letter of Agreements 3.3 Internal Review of GME Programs & Fellowships 3.4 Eligibility, Selection & Transfer of Applicants 3.5 International Medical Graduates .3.6 Resident Contract/Letter of Agreement 3.7 Licensing, Renewals & Certification 3.8 Nonrenewal & Renewal of Resident/Fellow Contract 3.9 Promotion of Residents 3.10 -2- GME Policies & Procedures Continued Evaluation of Residents, Fellows, Faculty & Program 3.11 Fair Hearing for Resident/Fellow Grievance(s) 3.12 Disciplinary Action and/or Dismissal of a Resident/Fellow 3.13 Counseling and Support Services for Residents/Fellows 3.14 Impairment 3.15 Productive Work Environment .3.16 Resident/Fellow Participation in Educational & Professional Activities3.17 Residents‖/Fellows‖ Organization Forum .3.18 Resident/Fellow Participation in Committees 3.19 Moonlighting .3.20 Leaves of Absences for Residents/Fellows .3.21 Medicare Supervision of Residents by Teaching Physicians 3.22 Supervision of a Residents/Fellows .3.23 Resident/Fellow Files - Content, Access & Retention .3.24 Resident/Fellow Anonymous Evaluation of Compliance 3.25 Dress Code 3.26 Personal Appearance 3.27 Margaret R Pardee Memorial Hospital / Dress Code .3.28 Margaret R Pardee Memorial Hospital / Meals .3.29 Margaret R Pardee Memorial Hospital / Medical Record 3.30 Mission Hospital / Dress & Appearance 3.31 Mission Hospital / Resident Meals 3.32 Mission Hospital/ Completion of Medical Records 3.33 Continuation of Benefits after leaving MAHEC 3.34 Non-Competitive Agreement 3.35 Reduction in Size or Closure of the GME & Dental Program(s) 3.36 Duty Hours and Work Environment for Residents/Fellows 3.37 Exception in Weekly Limit on Duty Hours 3.38 Annual Reports to Organized Medical Staffs 3.39 Transferring Residents/Fellows as a Result of Disaster 3.40 Interactions between Vendors and GME Programs 3.41 Accommodation for Disabilities 3.42 International Travel 3.43 Third Party Comments 3.44 Complaints 3.45 Record Review 3.46 Appropriate Treatment of Residents and Medical Students 3.47 Resident & Fellow Fatigue and Stress 3.48 Benefits Section Professional Liability Insurance .4.1 Health and Dental Insurance for Residents .4.2 Flexible Benefits Plan .4.3 -3- Benefits Continued Life Insurance/Accidental Death and Dismemberment 4.4 Certificates of Prior Coverage under the Plan 4.5 Long-Term Disability Insurance 4.6 Mental Health Benefits 4.7 Workers Compensation 4.8 Educational Funds 4.9 Licensing Fees Paid 4.10 United Services Credit Union .4.11 Pre-Paid Legal Services 4.12 Additional Benefits .4.13 General MAHEC Policies and Procedures Section Employment Verification/References 5.1 Salaries 2012-2013 5.2 Payday/Payroll Deductions .5.3 Direct Deposit of Payroll 5.4 Eating Facilities 5.5 Building Closings 5.6 Smoking 5.7 Illegal Drugs 5.8 Employee Assistance Program (EAP) .5.9 Risk Management, Corporate Compliance & Safety Office 5.10 Deficit Reduction Act & the False Claims Policy 5.11 Security .5.12 Incident Report 5.13 Risk Management Top Ten List .5.14 Claims/Lawsuits vs MAHEC Staff 5.15 Confidentiality Policy 5.16 Media and Public Relations 5.17 MAHEC Drug & Alcohol Free Workplace 5.18 Vehicle Insurance Coverage 5.19 Travel Policy and Procedure 5.20 Program Requirements Section ACGME Common Program Requirements ACGME Institutional Requirements RRC Family Medicine Program Requirements RRC Geriatric Medicine Fellowship Program Requirements RRC Hospice and Palliative Medicine Fellowship Program Requirements RRC Obstetrics and Gynecology Program Requirements CODA Standards Index Section Manual Index -4- 1.1 PURPOSE OF THIS MANUAL This manual contains current GME and GPR policies, ACGME Institutional and Program Requirements, CODA Requirements, MAHEC employee policies and benefits, and other general information for you as a MAHEC employee You should familiarize yourself with the manual and use it as a reference The Resident Physician & Dentist Contract/Letter of Agreements, state laws, ACGME Institutional and Program Requirements, CODA Requirements, and policies and procedures of MAHEC and GME/GPR formally specify terms of employment 1.2 ACKNOWLEDGMENT Pertinent information is contained in the resident manual to help make your orientation and your residency training goes smoothly Comments and/or suggestions for making this manual more useful are encouraged For our records, please sign below to verify that you were notified that the resident manual is available online with hard copies available in the GME office and in each program office I have been notified of how to access a copy of the MAHEC Resident Manual that outlines the benefits and policies related to the graduate medical and dental education programs and personnel of MAHEC I will familiarize myself and comply with the information contained in the manual The information in this manual is subject to change as situations warrant; I understand that changes may supersede, modify, or eliminate the policies in this manual The organization has a responsibility for keeping me informed of policy changes through my supervisor or through official notices There exists at all times an implied mutual trust in this agreement In the event that I need clarification on any policy, I understand it is my responsibility to contact my Program Director or the Graduate Medical and Dental Education office for assistance Nothing in this document will diminish or abrogate the responsibility and authority of the Director of the Residency Program(s) subject to MAHEC, NC AHEC Program, and UNC-CH policies and authorities related to graduate medical and dental education I understand I have an obligation to inform my supervisor or manager and the Department of Human Resources/Risk Management of any changes pertaining to my employment or employment benefits SAMPLE Signature Date -5- 1.3 FAMILY MEDICINE ASHEVILLE RESIDENTS / 2012-2013 First Year Jessica Anewalt, MD Samantha Fawcett, MD Helen Travis Paulson, MD Jesse Pace, DO Kate Rasche, MD Meredith Soles, MD Bart Steen, MD Matthew Swanson, MD Genevieve Verrastro, MD Medical School Saint Louis University School of Medicine University of Iowa Roy J & Lucille A Carver College of Medicine Florida State University College of Medicine Arizona College of Osteopathic Medicine of Midwestern University Albert Einstein College of Medicine of Yeshiva University University of North Carolina at Chapel Hill School of Medicine University of North Carolina at Chapel Hill School of Medicine University of Washington School of Medicine University of Massachusetts Medical School Second Year Yu Kwan Chan, MD Rebecca Cramer, MD Jan Esker, MD Julia Oat-Judge, MD James Romano, MD Bruce Ulrich, MD Vince van Acht, MD Bryant Ward, MD Liza Young, MD Medical School University of Maryland School of Medicine University of Wisconsin School of Medicine and Public Health Ohio State University College of Medicine Johns Hopkins University School of Medicine Drexel University College of Medicine University of Illinois College of Medicine West Virginia University School of Medicine The Brody School of Medicine at East Carolina University Ohio State University College of Medicine Third Year Christina McDonald, MD Susan McDowell, MD Lisa Niedergeses, MD Elsie Osei-Nkansah, MD Ginger Poulton, MD Timothy Poulton, MD Eric Smith, MD Benjamin Stepp, MD Susan Wilhoit, MD Medical School Georgetown University School of Medicine Virginia Commonwealth University School of Medicine University of Iowa East Tennessee State University University of Michigan Medical School University of Michigan Medical School East Tennessee State University University of North Carolina Chapel Hill University of Louisville School of Medicine Geriatric Fellows Matthew Moye, DO Blythe Winchester, MD Medical School Edward via Virginia College of Osteopathic Medicine University of North Carolina Chapel Hill Hospice & Palliative Medicine Fellow Alhley Albers, DO Medical School AT Still University-Kirksville College of Osteopathic Medicine -6- 1.4 GENERAL PRACTICE DENTAL RESIDENTS / 2012-2013 Dentist Ashton Janet Butler, DDS Marissa DeAngelis, DDS Garrick McGrath, DMD Britney Taylor, DDS 1.5 Dental School University of Maryland Baltimore College of Dental Surgery Virginia Commonwealth University School of Dentistry Georgia Health Sciences University College of Dental Medicine University of Tennessee College of Dentistry FAMILY MEDICINE HENDERSONVILLE RESIDENTS / 2012-2013 First Year Ryan Eichhorn, DO Harry Holt, MD Cristin O‖Grady, MD Medical School Edward via Virginia College of Osteopathic Medicine Eastern Virginia Medical School Tufts University School of Medicine Second Year Adrian Mancheno, MD Amanda Maxwell, MD Brent Meadows, DO Medical School Pontificia Universidad Catolica del Ecuador University of North Carolina School of Medicine Chapel Hill Philadelphia College of Osteopathic Medicine Third Year Evan Beasley, MD Anibal Martinez, MD Grey Tilden, MD Amanda Williams, DO Medical School Louisiana State University Universidad de La Republica University of Alabama Pikeville College School of Osteopathic Medicine -7- 1.6 OBSTETRICS AND GYNECOLOGY RESIDENTS / 2012-2013 First Year Laurel Berry, MD Breanna Bolivar, MD Jon Larrabee, MD Karen Wang, MD Medical School Florida State University College of Medicine Wright State University Boonshoft School of Medicine Oregon Health and Science University School of Medicine University of Maryland School of Medicine Second Year Jennifer Bliss, MD Sarah Bradley, MD Regan Gage, MD Jonathan Freeman, MD Medical School University of Texas School of Medicine University of Missouri School of Medicine George Washington University School of Medicine Texas Tech University Third Year Elizabeth England, MD Bennett Gardner, MD Nathaniel Jones, MD Richard Loftis, MD Medical School East Tennessee State University Medical College of Georgia East Tennessee State University Medical College of Georgia Fourth Year Rongrong Fan, MD Brandi Spence, MD Medical School Columbia University College of Physicians and Surgeons Loma Linda University School of Medicine -8- 1.7 FACULTY Family Medicine Residency - Asheville Faculty Mike Coladonato, MD Blake Fagan, MD Dan Frayne, MD Benjamin Gilmer, MD Melissa Hicks, MD Stephen Hulkower, MD Suzanne Landis, MD Eric Pyeritz, MD Lisa Ray, MD John Rowe, MD Adjunct Faculty Walter Accles, PA Mary Lynn Barrett, LCSW Bill Hitch, PharmD Valerie Krall, LPC, LPA Maggie Weshner, EdD Courtenay Wilson, PharmD Geriatric Medicine Fellowship Program Faculty Amy Cohen, MD Neil Garroway, MD Anna Hicks, MD Tim Plaut, MD Hospice and Palliative Medicine Fellowship Faculty John P Langlois, MD Jennie Barnhardt, MD Darilyn Dealy, MD Dan Mackey, MD Jeff Stillson, MD Marianne Soufas, MD Jeffrey Tait, MD Carlos A Vargas, MD Adjunct Faculty Kate Zurich, PA-C Courtenay Wilson, PharmD Maggie Weshner, EdD Family Medicine Residency - Hendersonville Faculty Steve Crane, MD Diana Curran, MD Bryan Hodge, DO Richard Hudspeth, MD Geoffrey Jones, MD Hayam Shaker, MD Natascha Lautenschlaeger, MD Andrew Morris, MD Magdalena Michael, MD Adjunct Faculty Barbara Davenport, CNM Martha Dysart, CNM Vicki Fleury, CNM Jim Hall, PhD Lynne Parsons, PsyD Deb Phillips, LCSW Beth Saft, DO Cynthia Van Deusen, FNP, GNP Ruth Christos, FNP Susan McKenney, FNP General Practice Dental Residency Faculty Ed Coryell, DDS William T Ryals, Jr., DMD Adjunct Faculty Bill Hitch, PharmD, BCPS Obstetrics & Gynecology Residency Faculty Elizabeth A Buys, MD Carol C Coulson, MD Andrea F Currens, MD Casey Graybill, MD Ursula Harkness, MD Margaret A Harper, MD James Holman, MD Kellett Letson, MD Arthur Ollendorff, MD Kiran Sigmon, MD Allen H Van Dyke, MD Jennifer Warren, MD Adjunct Faculty Ann Brown, CNM, MSN Dolly Pressley Byrd, CNM Alison Christopher, CNM Shelley Galvin, MA Elizabeth Korb, CNM, MSN Susan Meade, FPNP Mollie Milner, MSW, LCSW Amanda Murphy, CNM Linda Rowe, RN, LCSW - 104 - 5.14 RISK MANAGEMENT TOP TEN LIST TOP TEN REASONS TO CONTACT MAHEC RISK MANAGEMENT subpoenas, court orders, a summons/complaint, and deposition requests request for records or other patient information for purposes other than payment, treatment or operations such as from an attorney, auditor, social worker, law enforcement agent inquires or requests by governing boards, law enforcement agents for example, NC Medical Board, NC State Board of Dental Examiners, Blue Cross/Blue Shield (investigation/audit), Medicare/Medicaid, Sheriff‖s Department, DSS written or verbal complaints/threats by patients or family members errors or delays in diagnosis/treatment anticipated or unanticipated adverse outcomes disease/blood borne pathogen exposure, employee injury informed consent issues; who has authority to sign consent; failure to obtain informed consent breach of confidentiality 10 discharge of patients from practice CONTACT RISK MANAGEMENT AT (828) 257-4415 OR (828) 257-4408 - 105 - 5.15 CLAIMS/LAWSUITS VS MAHEC STAFF POLICY PURPOSE: In the healthcare industry, it is important to recognize that the organization and its personnel may be subject to claims/lawsuits arising out of the delivery or nondelivery of services The purpose of this policy is to provide a set of guidelines to use when this occurs POLICY: It is the policy of the Mountain Area Health Education Center to support current and former staff when they are named in claims/lawsuits arising out of their employment PROCEDURE: Below are the guidelines that should be followed when a current or former MAHEC employee is named in a claim/lawsuit arising out of his/her employment I Claim/Lawsuit A Notification/Representation The staff member should notify his/her supervisor and MAHEC Risk Management immediately upon receiving notice that he/she is named in a claim/lawsuit If the office of the President/CEO or MAHEC Risk Management is served with the claim/complaint, Risk Management shall immediately notify all MAHEC parties involved MAHEC Risk Management will discuss the claim/lawsuit with the President/CEO after which other MAHEC staff and appropriate MAHEC insurance/legal representatives may be consulted Risk Management will also be responsible for coordinating the securing of records and/or requests for information The employee named in the claim/lawsuit will be provided legal representation through the appropriate MAHEC insurance coverage unless the act complained of is not covered In such cases, the President/CEO will determine whether legal representation is to be provided Any employee named in a claim/lawsuit may obtain legal/insurance representation from another provider; however, unless otherwise approved by the President/CEO MAHEC will not cover any expenses associated with such representation B Settlement Negotiations The President/CEO and MAHEC Risk Management will discuss the feasibility of defending/settling the claim/lawsuit with the appropriate MAHEC insurance/legal representatives and MAHEC staff named in the complaint Other MAHEC staff (i.e faculty) may also be consulted The President/CEO will make the final decision The President/CEO and Risk Management will discuss the appropriateness of reporting payments to the National Data Bank with the appropriate MAHEC insurance/legal representatives and MAHEC staff during settlement negotiations - 106 II Professional Review/Licensing Board/Insurance Agencies If a member of the MAHEC staff is requested to appear before or respond to a professional review/disciplinary/licensing board/insurance agency, etc inquiry, the staff member should notify his/her supervisor and MAHEC Risk Management immediately Risk Management will discuss the request with the President/CEO after which appropriate MAHEC staff and insurance/legal representatives may be consulted If the employee is requested to submit a written response or other information, MAHEC Risk Management should review the response/information before it is released If the employee is requested to appear before a professional review board, he/she may request that MAHEC provide him/her with legal representation Recognizing that the situation may potentially be adversarial between MAHEC and the employee, the President/CEO will determine if legal representation is appropriate The employee may obtain legal representation on his/her own; however, unless otherwise approved by the President/CEO, any costs associated with such representation will be the responsibility of the employee The employee must keep his/her supervisor and Risk Management informed of the status of the request and the ultimate outcome III Other Incidents If a MAHEC staff member receives a subpoena or other formal request for information that involves a patient/customer/employee where unexpected/unintended outcomes have occurred, an incident report should be completed and MAHEC Risk Management consulted before information is released Examples may include: letters/correspondence from health insurers, attorneys, patients/patient‖s family, Department of Social Services Risk Management will review the request and determine if other staff and/or insurance/legal representatives should be consulted IV Questions If you have questions about this policy, please call Risk Management at 257-4415 - 107 - 5.16 CONFIDENTIALITY POLICY The organization recognizes that employees often come in contact with highly personal and confidential information about patients, employees, students, faculty, vendors as well as the organization It is important that the organization have standards regarding the release of such information Employees are expected to abide by all MAHEC policies and procedures regarding confidentiality, as outlined in the Standards of Conduct and the HIPAA Privacy and Security Regulations as it applies to protected health information; the MAHEC Confidentiality Statement, and all other policies or procedures which relate to confidential issues This includes employee information, (i.e salary, insurance, home phone, address, date of birth, social security number, personnel actions) which are also confidential and should not be discussed or released without the employee's consent or as necessary to perform the responsibilities of your job Any unauthorized disclosure or misuse of confidential information may be cause for serious disciplinary action, including immediate termination This includes all forms of communication, for example, letters, memorandums, facsimiles, electronic mail, conversations in person and by phone - 108 - MAHEC CONFIDENTIALITY STATEMENT I understand that all patient information is the same as “protected health information (PHI)” and includes, but is not limited to: any information that is protected under state or federal law, including all medical, dental, and personal information concerning MAHEC patients; information regarding the provision of services or submissions of claims; any document containing a patient’s name or identification number; any information that identifies an individual and relates to past, present or future physical, dental, or mental health condition or care; information about billing or payment of health care services for an individual; information about eligibility or enrollment of an individual for services I agree to hold PHI in the strictest confidence and to not disclose or use PHI except as necessary for me to perform my customary and regular job duties I will only access PHI for which I have a legitimate business and/or clinical need to know; I shall only discuss PHI with or disclose to persons outside the specific medical or dental office where I work provided the disclosure is consistent with MAHEC’s Notice of Privacy Practices and HIPAA Privacy and Security Policies and Procedures; I shall only discuss PHI with or disclose to persons inside the medical or dental office where I work for the purpose of treatment, billing and MAHEC operations consistent with MAHEC’s Notice of Privacy Practices and HIPAA Privacy and Security Policies and Procedures Discussions shall not held in areas where unauthorized persons can overhear the conversation I agree that I will not access my own and/or family members PHI, which includes billing information I agree to hold employee information (i.e salary, insurance, home phone, address, date of birth, social security number, etc.) and student information in the strictest confidence and to only use or disclose employee and student information in accordance with MAHEC’s Policies and Procedures I may have access to Medicare/Medicaid customer and claims information which is subject to the provisions of the Freedom of Information Act I agree to use this information only in connection with the determination of eligibility and payments of Medicare/Medicaid and not to misuse or disclose this information to unauthorized persons If I not comply, I may be subject to the criminal penalties in section 1106(a) of the Social Security Act which state that I shall be deemed guilty of a felony and, upon conviction thereof, shall be punished by a fine not exceeding $10,000 for each occurrence of a violation, or by imprisonment not exceeding five (5) years, or both I understand that noncompliance is also a violation of the Privacy Act of 1974, as amended and carries a criminal penalty of a misdemeanor and fine of not more than $5,000 I understand and acknowledge that failure to comply with the obligations contained in this Confidentiality Statement will result in disciplinary action, up to and including immediate termination I further agree that the obligations contained in this Confidentiality Agreement will continue after termination of employment I have read this statement and agree to the requirements _ Name Printed _ Employee Signature Date - 109 - 5.17 MEDIA AND PUBLIC RELATIONS POLICY PURPOSE: To define MAHEC‖s policy and procedures in working with regional, state, and national television, radio, and print media POLICY: MAHEC is committed to the enhancement of excellent working relationships with the media in initiating or responding to requests from the media for information and/or attending programs sponsored by MAHEC PROCEDURES: The President/CEO or Director of Marketing will designate institutional representatives to work with the media When MAHEC is contacted by representatives of the media: If a MAHEC employee is contacted by the media for an interview, consultation with the Director of Marketing or the President/CEO will be made prior to confirming the interview when possible When prior consultation is not possible, the MAHEC employee will use his or her best judgment in talking with the media and will inform the Director of Marketing or President/CEO after the interview When a media representative asks in advance to participate in a MAHEC activity, the President/CEO or the Director of Marketing should be informed of the request, and permission will be obtained from the faculty or consultant providing the program or service for MAHEC and participants involved in the activity, including permission for photographs or videotaping(s) When a media representative attends a MAHEC activity without prior notice, the director or coordinator of the activity will work with the media representative, faculty or consultant, and participant(s) in the most facilitative way possible to obtain permission(s) from those involved, including for photographs or videotaping(s), and to provide the information requested by the media representative If written information is requested by the media representative, such as evaluations of a MAHEC activity, permission from the faculty or consultant will be obtained before information or documentation is released When MAHEC initiates contact with the media: Copies of the press releases will be forwarded to the Director of Marketing and the President/CEO The Director of Marketing or the President/CEO will be consulted when requesting news coverage of a MAHEC activity and appropriate permission(s) obtained when necessary - 110 - 5.18 DRUG & ALCOHOL FREE WORKPLACE POLICY PURPOSE: To protect employees, patients, visitors, and students from risks of accident or injury, MAHEC will provide and maintain a drug- and alcohol-free workplace in keeping with our values and goals POLICY STATEMENT: It is the policy of the Mountain Area Health Education Center (MAHEC) that all employees will observe the rules and procedures for a drug- and alcoholfree workplace laid out in this policy MAHEC encourages any employee with a substance abuse problem to voluntarily seek help from the MAHEC Employee Assistance Program (EAP) Prohibited Employee Conduct The following conduct is prohibited and violations will result in appropriate disciplinary action ranging from a mandatory referral to the Employee Assistance Program (EAP) to termination: A Unauthorized use, possession, manufacture, distribution, intent to sell, or sale of illegal drugs in any MAHEC workplace (i.e., offices, clinics, classrooms, restrooms, vehicles), or while “on duty” as defined in this policy B Being “under the influence” of alcohol or a legal or an illegal drug while “on duty.” C The consumption or possession of alcoholic beverages while “on duty” or on MAHEC property, with the following Exceptions: a Consumption of authorized beer, wine, and other alcoholic beverages served to visitors or guests at MAHEC-sponsored events b Possession of wine or alcohol intended as gifts or for MAHEC- sponsored events c Storage of alcoholic beverages in a personal vehicle on MAHEC property d Other exceptions specifically authorized by the President/CEO of MAHEC or designee D Failing to report an “on duty” accident resulting in damage to property or personal injury E Refusing to be tested when authorized by this policy F Altering or falsifying a screening/testing sample G Refusing to participate or cooperate with a mandatory referral to the EAP NOTE: In addition, a conviction or plea of nolo contendere to an alcohol- or drugrelated criminal offense may result in appropriate disciplinary action - 111 - Reasonable Suspicion Testing/Screening of Employees A When the Human Resources Director or designee determines there is reasonable suspicion, as defined in this policy, that any employee “on the job” is under the influence of legal or illegal drugs or alcohol, the employee will be tested B Reasonable suspicion, as defined in this policy, must be based on specific, objective facts, or reasonable inferences drawn from facts, which would cause a reasonable person to suspect that the employee is under the influence of drugs or alcohol Screening/Testing Procedure A Any employee or other individual raising an issue of reasonable suspicion should contact the Director of Human Resources or designee If appropriate, (1) the completion of at least two, independent, Reasonable Suspicion Observation Forms verifying behaviors that support a request for drug and/or alcohol testing will be coordinated; (2) the employee to be tested and his/her supervisor will be notified; (3) drug and/or alcohol testing will be approved/disapproved, and (4) if approved, transportation of the employee to and from the testing laboratory will be arranged B After the specimen collection and screening is completed, the employee will be transported to an appropriate location The employee should not return to work until results of the drug and/or alcohol testing have been received by the Director of Human Resources or designee, reported to the employee and employee‖s supervisor, and next steps determined C The laboratory will report test results directly to the Director of Human Resources or designee The Director of Human Resources or designee is responsible for notifying the employee and the employee‖s supervisor of the test results Appropriate next steps will be determined at that time – provided, of course, that the Human Resources Director (or designee) has been consulted prior to any disciplinary action begin taken D In the event of a positive drug test result, an employee may request a second, independent drug test at a certified laboratory This additional test, at the employee‖s expense, must be done within twenty-four (24) hours of the original test results with remaining samples (if urine or blood are to be retested) taken at the time of the first test E After-Hours Testing If reasonable suspicion testing is authorized pursuant to Section 3.1 of this policy while a MAHEC employee is “on duty” between the hours of p.m to a.m Monday – Friday, or anytime during Saturday or Sunday: the employee will be escorted to the emergency Room designated by the Human Resources Director (e.g., Mission Hospital, Pardee Hospital) for testing; following the sample collection for testing, the employee will be escorted home or to another appropriate location; and the employee will not return to work until notified - 112 - 5.19 VEHICLE INSURANCE COVERAGE FREQUENTLY ASKED QUESTIONS Definition: Automobile Physical Damage Loss of or damage to an automobile Automobile physical damage coverage is provided by comprehensive and collision coverage in an auto policy Comprehensive provides coverage for losses caused by events, other than collision, including fire, theft, vandalism, and windstorm Collision provides coverage for losses arising from a collision with another vehicle, object or animal (i.e a deer) Does MAHEC’s insurance policy cover me while I am conducting MAHEC business using my personal vehicle? There are several parts to this question Workers‖ compensation covers MAHEC employees who have an accident and are injured in the course of doing business for MAHEC regardless of fault There are certain exceptions to this coverage (i.e employee is under the influence of drugs/alcohol at the time of accident, etc.) If your vehicle is damaged in an accident which is your fault: MAHEC‖s policy will not cover damage to your vehicle; only your personal insurance will—provided you carry collision/comprehensive If another vehicle is damaged in an accident that is your fault: MAHEC‖s policy will not cover damage to another vehicle unless MAHEC is liable as the employer and this would only be for another vehicle or persons injured over and above your personal insurance limits The same is true for any personal injury to another that results from your negligence If your vehicle is damaged in an accident that is someone else‖s fault: The insurance coverage of the person at fault would cover your vehicle If that person is uninsured or underinsured, your personal insurance would apply—MAHEC coverage would not If I am transporting MAHEC equipment/property in my vehicle and my vehicle gets damaged in the process (i.e the seat gets torn), does MAHEC’s insurance policy cover this? No, you would need to file a claim for your vehicle‖s damage with your personal insurance Would MAHEC’s insurance policy cover theft/damage of MAHEC equipment/property in my car? Yes - 113 Would MAHEC’s insurance policy cover theft/damage of my personal belongings—out of my car or a MAHEC vehicle? No, you would need to file a claim with your insurance company Does MAHEC’s insurance policy cover me while I am driving a MAHEC vehicle? Yes If property damage/personal injury results from an accident that is your fault, you and MAHEC are covered under the liability If property damage/personal injury result from an accident that is another‖s fault and that driver is underinsured or uninsured, you and MAHEC are covered under the endorsement for underinsured/uninsured motorists Are passengers covered while riding in MAHEC vehicles? Yes MAHEC‖s policy has $10,000 medical pay coverage; this covers any passenger up to $10,000 per person If injuries sustained lead up to more than $10,000 it becomes a bodily injury claim and is covered under MAHEC‖s liability insurance if the accident was caused by negligence of MAHEC or the person driving on behalf of MAHEC Is my vehicle covered if damage occurs in the MAHEC parking lot? No, your own automobile/homeowner‖s insurance would have to cover this damage The only exception to this would be if a MAHEC vehicle does the damage If I am renting/leasing a vehicle for MAHEC business, should I purchase additional insurance for the vehicle? No, MAHEC has coverage on any vehicle that you rent/lease for use when conducting MAHEC business but only if it is leased in MAHEC‖s name, not your own What I if I am involved in a vehicle accident? Below are procedures for MAHEC employees to follow when they are involved in vehicle accidents while conducting MAHEC business This includes any vehicle (MAHEC, rental, personal)! Questions regarding these procedures should be directed to Risk Management at (828) 257-4415 or 257-4408  In the case of an accident, if there are no injuries and the vehicle is drivable, move your vehicle to the shoulder of the road or another safe place Once you have moved your car to the side of the road, contact law enforcement by dialing 911  Do not admit fault Make no commitments and not argue with anyone at the scene  Complete a MAHEC Incident Report within one business day of accident Attach the police report to Incident Report and send to Risk Management  If the accident caused a MAHEC employee riding in the vehicle bodily injury, Workers‖ Compensation guidelines must be followed - 114 - 5.20 TRAVEL POLICY AND PROCEDURE Listed below are the four basic components of travel for which reimbursement will be made You may obtain further details and the complete travel policy that includes a list of approved one-way and round-trip mileage totals along with the proper forms by contacting Fiscal Services or your Program Coordinator Transportation This includes the use of any common carrier (such as scheduled airline, rail or bus), privately owned vehicle or airplane, or rented vehicle Mileage is reimbursed for your privately owned vehicle at the rate $0.405 per mile as of January 1, 2005 Subsistence This is reimbursed on a standard, per meal, basis, limited to the following rates: Breakfast Lunch Dinner In-State $ 6.00 $ 8.00 $14.00 Out-Of-State $ 6.00 $ 8.00 $16.00 Registration Fees Other Expenses Including business telephone calls, baggage handling tips, parking fees or other business expenses, but does not include personal expenses, including tips for the service of meals PLEASE REMEMBER THAT ORIGINAL RECEIPTS ARE NEEDED FOR ALL EXPENSES EXCEPT FOR MEALS - 115 - 6.1 PROGRAM REQUIREMENTS ACGME Common Program Requirements http://www.acgme.org/acWebsite/dutyHours/dh_dutyhoursCommonPR07012007.pdf ACGME Institutional Requirements http://www.acgme.org/acWebsite/irc/irc_IRCpr07012007.pdf ACGME RRC Family Medicine Requirements http://www.acgme.org/acWebsite/RRC_120/120_prIndex.asp ACGME RRC Geriatric Medicine Fellowship Program Requirements http://www.acgme.org/acWebsite/RRC_120/120_prIndex.asp ACGME RRC Hospice and Palliative Medicine Fellowship Program Requirements http://www.acgme.org/acWebsite/RRC_120/120_prIndex.asp ACGME RRC Obstetrics and Gynecology Program Requirements http://www.acgme.org/acWebsite/RRC_220/220_prIndex.asp CODA General Practice Residency Standards http://www.ada.org/sections/educationAndCareers/pdfs/gpr.pdf - 116 - 7.1 INDEX Topic Page No Accommodation for Disabilities 77 Acknowledgment .4 Additional Benefits 91 Annual Reports to the Organized Medical Staffs 72 Appropriate Treatment of Residents and Medical Students Policy .81 Building Closings / Weather Emergencies 94 Certificates of Prior Coverage under the Plan 88 Claims/Lawsuits vs MAHEC Staff .105 Complaints (GPR) 80 Confidentiality Policy .107 Continuation of Benefits after Leaving MAHEC 65 Counseling and Support Services for Residents/Fellows 42 Deficit Reduction Act and the False Claims Policy 101 Department of Fiscal Services 16 Department of Human Resources .17 Direct Deposit of Payroll 92 Disciplinary Action and/or Dismissal of a Resident/Fellow 41 Diversity Statement 11 Division of Administration 15 Division of Dentistry 17 Division of Family Medicine 17 Division of Obstetrics and Gynecology 20 Division of Regional Services .22 Dress Code 60 Drug & Alcohol Free Workplace Policy 110 Duty Hours and Work Environment for Residents & Fellows 67 Eating Facilities 93 Educational Funds 88 Eligibility, Selection & Transfer of Applicants for Residency/Fellowship 29 Employee Assistance Program (EAP) Policy 96 Employment Verification/References 92 Evaluation of Residents, Fellows, Faculty and Program .38 Exception in Weekly Limit on Duty Hours 72 Facility Locations / Information 14 Faculty Fair Hearing for Resident/Fellow Grievance(s) 39 - 117 Topic Page No Family Medicine Residents - Asheville Family Medicine Residents - Hendersonville Flexible Benefits Plan 87 General Practice Dental Residents Geriatric Fellows Geriatric Medicine Fellowship Program .18 Graduate Medical & Dental Education Committee(s) 25 Health and Dental Insurance for Residents 86 History of MAHEC .11 History of the NC Area Health Education Program .10 Hospice and Palliative Medicine Fellows .5 Hospice and Palliative Medicine Fellowship Program .19 Illegal Drugs 95 Impairment 44 Incident Report 103 Institutional Master Affiliation & Program Letter of Agreements 26 Institutional Commitment to GME/GPR 23 Interactions between Vendors and GME Programs 75 Internal Review of GME Programs/Fellowships 28 International Medical Graduates 31 International Travel 77 Leaves of Absences for Residents .51 Licensing Fees Paid 90 Licensing, Renewals, and Certification .32 Life Insurance/Accidental Death and Dismemberment 88 Long-Term Disability Insurance 88 Margaret R Pardee Hospital / Dress Code 61 Margaret R Pardee Hospital / Meals 62 Margaret R Pardee Hospital / Medical Record 63 NC AHEC Map 10 Media and Public Relations 109 Medicare Supervision 56 Mental Health Benefits .88 Mission Hospital / Completion of Medical Records 65 Mission Hospital / Dress & Appearance 64 Mission Hospital / Resident Meals 64 Mission Statement 11 Moonlighting .49 Non-Competitive Agreement 66 Nonrenewal & Renewal of Resident/Fellow Contract 35 Obstetrics and Gynecology Residents Organizational Chart 13 Payday/Payroll Deductions 92 Personal Appearance 60 - 118 Topic Page No Pre-Paid Legal Services 91 Productive Work Environment 44 Professional Liability Insurance 85 Program Requirements 115 Promotion of Residents 37 Purpose of This Manual .4 Record Review (GPR) 81 Reduction in Size or Closure of the GME/GPR Program(s) 66 Resident Anonymous Evaluation of Compliance 60 Resident Contract/Letter of Agreement .32 Resident & Fellow Fatigue and Stress 83 Resident/Fellow Files - Content, Access & Retention 58 Resident Participation in Committees 48 Resident Participation in Educational & Professional Activities 47 Residents‖/Fellows‖ Organization Forum 48 Risk Management, Corporate Compliance & Safety Programs .98 Risk Management Top Ten List 104 Salaries 2012-2013 92 Security 102 Smoking 95 Strategic Plan .12 Supervision of a Resident Physician 57 Third Party Comments (GPR) .80 Transferring Residents/Fellows as a Result of Disaster 73 Travel Policy and Procedure 114 United Services Credit Union .91 Vehicle Insurance Coverage .112 Workers Compensation 89 ... Gynecology Program Requirements CODA Standards Index Section Manual Index -4- 1.1 PURPOSE OF THIS MANUAL This manual contains current GME and GPR policies, ACGME Institutional and Program... contained in the manual The information in this manual is subject to change as situations warrant; I understand that changes may supersede, modify, or eliminate the policies in this manual The organization... unless the resident/fellow authorizes the release of it If a resident/fellow is referred to or accesses counseling and support services outside the EAP, expenses are the responsibility of the resident/fellow