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TCH Policies



Chapter 0 : Transitional Care Hospital (TCH) Policy Table of Contents

TCH Policy Table of Contents

Chapter 1 : Governance and Leadership

Section 1 : Governance and Leadership

0001 : TCH Policy: Transitional Care Hospital Policy and Administrative Standard Operating Procedures

0005 : TCH Policy: Creating a Tobacco Free Environment at the Transitional Care Hospital

0034 : TCH Policy: Legal Inquiries

0049 : TCH Policy: Management of Transitional Care Hospital Public Space

0066 : TCH Policy: Food and Drink Restrictions

0067 : TCH Policy: Transitional Care Hospital Space Allocation and Reallocation

0105 : TCH Policy: Ethics and Patient Care Consultation

0132 : TCH Policy: The Quality Reporting Process

0217 : TCH Policy: Corporate Compliance Auditing and Monitoring Plan

0223 : TCH Policy: Government and Regulatory Investigation Response

0235 : TCH Policy: Compliance Code of Conduct

0255 : TCH Policy: Mandatory Reporting of Healthcare Practitioners

0279 : TCH Policy: Professional Practice Evaluations for Members of the Clinical Staff

0283 : TCH Policy: Behavioral Code of Conduct

0291 : TCH Policy: Code of Conduct for Providers Who Hold Clinical Privileges

0314 : TCH Policy: Use of Electronic Cigarettes

0315 : TCH Policy: Management of Observers

0320 : TCH Policy: Participation In and Submission of Data to a Patient Safety Organization

Chapter 2 : External Relations

Section 1 : External Relations

0013 : TCH Policy: Vendors, Sales and Service Representatives

0050 : TCH Policy: Patient Visitation

0058 : TCH Policy: Transitional Care Hospital Volunteers

Chapter 3 : Emergency Response

Section 1 : Emergency Response

0172 : TCH Policy: Preventing and Responding to Violence in the Workplace

0187 : TCH Policy: Medical Emergency Response

0265 : TCH Policy: Emergency Response Training

Chapter 4 : Safety, Security, and Environment of Care

Section 1 : Equipment Management

0019 : TCH Policy: Alerts and Recalls of Products, Supplies, Tissues, Devices, Implants and Pharmaceuticals

0055 : TCH Policy: Use of Non-University of Virginia Transitional Care Hospital Equipment

0076 : TCH Policy: Management of Medical Devices Used in Patient Care

0139 : TCH Policy: Cell Phones, Wireless Devices and Other Radio Frequency Producing Equipment

0165 : TCH Policy: Medical Device Failures and Safe Medical Devices Act Reporting

0222 : TCH Policy: Reprocessing and Reuse of Single Use Devices

0254 : TCH Policy: Clinical Alarm Management

0273 : TCH Policy: Use of Transitional Care Hospital Equipment for Non-Transitional Care Hospital Functions

0289 : TCH Policy: Environmental Management and Sustainability Practices

0319 : TCH Policy: Medical Supply Expiration

0327 : TCH Policy: Cardiac Monitoring Orders

Section 2 : General Safety

0054 : TCH Policy: Hazardous Material Spill/Accident Notification

0246 : TCH Policy: Therapy Animal and Pet Visitation

0338 : TCH Policy: Service Animals for Patients and Visitors

Section 3 : Infection Control

0091 : TCH Policy: Infection Prevention and Control

0134 : TCH Policy: Transmissible Bloodborne Pathogens

0290 : TCH Policy: Hand Hygiene

Section 4 : Security Management

0174 : TCH Policy: Regulation of Weapons, Fireworks and Explosives on University Property

0209 : TCH Policy: High Profile Patients

Chapter 5 : Finance and Business

Section 1 : Expenditure Management

0015 : TCH Policy: Travel Reimbursement

0189 : TCH Policy: Transitional Care Hospital Procurement Guidelines

0238 : TCH Policy: Local Funds

Section 2 : Patient Accounting and Billing

0010 : TCH Policy: Billing Deferments/Adjustments

0027 : TCH Policy: Charge Control and Documentation

0059 : TCH Policy: External Review Organizations On-site Payor Reviews

0249 : TCH Policy: International Patients Billing/Collections

Chapter 6 : Human Resources

Section 1 : Human Resources

0117 : TCH Policy: Testing for HIV and Hepatitis Virus Following Certain Exposures to Blood or Body Fluids

0215 : TCH Policy: Employee, Volunteer, and Vendor Background Screening

0242 : TCH Policy: Clinicians' Wellness Program

0262 : TCH Policy: Standards for Professional Behavior

0294 : TCH Policy: The Aging Practitioner

Chapter 7 : Information Management/HIPAA Security and Privacy

Section 1 : Information Services

0030 : TCH Policy: The Use of Cameras and other Electronic Devices and Media

0193 : TCH Policy: Electronic Mail (e-mail)

0244 : TCH Policy: Electronic Medical Record Access Auditing

0266 : TCH Policy: Records Management: Records/Document Retention and Disposition

Section 2 : Patient Information

0084 : TCH Policy: Health Information Request for Non-Patient Care Usage

0092 : TCH Policy: Release of Patients’ Protected Health Information

0201 : TCH Policy: Patient Identification

0218 : TCH Policy: Definition, Characteristics, Authentication and Maintenance of the Medical Record and Designated Record Set

0253 : TCH Policy: Verification for Release of Patient Information

0256 : TCH Policy: Accounting of Disclosures of Protected Health Information

0286 : TCH Policy: Prevention, Detection, and Mitigation of the Theft of Patients' Identities

Chapter 8 : Provision of Care, Treatment, and Service

Section 1 : Admissions, Transfers, and Discharges

0025 : TCH Policy: Discharge Planning

0031 : TCH Policy: Insurance Certification/Authorization Requirements for Planned Services

0039 : TCH Policy: Reservation, Registration, and Admission Requirements for Admissions

0063 : TCH Policy: Internal Inpatient Transfers

0301 : TCH Policy: Orders for Patient Status

Section 2 : Consent

0024 : TCH Policy: Informed Decision-making

0293 : TCH Policy: Disclosure of Outcomes

Section 3 : Patient Rights

0023 : TCH Policy: Loss, Damage or Theft of Patient, Employee or Transitional Care Hospital Property

0070 : TCH Policy: Patient Complaints and Grievances

0094 : TCH Policy: Patient Care Documentation (Electronic Medical Record)

0142 : TCH Policy: Advance Directives

0220 : TCH Policy: Interactions with Law Enforcement Authorities

Section 4 : Special Circumstances of Patients

0098 : TCH Policy: Organ, Tissue and Eye Donation

0192 : TCH Policy: Medical Treatment of Prisoners

0207 : TCH Policy: Organ Procurement in Donors After Cardiac Death

0213 : TCH Policy: Abuse, Neglect or Exploitation of Patients

0219 : TCH Policy: Searching a Patient, Patient’s Belongings, and/or Room (Inpatient)

0321 : TCH Policy: Management of Patients who Leave their Assigned Patient Care Areas

0337 : TCH Policy: Medically and Ethically Inappropriate Treatment is Not Required

Section 5 : Support Services for Patients

0156 : TCH Policy: Language, Interpretive and Other Assistance Services

0269 : TCH Policy: Provision and Documentation of Patient and Family Education

Section 6 : Treatment of Patients

0079 : TCH Policy: Code Status Orders and Associated Treatment Plans

0083 : TCH Policy: Medical Laboratories Specimen Acceptance/Rejection Criteria

0090 : TCH Policy: Consultations

0102 : TCH Policy: Discharges Against Medical Advice

0109 : TCH Policy: Medical Orders for Patient Care

0115 : TCH Policy: Procedures for the Determination of Death By Cardiorespiratory or Neurologic Criteria

0125 : TCH Policy: Reporting of Critical Values and Findings

0146 : TCH Policy: Blood Utilization and Administration

0153 : TCH Policy: Procedural Sedation by Non-Anesthesiology Providers

0159 : TCH Policy: Restraint and Seclusion of Patients

0191 : TCH Policy: Refusal of Treatment

0197 : TCH Policy: Suicide Risk Assessment and Prevention

0203 : TCH Policy: Point of Care Testing

0204 : TCH Policy: Clinical Pathways, Clinical Practice Guidelines, and Protocols

0221 : TCH Policy: Board Certification Requirements for Transitional Care Hospital Providers with Clinical Privileges

0224 : TCH Policy: Provision of Non-Prescription Home Supplies after Discharge

0239 : TCH Policy: Pain Assessment and Management

0250 : TCH Policy: Universal Protocol for Preoperative/Pre-Procedure Verification

0270 : TCH Policy: Death Certificates, Fetal Death Reports and Autopsy

0285 : TCH Policy: Laboratory Testing for Patients Receiving Anticoagulant Therapy

0304 : TCH Policy: Responsibilities of Attending Physicians on Transitional Care Hospital Inpatient Services

0324 : TCH Policy: Clinical Communication and Escalation of Care/Inpatient Services

0330 : TCH Policy: Attending Presence During Invasive Procedures

0334 : TCH Policy: Board Certification Requirements for Advanced Practice Providers

Section 7 : Medication Management

0171 : TCH Policy: Use of a Patient's Own Medications

0212 : TCH Policy: Closed Formulary System

0259 : TCH Policy: Medication Management

0267 : TCH Policy: Administration of Intravenous Medications on Adult Acute and Intermediate Care Units

0268 : TCH Policy: Handling of Hazardous Medications

0299 : TCH Policy: Controlled Substances

0300 : TCH Policy: Medication Reconciliation

0303 : TCH Policy: Pyxis Medication Management

0306 : TCH Policy: Management and Documentation of Allergies in Patient Care

0307 : TCH Policy: Patient Weights

0326 : TCH Policy: Medication Management - Chemotherapy

Chapter 9 : Merged, Migrated & Retired TCH Policies

Section 1 : Migrated Policies

0004 : TCH Policy: Transitional Care Hospital Identification - MIGRATED to Health System Policy ACC-001 Health System Identification

0008 : TCH Policy: Gifts and Gratuities - MIGRATED to Health System Policy BEH-002 Conflict of Interest and Conflict of Commitment

0009 : TCH Policy: Solicitations - MIGRATED to Health System Policy HSG-004 Solicitations

0021 : TCH Policy: Confidentiality of Patient Information - MIGRATED to HS Policy HPA-001 Confidentiality of Patient Information

0026 : TCH Policy: Patient Rights and Responsibilities - MIGRATED to Health System Policy HSG-006 Patient Rights and Responsibilities

0032 : TCH Policy: Acquisition of IT Enabled Resources - MIGRATED to Health System Policy IT-001 Technology Acquisition - Acquisition of IT-Enabled Resources Connecting to Health System Resources

0038 : TCH Policy: Release of Information to the News Media - migrated to Health System Policy INM-002

0041 : TCH Policy: Parking and Enforcement in Controlled Areas - MIGRATED to Health System Policy HSG-007 Parking and Enforcement in Controlled Areas

0051 : TCH Policy: Professional Appearance - MIGRATED to Health System Policy BEH-003 Professional Appearance

0052 : TCH Policy: Bomb Threat Incident - migrated to Health System Policy SAF-001 Emergency Management Procedures

0069 : TCH Policy: Transitional Care Hospital Tours - Migrated to HS Policy ACC-003 Health System Tours

0141 : TCH Policy: Infant/Child Abduction - MIGRATED to Health System Policy SAF-001 Emergency Management Procedures

0150 : TCH Policy: Requests for Restriction of Patient Information - MIGRATED to HS Policy HPA-004 Requests for Restriction of Patient Information

0163 : TCH Policy: Access to Electronic Medical Records and Institutional Computer Systems - MIGRATED to HS IT -002

0166 : TCH Policy: Hostage Incident - MIGRATED to Health System Policy SAF-001 Emergency Management Procedures

0176 : TCH Policy: Access Control to TCH Facilities - MIGRATED to Health System Policy ACC-002 Access Control to Health System Facilities

0194 : TCH Policy: Faxing of Patient Information - MIGRATED to HS INM-003

0202 : TCH Policy: Internet and Intranet Access/Usage - MIGRATED to Health System Policy IT-002

0227 : TCH Policy: Protection of Electronic Information and Information Systems- MIGRATED to HS IT-002

0233 : TCH Policy: Conflict of Interest - Migrated to HS Policy BEH-002 Conflict of Interest and Conflict of Commitment

0245 : TCH Policy: Minimum Necessary Use and Disclosure of Protected Health Information - MIGRATED to HS Policy HPA-002 Minimum Necessary Use and Disclosure of Protected Health Information

0248 : TCH Policy: Amendment of Medical and Billing Records - MIGRATED to HS Policy HPA-003 Amendment of Medical and Billing Records

0251 : TCH Policy: Use and Disclosure of Protected Health Information for General Fundraising Purposes - MIGRATED to Health System HSG-009 Use and Disclosure of Protected Health Information for General Fundraising Purposes

0252 : TCH Policy: Use and Disclosure of Protected Health Information for Marketing and Related Purposes - MIGRATED to HS Policy HSG-010 Use and Disclosure of Protected Health Information for Marketing and Related Purposes

0281 : TCH Policy: Health Screenings and Maintenance for Practitioners who hold Clinical Privileges - MIGRATED to HS Policy OCH-002

0284 : TCH Policy: Alcohol/Drug Free Work Place - MIGRATED to HS Policy BEH-004 Alcohol and Drug Free Environment

0316 : TCH Policy: Management of Student Practicum/Preceptorships - MIGRATED to Health System Policy HSG-008 Management of Student Practicum/Preceptorships

Section 2 : Merged Policies

0014 : TCH Policy: Death Certificates, Consultation/Disposition Forms - MERGED into TCH Policy 0270

0151 : TCH Policy: Patient Choice in Selection of Home Health Agencies - MERGED into TCH Policy 0025

0175 : TCH Policy: Threat Assessment at the Transitional Care Hospital - MERGED into TCH policy 0172

0206 : TCH Policy: Missing/Eloped Adult Patients - MERGED into TCH policy 032

0208 : TCH Policy: Management of Latex Allergy in Patients and Healthcare Workers - MERGED into TCH Policy 0306

0295 : TCH Policy: Patients Leaving Inpatient Care Units - MERGED into TCH policy 0321

Section 3 : Retired Policies

0016 : TCH Policy: Medical Record/Billing Audit - RETIRED Policy

0068 : TCH Policy: Patient Financial Requirements Prior to Scheduling an Inpatient Admission for Elective or Routine Medical Care - RETIRED Policy

0097 : TCH Policy: TCH Bed Assignment - RETIRED policy

0119 : TCH Policy: Tissue Review by Pathology - RETIRED policy

0125 : TCH Policy: Appendix A to TCH Policy 0125 - RETIRED Policy Appendix

0125 : TCH Policy: Appendix A1 to TCH Policy 0125 - RETIRED policy appendix

0140 : TCH Policy: Judicial Treatment Orders - RETIRED policy

0214 : TCH Policy: Medical Screening and Stabilizing Treatment For Emergency Medical Conditions - RETIRED Policy

0216 : TCH Policy: Clinical Use of Large Lumen Catheters - RETIRED Policy

0263 : TCH Policy: Transitional Care Hospital Code of Ethics and Ethics Committee - RETIRED Policy

0272 : TCH Policy: Labeling of Non-IV Tubing - RETIRED Policy

0305 : TCH Policy: General Requirements for Clinicians Holding Clinical Privileges at the Transitional Care Hospital - RETIRED Policy

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