Written Policies, Protocols and Procedures of Delegate Agencies

Section 635 Section 635.80  Written Policies, Protocols and Procedures of  Delegate Agencies a)         The delegate agency must develop written policies, protocols and procedures for family planning services.  Written policies, protocols and procedures under which physicians, nurse practitioners, certified nurse midwives, physician assistants and nutritionists provide family planning  services must be approved by the delegate agency's medical director. b)         Policies regarding eligibility for services shall not exclude anyone on the basis of duration of residency, age, race, marital status, religion, color, national origin, creed, handicap, sex, number of pregnancies, method of referral, or contraceptive preference.  Services shall be provided only on a voluntary basis.  These documents shall be updated as needed based on current state of the art in family planning and Federal and State Regulations.  Agency protocols will be subject to intensive review at site visits by Department staff to determine their completeness and compliance with this Part. c)         Written policies, protocols and procedures must include: 1)         Intake procedures for new clients 2)         Patient education 3)         Obtaining written informed consent 4)         Schedule and content of visits A)        Initial B)        Annual C)        Scheduled return visits, specific to type of method of contraception D)        Problem visits, specific to type of problem 5)         Counseling procedures 6)         Referral procedures 7)         Follow-up procedures for appointments, failed appointments, and referrals 8)         Maintenance of client records 9)         Approved medical orders 10)         Maintenance and distribution of pharmaceuticals 11)         Organizational structure of the unit and functional responsibilities of medical, nursing and ancillary personnel 12)         Medical Procedures A)        Pap smears and gonorrhea cultures B)        Intrauterine device (IUD) insertions C)        Fitting diaphragms/cervical caps D)        Treatment of sexually transmitted diseases (STD) E)        Initiating oral contraceptives F)         Laboratory procedures G)        Treatment of minor gynecologic problems H)        Other medical procedures performed 13)         Release of patient records 14)         Emergency procedures