                         No. 14-1077

                         IN THE
                     SUPREME COURT
                        OF TEXAS



        In re CHRISTUS Santa Rosa Health System d/b/a
        CHRISTUS Santa Rosa Hospital – New Braunfels



On Petition for a Writ of Mandamus from Cause No. C-2013-0566C
 From the 274th Judicial District Court of Comal County, Texas
              The Honorable Dib Waldrip, presiding



              SUPPLEMENTAL RECORD TO
         RELATOR’S REPLY BRIEF ON THE MERITS



                               KROGER | BURRUS

                               Edward J. Kroger
                               State Bar No. 11729700
                               Leah A. Greene
                               State Bar No. 24012729
                               Meredith Massey
                               State Bar No. 24077190
                               3100 Weslayan, Suite 300
                               Houston, Texas 77027
                               Telephone:      713-961-7952
                               Facsimile:      713-961-7953
                               E-mail:         greene@krogerlaw.com

                               COUNSEL FOR RELATOR
                         Supplemental Record Index


Tab 1 – Documents


 1.   Documents Responsive to Real Party’s Requests for Production R. 1:1

 2.   Objections & Answers to Real Party’s First Interrogatories   R. 1:55

 3.   Excerpts of Deposition of Pamela Holden                      R. 1:65

 4.   Excerpts of Deposition of Cassie McKeen                      R. 1:68
REQUEST FOR PRODUCTION NOs. 1, 6, 7, 8




                                         R. 1:1
                     Most Recent
Binder               Review                                                                     Date Due
No.    Policy No.    Date        Title                                                Column1   for Review
                                 ADMINISTRATION
       LEADERSHIP
  1    CO-AD-01-01     5/21/10 Mission, Core Values And Vision                                    5/20/13
  1    CO-AD-01-04   11/30/2012Policy on Policies & Procedures                                   11/30/15
  1    CO-AD-01-05   12/30/2011Administrative Call Coverage                                      12/29/14
  1    CO-AD-01-06    9/30/2011Transaction Approval Levels                                        9/29/14
  1    CO-AD-01-07    10/1/2011Patient Visitation                                                 9/30/14
  1    CO-AD-01-09     3/1/2011Intermediate Sanctions                                             2/28/14
                               Event Scheduling(Room scheduling,Catering Room Set-
  1
       CO-AD-01-11   1/29/2010 Up, Audio-Visual Equipment)                                        1/28/13
  1    CO-AD-01-14    9/1/2013 Paging- Overhead                                                   8/31/16
  1    CO-AD-01-15   1/31/2012 Meetings Of The Directors                                         1/30/15
  1    CO-AD-01-16   1/31/2012 Board Of Directors Orientation Program                             1/30/15
  1    CO-AD-01-18    5/1/2012 Plan For Provision Of Care And Hospital Services                    5/1/15
  1    CO-AD-01-19    6/1/2011 Leadership Values- Based Decisions Making Process                 5/31/14
  1    CO-AD-01-20    1/1/2014 Contract Management                                               12/31/16
  1    CO-AD-01-21   9/28/2009 Sponsorship, Contribution, Donation Guidelines                    9/27/12
                               Governance- Governing Boards And Other Governance
  1
       CO-AD-01-23 10/15/2010 Principles                                                         10/14/13
  1    CO-AD-01-25    3/1/2012 Emergency Service Diversions Policy                                3/1/15
  1    CO-AD-01-26    1/1/2011 In- House Catering                                                12/31/13
  1    CO-AD-01-27    1/1/2011 Alcohol Service at Catering Events                                12/31/13
  1    CO-AD-01-28   10/1/2013 Contract Management Rose                                           9/30/16
  1    CO-AD-01-29   10/1/2013 Access to Regional Contract Database                               9/30/16
  1    CO-AD-01-30   10/1/2013 Entering and Uploading Contract in Contract Database               9/30/16
  1    CO-AD-01-31   10/1/2013 Storage and Security of Contract Documents                         9/30/16
       BUSINESS OFFICE
  1    CO-FM-02-02   9/11/2009 Petty Cash                                                         9/10/12
                               Approval Of Company-Sponsored And Company Directly
  1    CO-FM-02-03    1/1/2008 Paid Credit Cards                                                 12/31/10
  1    CO-FM-05-07   12/1/2010 Chaplain Housing Allowance                                        11/30/13




                                                                                                        R. 1:2
                     Most Recent
Binder               Review                                                                      Date Due
No.    Policy No.    Date        Title                                                 Column1   for Review
       FINANCE
                                Reimbursement of Business Expenses to CHRISTUS Santa
  1    CO-AD-03-01    10/1/2012 Rosa Health Care Associates                                        10/1/15
  1    CO-FM-01-01     4/1/2012 Charity Care                                                        4/1/15
                                Professional Courtesy And Prompt Pay Discounts For
  1    CO-FM-01-02     4/1/2012 Health Services                                                     4/1/15
  1    CO-FM-01-03    2/28/2011 Patient Charge Capture And Reconciliation                          2/27/14
  1    CO-FM-01-05   11/29/2010 Awarding Construction Projects                                    11/28/13
  1    CO-FM-01-07    3/31/2011 Cost-Capitalization                                                3/30/14
       ADVOCACY
       ORGANIZATIONAL DEVELOPMENT
  1    AD-01-03     12/30/2011 CSRHS FULL ORG CHART DEC 2011                                      12/29/14
  1                 12/30/2011 ORG CHAR - AH                                                      12/29/14
  1                 12/30/2011 ORG CHART - CH of SA                                               12/29/14
  1                 12/30/2011 ORG CHART - MC                                                     12/29/14
  1                 12/30/2011 ORG CHART - NB                                                     12/29/14
  1                 12/30/2011 ORG CHART - WH                                                     12/29/14
       FUNDRAISING
  1    CO-FM-04-02    1/4/2011 Use Of Charitable Gifts                                              1/3/14
  1    CO-FM-04-03   1/31/2011 Charitable Raffles                                                  1/30/14
       PUBLIC AND COMMUNITY RELATIONS
       STRATEGIC PLANNING
                               ADMITTING
                               ADMINISTRATION
  1    CO-FM-06-16   12/1/2011 Red Flag Policy                                                    11/30/14
                               CASH HANDLING
  1    CO-FM-06-04   12/1/2011 ED Collections                                                     11/30/14
  1    CO-FM-06-12   12/1/2011 Cash Management                                                    11/30/14
  1    CO-FM-06-15   12/1/2011 Cash Drawer Policy                                                 11/30/14
                               REGISTRATION
  1    CO-FM-06-01   12/1/2011 Inpatient Requirements                                             11/30/14
  1    CO-FM-06-02   12/1/2011 Pre-Admission Process                                              11/30/14
  1    CO-FM-06-05   12/1/2011 Medicare Secondary Payer Questionaire                              11/30/14


                                                                                                         R. 1:3
                       Most Recent
Binder                 Review                                                                               Date Due
No.      Policy No.    Date          Title                                                        Column1   for Review
   1     CO-FM-06-06    12/1/2011    Consent Signatures, Obtaining                                            11/30/14
   1     CO-FM-06-07    12/1/2011    Medical Necessity Standards                                              11/30/14
   1     CO-FM-06-08    12/1/2011    Protected Health Information, Use and Disclosure of                      11/30/14
   1     CO-FM-06-09    12/1/2011    Confidential Communication, Patient Request for                          11/30/14
   1     CO-FM-06-10    12/1/2011    Requiest for Restricting or Revoking Consent                             11/30/14
   1     CO-FM-06-11    12/1/2011    Privacy Practices, Notice of                                             11/30/14
   1     CO-FM-06-13    12/1/2011    Care Givers, Non-Staff                                                   11/30/14
   1     CO-FM-06-14    12/1/2011    Room and Board Transfer Process                                          11/30/14
   1     CO-FM-06-17    12/1/2011    Outpatient Registration Process                                          11/30/14
   1     CO-FM-06-18    12/1/2011    Patient Identification                                                   11/30/14
   1     CO-FM-06-19    12/1/2011    Downtime Policy                                                          11/30/14
                                     SCHEDULING
  1      CO-FM-06-03    12/1/2011    Ancillary Scheduling                                                    11/30/14
                                     CARE MANAGEMENT
                                     CASE MANAGEMENT
  1                                  Care Management Plan - Adult 2014

  1      CO-CM-01-05    9/1/2013     Code 44, Inpateint Admission Changed to Observation                        8/31/16
                                     Clinical Determination of Patient Status and Level of Care
  1      CO-CM-01-07    9/1/2013     Guidelines                                                               8/31/16
  1      CO-PM-06-12    1/5/2012     Documentaion in Meditech UR Module                                       1/4/15
  1      CO-PM-06-19    1/1/2012     Ordering Durable Medical Equipment                                      12/31/14
  1      CO-PM-06-21    1/1/2012     Documentaion Discharge Plan in Medical Record                           12/31/14
                                     Notifying Medicare Beneficiaries of Their Discharge
  1      CO-PM-06-26    1/1/2012     Appeal Rights                                                           12/31/14
  1      CO-PM-06-27    1/1/2012     Financial Referral                                                      12/31/14
  1      CO-PM-06-28    1/1/2012     Denials: Insurance Notification                                         12/31/14
  1      CO-PM-06-29    1/1/2012     Potential Avoidable Day Opportunity                                     12/31/14
  1      CO-PM-06-31    2/1/2012     Multidisciplinary Care & Discharge Planning                              1/31/15
  1      CO-PM-06-32    1/1/2012     Acute Care Readmissions                                                 12/31/14
  1      CO-PM-06-33    1/1/2012     Patient Right to Choice in Community Resources                          12/31/14
  1      CO-PM-06-35    1/1/2012     Advance Beneficiary Notice of Non-Coverage/ABN                          12/31/14



                                                                                                                    R. 1:4
                     Most Recent
Binder               Review                                                                         Date Due
No.    Policy No.    Date        Title                                                    Column1   for Review

  1    CO-PM-06-41     1/1/2012   Case Management Patient Status Determination Protocol              12/31/14
                                  SOCIAL WORK
                                  Emergency Possession of Certain Abandoned
  1    CO-PM-06-1A    11/1/2011   Children/Baby Moses Laws                                           10/31/14
  1    CO-PM-06-02    11/1/2011   Mental Health Commitments                                          10/31/14
  1    CO-PM-06-05    11/1/2011   Suspected Elderly Abuse/Neglect                                    10/31/14
  1    CO-PM-06-5A    11/1/2011   Domestic Violence                                                  10/31/14
  1    CO-PM-06-6A    11/1/2011   Physical Child Abuse                                               10/31/14
  1    CO-PM-06-11     2/1/2012   Guardianship                                                        1/31/15
  1    CO-PM-06-14     1/5/2012   Discharge Transportation                                            1/4/15
  1    CO-PM-06-15     1/1/2012   Meal Tickets                                                       12/31/14
  1    CO-PM-06-17     1/1/2012   Discharge Planning Skilled Nursing Facility Placement              12/31/14
  1    CO-PM-06-20     1/1/2012   Patient/Family Conference                                          12/31/14
  1    CO-PM-06-30     1/1/2012   Discharge Planning: Long Term Acute Care Placement                 12/31/14
                                  PATIENT INTAKE CENTER
  1    CO-PM-06-39     1/1/2012   Patient Intake Center Operations                                   12/31/14
  1    CO-PM-06-40     1/1/2012   Record-Keeping for Patient Intake Center                           12/31/14
  1    CO-PM-06-42     1/1/2012   Patient Intake Center Admit Screening Policy                       12/31/14
                                  Transfer from Outlying Hospitals to Medical Center
  1    CO-PM-06-47     1/1/2012   Campus                                                             12/31/14
                                  CLINICAL DOCUMENTATION IMPROVEMENT
                                  UTILIZATION REVIEW
                                  CHRISTUS TRANSPLANT INSTITUTE
                                  ADMINISTRATIVE
  1    CHECKLISTS                 Competency Checklist
  1    CTI-A-01        3/1/2011   Policy For Transplant Regulatory Compliance                         2/28/14
  1    CTI-A-03        3/1/2011   Final Transplant Compatibility Protocol                             2/28/14
  1    CTI-A-04        3/1/2011   Documentation And Medical Record Components                         2/28/14
  1    CTI-A-05        3/1/2011   Clinical Nutritional Services Protocol                              2/28/14
                                  Policy For Quality Assessment and Performance
  1    CTI-A-06       11/1/2011   Improvement And Adverse Event Follow Up                            10/31/14



                                                                                                            R. 1:5
                    Most Recent
Binder              Review                                                                         Date Due
No.    Policy No.   Date        Title                                                    Column1   for Review
                                Policy For Patient And Living Donor Nutritional
  1    CTI-A-07      11/1/2011 Management                                                           10/31/14
  1    CTI-A-09      11/1/2011 CTI Onsite Program Coverage Plan                                     10/31/14
  1    CTI-A-10      11/1/2011 Organ Procurement Organ Recovery                                     10/31/14
  1    CTI-A-12      11/1/2011 ABO Compatibility Verification Donor-Recipient                       10/31/14
  1    CTI-A-13      11/1/2011 After Hours Accessibility                                            10/31/14

  1    CTI-A-14      11/1/2011   Standard Operating Procedure Clinical Drug Monitoring              10/31/14
  1    CTI-A-15       3/1/2011   Clinical Transplant Coordinator Competency Testing                 2/28/14
  1    CTI-A-16       3/1/2011   Continuity Of Care                                                  2/28/14
  1    CTI-A-18       3/1/2011   Financial Coordinator Core Competencies                            2/28/14
  1    CTI-A-19       3/1/2011   Financial Coordinator Flow Process                                  2/28/14
  1    CTI-A-20       3/1/2011   Fire Protection                                                     2/28/14

  1    CTI-A-22       3/1/2011   Medicare Certification For Active Transplant Programs               2/28/14
  1    CTI-A-23       3/1/2011   Organ Acquisition Billing                                           2/28/14
  1    CTI-A-24      11/1/2011   Patient Disposition                                                10/31/14
  1    CTI-A-25      11/1/2011   Patient Family Education                                           10/31/14
  1    CTI-A-26      11/1/2011   Patient Referral                                                   10/31/14
  1    CTI-A-27      11/1/2011   Patient Selection Committee Meeting                                10/31/14
  1    CTI-A-32      11/1/2011   Provision Of Arranged Services                                     10/31/14
  1    CTI-A-33       3/1/2011   Quality Indicatory Monitoring                                       2/28/14
  1    CTI-A-35       3/1/2011   Scope Of Patient Family Assessment                                  2/28/14
                                 Securing Of Medical Records Involved Litigation Or
  1    CTI-A-36       3/1/2011   Potential Litigation                                                2/28/14
  1    CTI-A-37      11/1/2011   Time Study Documentation                                           10/31/14
  1    CTI-A-38      11/1/2011   Transfer Into - Out Of CTI Transplant Program                      10/31/14
  1    CTI-A-39      11/1/2011   Transplant Adminstrative Director                                  10/31/14
  1    CTI-A-40      11/1/2011   Agreements                                                         10/31/14
  1    CTI-A-41       3/1/2011   Transplant Staff Core Competencies                                  2/28/14
  1    CTI-A-42       3/1/2011   Signature Policy                                                    2/28/14
  1    CTI-A-43       3/1/2011   Departmental Emergency Preparedness                                2/28/14
  1    CTI-A-44       9/1/2011   Transplant Program Disaster Emergency Plan                          8/31/14


                                                                                                           R. 1:6
                    Most Recent
Binder              Review                                                                             Date Due
No.    Policy No.   Date        Title                                                        Column1   for Review
                                Transplant Specific Sentinel Event and Significant
  1    CTI-A-45       1/1/2012 Adverse Event Reporting                                                  12/31/14

  1    CTI-A-46       6/1/2012   Protection Of Confidentiality Of Deceased Donor Identitiy               6/1/15
  1    CTI-A-47       9/1/2012   Student Residents Guidelines                                            9/1/15
                                 CLINICAL PRACTICE
                                 Renal, Renal Pancreas, and Pancreas Transplant Selection
  1    CTI-KP-01      8/1/2012   Criteria                                                                8/1/15
  1    CTI-KP-02      1/1/2012   Renal Pancreas Organ Selection Criteria                                12/31/14
  1    CTI-KP-03     12/1/2011   Independent Donor Advocate Team, Policy For                            11/30/14
                                 Membership Requirements For Renal And Pancreas
  1    CTI-KP-04      1/1/2012   Transplant Selection And Quality Oversight Meeting                     12/31/14
                                 Renal Pancreas Transplant Patient Education And
  1    CTI-KP-05      1/1/2012   Evaluation Informed Consent, Policy For                                12/31/14
  1    CTI-KP-06      1/1/2012   Living Renal Donor Transplant Psychosocial Protocol                    12/31/14
  1    CTI-KP-07      1/1/2012   Renal Pancreas Transplant Psychosocial Protocol                        12/31/14
  1    CTI-KP-08      1/1/2012   Renal Pancreas Transplant On Call Event Setup                          12/31/14
                                 Protocol For Ureteral Stent Removal In Renal And Renal
  1    CTI-KP-09      1/1/2012   Pancreas Recipients                                                    12/31/14
  1    CTI-KP-10     12/1/2012   Living Kidney Donor Evaluation and Selection Criteria                   12/1/15
  1    CTI-KP-11     12/1/2011   Living Donor Informed Consent                                          11/30/14
                                 Guidelines For Acute Renal And Renal- Pancreatic
  1    CTI-KP-12      7/1/2012   Cellular Rejection                                                      7/1/15
                                 Lymphocyte Depleting Induction + Tacrolimus+Steroids +
  1    CTI-KP-13      7/1/2012   Mycophenolate Mofetil (MMF)                                             7/1/15
  1    CTI-KP-14      7/1/2012   Standard Immunosuppression Guidelines                                   7/1/15
  1    CTI-KP-15      7/1/2012   Treatment Of Acute Humoral Rejections Guidelines                        7/1/15
                                 Guiedlines For Maintenance Immunosuppression Using
  1    CTI-KP-16      7/1/2012   Cyclosporine In Renal Transplant Recipients                             7/1/15
                                 Guidelines For Initiation And Maintenance
                                 Immunosuppression Using Tacrolimus In Renal And Renal-
  1    CTI-KP-17      7/1/2012   Pancreas Transplants                                                    7/1/15



                                                                                                                  R. 1:7
                    Most Recent
Binder              Review                                                                           Date Due
No.    Policy No.   Date        Title                                                      Column1   for Review
                                Guidelines For Initiation And Maintenance
                                Immunosuppression Using Cellcept In Renal And Renal-
  1    CTI-KP-18      7/1/2012 Pancreas Transplants                                                    7/1/15
                                Guidelines For Initiation And Maintenance
                                Immunosuppression Using Sirolimus In Renal and Renal-
  1    CTI-KP-19      7/1/2012 Pancreas Transplants                                                    7/1/15
                                Guidelines For The Use Of Antithymocyte Globulin As
                                Induction Immunosuppresion And/Or For Treatment Of
  1    CTI-KP-20      7/1/2012 Rejection                                                               7/1/15
                                Guidelines For Routine Infectious Disease Prophylaxis In
  1    CTI-KP-22      7/1/2012 Renal and Renal-Pancreas Transplants                                    7/1/15
                                Guidelines For Management Of Hypertension Post Renal
  1    CTI-KP-23      7/1/2012 and Renal-Pancreas Transplant                                           7/1/15
                                Protocol For Health Care Maintenance Post Renal And
  1    CTI-KP-26      1/1/2012 Renal-Pancreas Transplant                                              12/31/14
  1    CTI-KP-27      1/1/2012 Response To Decline In Renal Function                                  12/31/14
                                Communication With Dialysis Center And/Or Referring
  1    CTI-KP-28      1/1/2012 Physician                                                              12/31/14
  1    CTI-KP-29      7/1/2012 Steroid Elimination Guidelines                                           7/1/15
  1    CTI-KP-30      1/1/2012 Karnofsky Performance Status Scale                                     12/31/14
  1    CTI-KP-31      1/1/2012 Management Of The Deceased Donor Transplant List                       12/31/14
  1    CTI-KP-32      3/1/2013 Post Transplant Recipient Follow Up                                     2/29/16
                                Potential Candidate Evaluation Process Flow (Recipient
  1    CTI-KP-33     12/1/2011 And Live Donor)                                                        11/30/14
  1    CTI-KP-34      1/1/2012 PRA (Panel - Reactive Antibody) Monitoring                             12/31/14
  1    CTI-KP-35      1/1/2012 Preoperative Education For The Live Donor                              12/31/14
  1    CTI-KP-36      1/1/2012 Solid Organ Transplant Criteria Guidelines                             12/31/14
  1    CTI-KP-37      9/1/2011 Transplant Body Mass Index Protocol                                     8/31/14
  1    CTI-KP-38      1/1/2012 Wait List Management Of Transplant Patients                            12/31/14
  1    CTI-KP-39       1/1/2012 Expanded Donor Informed Consent                                       12/31/14
  1    CTI-KP-40     12/15/2011 TIEDI Data Entry and Maintenance                                      12/14/14
                                Organ Identification and Verfication Upon Arrival To
  1    CTI-KP-41      12/1/2011 Transplant Hospital                                                   11/30/14


                                                                                                                R. 1:8
                      Most Recent
Binder                Review                                                                             Date Due
No.    Policy No.     Date        Title                                                        Column1   for Review
   1   CTI-KP-42       12/1/2011 Preoperative Work-Up For Living Kidney Donors                             11/30/14
   1   CTI-KP-43        1/1/2012 Bariatric Referral                                                        12/31/14

  1    CTI-KP-44        4/1/2012   Status Changes for Waitlisted Kidney Transplant Patients                4/1/15
  1    CTI-KP-45        4/1/2012   Kidney and Pancreas Evaluation Testing                                  4/1/15
                                   Evaluation For Tuberculosis Infection In Renal Transplant
  1    CTI-KP-46        8/1/2012   Candidates                                                              8/1/15
  1    CTI-KP-47        1/4/2012   Contacting Donor For TEIDI Follow Up                                    1/3/15
                                   FINANCIAL GUIDELINES
                                   CLINICS/COMMUNITY HEALTH SERVICES
                                   CHILDREN'S MOBILE CLINIC
  1          1          8/1/2009   Vaccine Ordering, Handling, and Storage                                 7/31/12

  1         5           8/1/2009   Pediatric Mobile Clinic Emergency Preparedness Plan                     7/31/12
  1     CO-CL-01-02     4/1/2013   Emergency Kit                                                           3/31/16
  1     CO-CL-01-04     4/1/2013   Nursing Procedure Reference Book                                        3/31/16
  1     CO-CL-01-06     4/1/2013   Immunization Policy                                                     3/31/16
                                   ADULT CLINICS
                                   WIC CLINIC
  1    CO-CL-03-01      9/1/2012   Informing Associates of Formula in Stock                                9/1/15
  1    CO-CL-03-02      9/1/2012   Income Screening As A Certification Requirement                         9/1/15
  1    CO-CL-03-03      9/1/2012   Coordination of Program Operations                                       9/1/15
  1    CO-CL-03-04      9/1/2012   Thinning of Client Records                                              9/1/15
  1    CO-CL-03-05      4/1/2013   Filing of Client Records                                                3/31/16
  1    CO-CL-03-06      9/1/2012   Provision of Services to Individuals with Disabilities                   9/1/15
                                   Policy For Screening, Documenting and Reporting Child
  1    CO-CL-03-07      3/1/2013   Abuse                                                                   2/29/16
  1    CO-CL-03-08      9/1/2012   Identification of WIC Applicant                                          9/1/15
  1    CO-CL-03-09      9/1/2012   Staff Fraud and Abuse Policy                                             9/1/15
  1    CO-CL-03-10      9/1/2012   Quality Assurance Plan                                                   9/1/15
  1    CO-CL-03-11      9/1/2012   Dual Participant (DP) and Transfer Locks (TR)                            9/1/15
  1    CO-CL-03-12      9/1/2012   Physical Presence                                                       9/1/15
  1    CO-CL-03-13      9/1/2012   Referral Agencies Resource Directories                                  9/1/15


                                                                                                                    R. 1:9
                     Most Recent
Binder               Review                                                                    Date Due
No.    Policy No.    Date        Title                                               Column1   for Review
   1   CO-CL-03-14     9/1/2012 LA Orientation Training                                           9/1/15
                                 Limited English Proficiency (formerly
  1   CO-CL-03-15      9/1/2012 Translation/Interpretation Policy)                               9/1/15
  1   CO-CL-03-16      9/1/2012 Orientation Training                                             9/1/15
  1   CO-CL-03-17      9/1/2012 Calibration of Scales                                            9/1/15
  1   CO-CL-03-18      9/1/2012 Client Grievance                                                 9/1/15
  1   CO-CL-03-19      9/1/2012 Discrimination Complaints                                        9/1/15
  1   CO-CL-03-20      9/1/2012 Confidentiality Policy                                           9/1/15
  1   CO-CL-03-21      9/1/2012 Transfer of Participants within Project #89                      9/1/15
  1   CO-CL-03-22      9/1/2012 Management of Adverse Outcomes                                   9/1/15
  1   CO-CL-03-23      9/1/2012 Transporting Client Records                                      9/1/15
  1   CO-CL-03-24      9/1/2012 Contingency Plan For Certifying Authority Coverage               9/1/15
  1   CO-CL-03-25      9/1/2012 Scheduling Missed Appointments                                   9/1/15
  1   CO-CL-03-26      9/1/2012 End of Month Procedures                                          9/1/15
  1   CO-CL-03-27      2/1/2013 Order of WIC Program Records                                     2/1/16
  1   CO-CL-03-28      9/1/2012 High Risk Referrals                                              9/1/15
  1   CO-CL-03-29      9/1/2012 Record Retention and Proper Disposal                             9/1/15




                                                                                                      R. 1:10
                     Most
                     Recent                                                           Date
Binder               Review                                                           Due for       Former
 No. Policy No.      Date        Title                                                Review        Policy No.
                                 EMERGENCY PREPAREDNESS
  2   CO-EC-04-06     6/1/2013   Emergency Color Codes                                    5/31/16
                                 ETHICS, RIGHTS, AND RESPONSIBLITIES , PATIENT RIGHTS
                                 PATIENTS RIGHTS
  2   CO-ET-01-01     3/1/2013   Patient's Rights and Responsibilities                    2/29/16
  2   CO-ET-01-02     2/1/2013   Use of Medical Interpreters                               2/1/16
  2   CO-ET-01-03     5/1/2013   Patient Complaint/Grievance                              4/30/16
  2   CO-PM-01-03     2/1/2012   Human Research Protection Oversight                      1/31/15
  2   CO-PM-01-05     6/1/2011   Organ and Tissue Donation                                5/31/14
                                 Photographing of Patients for Educational - Performance
  2   CO-PM-01-32    4/10/2010   Improvement Purposes                                      4/9/13
  2   CO-PM-02-01    10/1/2011   Advance Directives                                       9/30/14
  2   CO-PM-02-02     1/1/2012   Physician - Family Medical Care                         12/31/14
      CO-PM-02-02-
  2   01              6/9/2010   CSRHS Ethics Committee                                   6/8/13
  2   CO-PM-02-03     6/9/2010   Do not Resuscitate/Allow Natural Death                   6/8/13
  2   CO-PM-02-04    10/1/2011   End of Life Care                                        9/30/14
  2   CO-PM-02-07     4/1/2012   Withdrawal Of Medical Treatments                         4/1/15
      ETHICS
  2   CO-ET-02-01    11/1/2012 Determination of Brain Death for Adults & Children        11/1/15
  2   CO-ET-02-02     5/1/2013 Misconduct In Science                                     4/30/16
      CO-PM-02-02-
  2   04              1/1/2012 Ethical Considerations For Life Threatening Pg.          12/31/14
      CO-PM-02-02-
  2   05              1/1/2012 Direct Sterilization                                     12/31/14
      CO-PM-02-02-
  2   08              1/1/2012 Donation After Cardiac Death                             12/31/14
      CO-PM-02-02-
  2   09              4/1/2011 Contraceptives                                            3/31/14




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                       Recent                                                              Date
Binder                 Review                                                              Due for      Former
 No. Policy No.        Date        Title                                                   Review       Policy No.
                                   FACILITIES,MAINTENANCE & PLANT OPS
                                   HAZARDOUS MATERIALS
  2   CO-EC.02.02.01   7/1/2012    Hazardous Materials Management Plan                       7/1/15
  2   CO-EC-01-02      1/1/2014    SDS Management                                          12/31/16
  2   CO-EC-03-8       6/1/2011    Hazardous Spills                                         5/31/14
  2   CO-EC-03-10      6/1/2011    Pharmaceutical Waste Disposal Management Program         5/31/14
                                   FIRE AND LIFE SAFETY
                                   MEDICAL EQUIPMENT
  2         0           2/4/2013   EC Compliance Manual                                      2/4/16
  2         1          11/1/2013   Biomedical Engineering Overview                         10/31/16
  2      800.01        2/22/2013   Medical Equipment Inventory                              2/22/16
  2      800.02        2/22/2013   Management, Inspection, and Repair of Medical Equipme    2/22/16
  2      800.03        2/22/2013   Medical Equipment Selection                              2/22/16
  2       800.4        1/26/2012   Retirement and Disposal of Medical Equipment             1/25/15
  2    EC-02.04.01      7/1/2012   Medical Equipment Program Management Plan                 7/1/15
                                                                                           12/30/02
  2        1000         3/1/2010   Table Of Contents                                        2/28/13
  2        1001         3/1/2010   Equipment Management Plan                                2/28/13
  2        1002         3/1/2010   Medical Equipment Management Program Criteria            2/28/13
  2        1003         3/1/2010   Medical Equipment Management Program Inventory           2/28/13
  2        1004         3/1/2010   Initial Inspection                                       2/28/13
  2        1005         3/1/2010   Equipment Contract Coverage Additions and Deletions      2/28/13
  2        1006        11/2/2011   Device Recalls and Alerts                                11/1/14
  2        1007         3/1/2010   Safe Medical Devices Act                                 2/28/13
  2        1008         3/1/2010   Record Keeping and Documentation                         2/28/13
  2       1008a         3/1/2009   End of Month Processing                                    2/29/12
  2        1009         3/1/2010   Service Codes                                            2/28/13
  2        1010         3/1/2010   Clinical Rounds                                          2/28/13
  2        1011         3/1/2010   Unscheduled Work Requests                                2/28/13
  2        1012         3/1/2010   Scheduled Maintenance                                    2/28/13
  2        1013         3/1/2010   Vendor Service                                           2/28/13
  2        1014        3/1/2009    In-Service Training                                      2/29/12
  2       1014a         3/1/2010   Maintainer Training                                      2/28/13


                                                                                                                 R. 1:12
                    Most
                    Recent                                                             Date
Binder              Review                                                             Due for   Former
 No. Policy No.     Date        Title                                                  Review    Policy No.
   2       1015      3/1/2010   Life Cycle Analysis                                      2/28/13
   2       1016      3/1/2010   Electrical Safety Inspections                            2/28/13
   2      1016a      3/1/2010   Lock Out Tag Out                                         2/28/13
   2       1017      3/1/2010   General Shop Safety                                      2/28/13
   2       1018      3/1/2009   Equipment Assessment Reports                             2/29/12
   2       1019      3/1/2010   Quality Assurance and Improvement                        2/28/13
   2       1020      3/1/2010   Service Manuals, Software and Specialized Test Equipmen 2/28/13
   2       1021      3/1/2010   Inspection Labels                                        2/28/13
   2       1022      3/1/2010   Non-Hospital Owned Medical Equipment                     2/28/13
   2       1023      3/1/2010   Environmental Sweep                                      2/28/13
   2       1024      3/1/2010   Test Equipment                                           2/28/13
   2       1025      3/1/2010   Employee Training Records                                2/28/13
                                UTILITIES MANAGEMENT
  2    CO-EC-07-2    1/1/2012   Standard on Hot Water Temperature                       12/31/14
  2   CO-EC.02.05.01 7/1/2012   Utility Sytems Management Plan                            7/1/15
                                MAINTENANCE /PLANT OPERATIONS
  2        1000      1/1/2012   Mission                                                 12/31/14
  2        1001      1/1/2011   Statement of Accountability and Responsibility          12/31/13
  2        1002      1/1/2012   Functions                                               12/31/14
  2        1004      1/1/2012   Hours of Service                                        12/31/14
  2        1005      1/1/2012   Staff Meetings                                          12/31/14
  2        1006      1/1/2012   Disaster Plan                                           12/31/14
  2       1006.1     1/1/2012   Department Response To A Disaster (Code Gray)           12/31/14
  2        1007      1/1/2012   Blue Prints                                             12/31/14
  2        1008      1/1/2012   Fire Plan                                               12/31/14
  2        1009      1/1/2012   Fire Watch                                              12/31/14
  2        1010      1/1/2012   Access Key Control                                      12/31/14
  2        2000      1/1/2012   Environmental Maintenance                               12/31/14
  2       2000.4     1/1/2012   Environmental Maintenance- Non- Patient Care Area       12/31/14
  2       2000.5     1/1/2012   Environmental Maintenance - Patient Care Area           12/31/14
  2       2000.6     1/1/2012   Environmental Maintenance - Mechanical Area             12/31/14
  2       2000.7     1/1/2012   Environmental Maintenance - Grounds                     12/31/14
  2       2000.8     1/1/2012   Interim Life Safety Measures                            12/31/14


                                                                                                          R. 1:13
                   Most
                   Recent                                                               Date
Binder             Review                                                               Due for    Former
 No. Policy No.    Date        Title                                                    Review     Policy No.
   2      2000.9    1/1/2012   Department Infection Control                               12/31/14
   2     2000.9A    1/1/2012   Infection Control - Airborne / Ventilation                 12/31/14
   2     2000.9B    1/1/2012   Infection Control - Operating Room Ventilation             12/31/14
   2     2000.9C    1/1/2012   Infection Control - Waterborne                             12/31/14
   2   2000.9D-1    1/1/2012   Infection Control - Decontamination                        12/31/14
   2     2000.9E    1/1/2012   Infection Control - Cooling Towers                         12/31/14
   2    2000.9G     1/1/2012   Infection Control - Ice Machines                           12/31/14
   2     2000.9F    1/1/2012   Infection Control - Dialysis Water                         12/31/14
   2       2001     1/1/2012   Maintenance and Inspection: Fire Warning and Safety Sys 12/31/14
   2      2001.1    1/1/2012   Fire Alarm System Reset                                    12/31/14
   2      2001.2    1/1/2012   Maintenance and Inspection: Fire Protection System         12/31/14
   2       2002     1/1/2012   Maintenance & Inspection: Electrical Distribution System & 12/31/14
   2      2002.1    1/1/2012   Electrical Generator Procedure                             12/31/14
   2       2003     1/1/2012   Maintenance & Inspection: Vertical & Horizontal Transpor 12/31/14
   2       2004     1/1/2012   Maintenance & Inspection: HVAC System                      12/31/14
   2      2004.1    1/1/2012   Christus Santa Rosa Health Care Chiller Operation Proced 12/31/14
   2      2004.3    1/1/2012   Air Filter P.M. Procedure                                  12/31/14
   2       2005     1/1/2012   Maintenance & Inspection: Water Distribution/Plumbing S 12/31/14
   2      2005.1    1/1/2012   Softner Operation Procedure on Units in Center for Childr 12/31/14
   2      2005.2    1/1/2012   Softner Operation Procedure Outside CTRC (Formerly Ot 12/31/14
   2       2006     1/1/2012   Maintenance & Inspection: Boiler/Steam System              12/31/14
   2      2006.1    1/1/2012   Christus Santa Rosa Health Care Boiler Operation Procedu 12/31/14
   2       2007     1/1/2012   Medical Gas System                                         12/31/14
   2       2008     1/1/2012   Maintenance & Inspection: Medical / Surgical Air and Vac 12/31/14
   2       2009     1/1/2012   Domestic Water Temperature                                 12/31/14
   2       2010     1/1/2012   Scheduled Equipment Maintenance                            12/31/14
   2      2010.1    1/1/2012   Plant Maintenance Shift Operations                         12/31/14
   2       2011     1/1/2012   Equipment / Furniture Repair                               12/31/14
   2      2011.1    1/1/2012   Identification of Repaired Equipment (Form 00117537)       12/31/14
   2      2011.2    1/1/2012   Monthly Report on Abuse & Operator Error                   12/31/14
   2       2012     1/1/2012   Pre-Purchase Evaluations                                   12/31/14
   2       2013     1/1/2012   Service Request / Work Order Control                       12/31/14
   2       2014     1/1/2012   ICRA - Renovation and Contstruction                        12/31/14


                                                                                                            R. 1:14
                  Most
                  Recent                                                             Date
Binder            Review                                                             Due for   Former
 No. Policy No.   Date        Title                                                  Review    Policy No.
   2      2015     1/1/2012   Relocation of Equipment and Furniture                   12/31/14
   2      2016     1/1/2012   Interior Furnishings, Finishes and Floors               12/31/14
   2      2017     1/1/2012   Equipment Inventory and Preventive Maintenance          12/31/14
   2     2017.1    1/1/2012   Equipment Critical to Patient Care                      12/31/14
   2     2017.2    1/1/2012   Building Maintenance Program                            12/31/14
   2     2017.3    1/1/2012   Regulatory Preventive Maintenance                       12/31/14
   2      2018     1/1/2012   Computerized Maintenance Management Improvement         12/31/14
   2      3000     1/1/2012   Job Descriptions                                        12/31/14
   2      3005     1/1/2012   Time and Attendance Collection System (KRONOS)          12/31/14
   2      3006     1/1/2012   Absenteeism and Tardiness (Call In Procedure)           12/31/14
   2      3007     1/1/2012   Dress Code                                              12/31/14
   2      3008     1/1/2012   Performance Evaluation                                  12/31/14
   2      4000     1/1/2012   Tool, Storage, Distribution and Inventory               12/31/14
   2      4001     1/1/2012   Use of Personal Tools                                   12/31/14
   2      4003     1/1/2012   Use of Vehicles for Hospital Business                   12/31/14
   2      5000     1/1/2012   Emergency Call Procedure                                12/31/14
   2      5001     1/1/2012   Loss of Electrical Power                                12/31/14
   2      5002     1/1/2012   CPSB Power Cubicles - City Centre                       12/31/14
   2      5003     1/1/2012   Elevator Failure and Passenger Evacuation               12/31/14
   2      5004     1/1/2012   Failure of Heating, Ventilation, A/C (HVAC) System      12/31/14
   2     5004.1    1/1/2012   System Failure on Chillers                              12/31/14
   2      5005     1/1/2012   Failure of Water Distribution System                    12/31/14
   2      5006     1/1/2012   Failure of Plumbing System / Flooding                   12/31/14
   2      5007     1/1/2012   Failure of Boiler / Steam Equipment                     12/31/14
   2      5008     1/1/2012   Failure of Medical Gas System - Oxygen                  12/31/14
   2      5009     1/1/2012   Failure of Medical Air System                           12/31/14
   2      5010     1/1/2012   Failure of Medical Vacuum System                        12/31/14
   2      5011     1/1/2012   Ethylene Oxide Leakage                                  12/31/14
   2      5012     1/1/2012   Toxic Eternal Atmosphere                                12/31/14
   2      5013     1/1/2012   Failure of Pneumatic Tube System                        12/31/14
   2      5014     1/1/2012   Maintenance of Plant Operations in Freezing Temperature 12/31/14
   2      5015     1/1/2012   Clean Up of Chemical Spills                             12/31/14
   2     5015.1    1/1/2012   Clean Up of Chemical Spills SLUG Control Plan           12/31/14


                                                                                                        R. 1:15
                  Most
                  Recent                                                                Date
Binder            Review                                                                Due for   Former
 No. Policy No.   Date        Title                                                     Review    Policy No.
   2      5016     1/1/2012   Failure of Fire Alarm System                               12/31/14
   2      5017     1/1/2012   Failure of Fire Protection System                          12/31/14
   2      5100     1/1/2012   Utility Shutdown                                           12/31/14
   2      5200     1/1/2012   Utility Incident Reporting                                 12/31/14
   2      6000     1/1/2012   Performance Improvement Procedure                          12/31/14
   2     6000.1    1/1/2012   Maintenance / Engineering Performance: Improvement M 12/31/14
   2     6000.2    1/1/2012   Energy Curtailment Program                                 12/31/14
   2      7000     1/1/2012   General Safety                                             12/31/14
   2      7001     1/1/2012   Electrical Safety - General appliances, Tools, TV, DVD, an 12/31/14
   2     7001.1    1/1/2012   Electrical Safety - Lockout Procedure                      12/31/14
   2      7003     1/1/2012   Hazardous Chemicals                                        12/31/14
   2      7004     1/1/2012   Asbestos Control Program                                   12/31/14
   2     7004.1    1/1/2012   Removal of Asbestos Containing Materials                   12/31/14
   2      7005     1/1/2012   Handling and Use of Compressed Gas Cylinders               12/31/14
   2      7006     1/1/2012   Radiation Protection Regulations: Guidelines for Maintena 12/31/14
   2      7007     1/1/2012   Life Safety Program / Inspection and Surveys               12/31/14
   2      8001     1/1/2012   Isolation Room Precautions                                 12/31/14
   2      8002     1/1/2012   Decontamination of Equipment                               12/31/14
                              FOUNDATION




                                                                                                           R. 1:16
                      Most
                      Recent                                                               Date
Binder                Review                                                               Due for
No.    Policy No.     Date          Title                                                  Review
                                    HIPAA
                                    HIM/MEDICAL RECORDS
  3    CO-IM-04-01       6/1/07     Concurrent Review Of Patient Records By Non-Hospital Em 5/31/10
  3    CO-IM-04-03      3/8/2011    Medical Staff Suspensions Policy-Medical Records Delinqu 3/7/14
  3    CO-IM-04-04     11/1/2006    Confidentiality And Release Of Medical Information       10/31/09
  3    CO-IM-04-05      3/1/2011    Maintenance And Security Of Patient Medical Records       2/28/14
  3    CO-IM-04-06      3/1/2011    Retrievel Of Requested Patient Medical Records            2/28/14
  3    CO-IM-04-07      3/1/2011    Individuals Authorized To Document In The Medical Reco 2/28/14
  3    CO-IM-04-08      3/1/2011    Approved/Unapproved Abbreviations And/Or Symbols          2/28/14
  3    CO-IM-04-09     10/1/2006    Forms Management                                          9/30/09
  3    CO-IM-04-10      3/1/2011    Patient Information Change                                2/28/14
  3    CO-IM-04-11      3/1/2011    Thinning Charts                                           2/28/14
  3    CO-IM-04-13      1/6/2011    Resolution of Correct Documentation on Abstract (ABS) Ho 1/5/14
  3    CO-IM-04-14    12/15/2010    Chart Completion                                         12/14/13
  3    CO-IM-04-15    12/31/2010    Administrative Closure of an Incomplete Medical Record 12/30/13
  3    CO-IM-04-16      5/1/2011    Legal Health Record                                       4/30/14
  3    CO-IM-04-17      4/1/2011    Medical Identity Theft or Red Flag Rules                  3/31/14
  3    CO-PM-01-20      3/1/2011    Accounting of Disclosures of Protected Healthcare Inform 2/28/14
                                    HUMAN RESOURCES
                                    INTRODUCTION
  3    CO-HR-01-01       4/1/2012   Human Resources Guidelines                                 4/1/15
  3    CO-HR-01-02       7/1/2011   Labor Statement                                           6/30/14
                                    EMPLOYMENT IMFORMATION
  3    CO-HR-02-02       5/1/2012   At Will Employment                                         5/1/15
  3    CO-HR-02-03      12/1/2012   Equal Opportunity Employment                              12/1/15
  3    CO-HR-02-05       4/1/2012   Pre-Employment Verification                                4/1/15
  3    CO-HR-02-07      12/1/2011   Diversity and Inclusion                                  11/30/14
  3    CO-HR-02-08.     12/1/2012   Government Postings                                       12/1/15
  3    CO-HR-02-13       4/1/2012   Associate Employment Record                                4/1/15
  3    CO-HR-02-15       6/1/2011   Confidentiality Of Information/HIPAA                      5/31/14
  3    CO-HR-02-17       9/1/2012   Rehiring Of Terminated Associates                          9/1/15




                                                                                                        R. 1:17
                       Most
                       Recent                                                              Date
Binder                 Review                                                              Due for
No.      Policy No.    Date          Title                                                 Review
   3     CO-HR-02-21      4/1/2012   Employment Of Relatives                                  4/1/15
   3     CO-HR-02-22     4/13/2010   Employment Eligibility Compliance                       4/12/13
   3     CO-HR-02-23     11/1/2010   Employment Of Minors                                   10/31/13
   3     CO-HR-02-29     11/1/2010   Classification Of Associates                           10/31/13
   3     CO-HR-02-37      4/1/2012   Quoting Of Entry Wages                                   4/1/15
   3     CO-HR-02-40      9/1/2012   Severance Plan (previously titled Severance Transition)  9/1/15
   3     CO-HR-02-41      1/1/2012   HR- Allied Health Professionals                        12/31/14
                                     WORKING CONDITIONS
  3      CO-HR-03-01     9/1/2013    Solicitation And Distributions                             8/31/16
  3      CO-HR-03-04     9/1/2012    Assignment Of Work                                          9/1/15
  3      CO-HR-03-06     4/1/2010    Entry Period Of Employment                                 3/31/13
  3      CO-HR-03-10    7/31/2011    Staff Requests Involving Patient Care                      7/30/14
  3      CO-HR-03-13     4/1/2012    Attendance and Punctuality                                  4/1/15
  3      CO-HR-03-15    5/31/2011    Time And Attendance System                                 5/30/14
  3      CO-HR-03-18     4/1/2012    Inclement Weather                                           4/1/15
  3      CO-HR-03-24     4/1/2012    Moonlighting                                                4/1/15
  3      CO-HR-03-27    6/30/2011    Transfers- New Facility                                    6/29/14
  3      CO-HR-03-28    6/30/2011    Transfers- Internal (CSR)                                  6/29/14
  3      CO-HR-03-29     4/1/2012    Promotion/Demotion                                          4/1/15
  3      CO-HR-03-30   12/31/2011    Performance Plans And Evaluations                         12/30/14
  3      CO-HR-03-31   10/31/2010    Associate Competency Assessment                           10/30/13
  3      CO-HR-03-32    11/1/2012    Termination Voluntary-Resignation                          11/1/15
  3      CO-HR-03-34     4/1/2012    Termination-Involuntary                                     4/1/15
  3      CO-HR-03-36     6/1/2011    Associate Clearance Upon Termination Of Unemployment       5/31/14
  3      CO-HR-03-40     4/1/2012    Final Paychecks                                             4/1/15
  3      CO-HR-03-42    12/1/2012    Dress Code/Uniforms Standards                              12/1/15
  3      CO-HR-03-44    7/31/2011    Personal Electronic Devices                                7/30/14
  3      CO-HR-03-62     6/3/2011    Transitional Duty                                           6/2/14
  3      CO-HR-03-66     4/1/2012    Failure Of State Board Nursing Examination                  4/1/15
  3      CO-HR-03-74     6/1/2012    Associate Licenses                                          6/1/15
  3      CO-HR-03-76     6/1/2012    Contractors                                                 6/1/15
                                     Student Educational Experience Reporting and
  3      CO-HR-03-77    7/31/2012    Orientation Policy                                        7/31/15


                                                                                                          R. 1:18
                       Most
                       Recent                                                             Date
Binder                 Review                                                             Due for
No.      Policy No.    Date         Title                                                 Review
   3     CO-HR-03-78    11/1/2010   Tranfers (Christus-wide)                               10/31/13
   3     CO-HR-03-83     1/1/2013   New Associate Orientation                                1/1/16
   3     CO-HR-03-97    1/31/2012   Language Competency For Associates                      1/30/15
                                    Wage And Salary Administration
  3      CO-HR-04-01     4/1/2012   Wage And Salary Administration                             4/1/15
  3      CO-HR-04-04     4/1/2012   Non-Exempt Compensation                                    4/1/15
  3      CO-HR-04-06     4/1/2012   Exempt Compensation                                        4/1/15
  3      CO-HR-04-12     4/1/2012   On Call And Call Back Pay                                  4/1/15
  3      C0O-HR-4-18     9/1/2012   Merit Increases                                            9/1/15
  3      CO-HR-04-20     2/1/2013   Pharmacist Incentive Pay Plan                              2/1/16
  3      CO-HR-04-22    1/31/2010   Extracorporeal Membrane Oxygenation (ECMO) Hourly P       1/30/13
  3      CO-HR-04-23    3/11/2012   Holiday Differential                                      3/11/15
  3      CO-HR-04-38     4/1/2012   Job Descriptions                                           4/1/15
  3      CO-HR-04-46     4/1/2012   Job Evaluation                                             4/1/15
  3      CO-HR-04-51     1/1/2013   Interim Department Directors, Managers, And Supervisor     1/1/16
  3      CO-HR-04-52     3/1/2012   Education Hours                                            3/1/15
  3      CO-HR-04-54     7/1/2012   Emergency Staffing Pay (formerly ESI)                      7/1/15
  3      CO-HR-04-55     4/1/2012   Direct Deposit                                             4/1/15
  3      CO-HR-04-56    5/31/2011   Secondary Job/Dual Job                                    5/30/14
  3      CO-HR-04-58    7/31/2011   Disaster Pay Practices                                    7/30/14
  3      CO-HR-04-59     3/1/2012   Shift Differential Pay                                     3/1/15
  3      CO-HR-04-60     3/1/2012   Overtime Pay                                               3/1/15
  3      CO-HR-04-61     3/1/2012   Daylight Savings Time                                      3/1/15
                                    BENEFITS
  3      CO-HR-05-01     3/1/2013   Paid Time Off (PTO)                                        2/29/16
  3      CO-HR-05-10     5/1/2012   Payroll Deduction For Meals                                 5/1/15
  3      CO-HR-05-15    3/31/2010   Meal and Rest Breaks                                       3/30/13
  3      CO-HR-05-17    8/31/2012   Short Term Absences (Jury Duty,Funeral Leave, Witness R    8/31/15
  3      CO-HR-05-18    7/31/2012   Leave Of Absence                                           7/31/15
  3      CO-HR-05-30   12/31/2011   Success Sharing                                           12/30/14
  3      CO-HR-05-62    4/30/2011   Health And Welfare Benefits                                4/29/14
  3      CO-HR-05-69   10/31/2010   ADCAP Tuition Assistance                                  10/30/13
  3      CO-HR-05-70    1/31/2012   Tuition Reimbursement                                      1/30/15


                                                                                                         R. 1:19
                       Most
                       Recent                                                               Date
Binder                 Review                                                               Due for
No.      Policy No.    Date         Title                                                   Review
   3     CO-HR-05-71    2/25/2010   National Nursing Certification Program                    2/24/13
   3     CO-HR-05-72     4/1/2012   Recognition Of Associates At Retirement                    4/1/15
   3     CO-HR-05-95    1/15/2010   Mother-Friendly Distinction For Breastfeeding Associates 1/14/13
                                    CONDUCT AND ETHICS
  3      CO-HR-06-1      1/1/2012   Code Of Ethics For Associates                            12/31/14
  3      CO-HR-06-2      2/1/2012   Associate Standards Of Conduct                            1/31/15
  3      CO-HR-06-3      6/1/2012   Disciplinary And Corrective Action Process                 6/1/15
  3      CO-HR-06-10     4/1/2012   Performance Probation                                      4/1/15
  3      CO-HR-06-19    5/31/2011   Workplace Principles (Harassment And Retaliation)         5/30/14
  3      CO-HR-06-21    11/1/2010   Violence- Free Workplace                                 10/31/13
  3      CO-HR-06-24    9/30/2010   Drug Free Work Place                                      9/29/13
  3      CO-HR-06-25     9/1/2013   Tobacco-Free Environment                                  8/31/16
  3      CO-HR-06-26     4/1/2012   Consumption Of Alcoholic Beverages At CSRHC                4/1/15
                                    COMMUNICATIONS
  3      CO-HR-07-02    9/1/2013    Problem Solving Process For Associates                    8/31/16
  3      CO-HR-07-20   10/31/2010   Educational Requirements and Resource Support for CSRH 10/30/13
  3      CO-HR-07-26    9/1/2012    Exit Surveys                                               9/1/15
                                    GENERAL INFORMATION
  3      CO-HR-08-05     4/1/2012   Endorsements, Referrals, And/Or Recommendations            4/1/15
  3      CO-HR-08-09   12/31/2011   Conflict Of Interest                                     12/30/14
  3      CO-HR-08-10    2/28/2011   Associate Consent To Record Or Film                       2/27/14
                                    ASSOCIATE HEALTH
  3      CO-HR-09-03     9/1/2013   Vaccine Preventable Diseases and Immunizations            8/31/16
  3      CO-HR-09-04     5/1/2012   Post Offer Health Screen                                   5/1/15
  3      CO-HR-09-05     3/1/2012   Tuberculosis Screening For Volunteers And External Staff 3/1/15
  3      CO-HR-09-06    10/1/2010   Tuberculosis Screening For Associates                     9/30/13
  3      CO-HR-09-07    12/1/2011   Tuberculosis Screening For Physicians                    11/30/14
  3      CO-HR-09-09    9/30/2011   Hepatitis B Vaccination For Associates                    9/29/14
  3      CO-HR-09-10     9/1/2012   Post Exposure And Follow Up To Blood And Other Infectio 9/1/15
  3      CO-HR-09-15    6/30/2011   Employee Assistance Program (EAP)                         6/29/14
  3      CO-HR-09-16     5/1/2012   Work Restrictions Related To Communicable Disease          5/1/15
  3      CO-HR-09-17    4/30/2012   Texas Occupational Injury Assistance Plan (TOIAP)         4/30/15



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                      Recent                                                                   Date
                      Review                                                                  Due for
Binder Policy No.     Date        Title                                                       Review
                                  INFECTION CONTROL AND PREVENTION
                                  OVERVIEW
  4    CO-IC-01-2      2/1/2012   Goals Of The Infection Control and Prevention Program       1/31/15
  4    CO-IC-01-3      2/1/2012   Infection Control Committee                                 1/31/15
  4    CO-IC-01-4      2/1/2012   Policy Review - Procedures With A High Infection Potent     1/31/15
  4    CO-IC-01-5      2/1/2012   Occupational Health / Infection Control Interaction         1/31/15
                                  PATIENT MANAGEMENT
  4    CO-IC-01-01     2/1/2012   Role Of Our Associates In Infection Control                 1/31/15
  4    CO-IC-04-01     5/1/2012   Guidelines For Patient Placement                             5/1/15
  4    CO-IC-07-01     5/1/2012   Patient Teaching - Communicable Diseases (State Law)         5/1/15
  4    CO-IC-07-02     2/1/2012   Hand Hygiene                                                1/31/15
  4    CO-IC-07-08     2/1/2012   Patient Cultures                                            1/31/15
  4    CO-IC-07-09     5/1/2012   Portable Fans / Celing Fans                                  5/1/15
  4    CO-IC-08-02     5/1/2012   Management Of Patients With Lice Or Scabies                  5/1/15
                                  DISEASE SPECIFIC AND EXPOSURE MANAGEMENT
  4    CO-IC-05-04     5/1/2012   Care Of The Body After Death Of Person With A Commu          5/1/15
  4    CO-IC-07-13    8/31/2012   Chemoprophylaxis For Occupational Exposure To HIV           8/31/15
  4    CO-IC-07-14     2/1/2012   Investigation Of Suspected Outbreaks                        1/31/15
  4    CO-IC-08-05     5/1/2012   Prevention Of Transmission Of HIV and HBV By Infected        5/1/15
  4    CO-IC-08-06    10/1/2012   Tuberculosis Prevention And Control Plan                    10/1/15
  4    CO-IC-08-07    11/1/2012   Bloodborne Pathogens - Exposure Control Plan                11/1/15
  4    CO-IC-08-08     5/1/2012   Legionella Prevention And Control                            5/1/15
  4    CO-IC-08-09     5/1/2012   Infection Control Precautions For Patients With Cystic Fi    5/1/15
  4    CO-IC-08-12     2/1/2012   Pandemic Respiratory Infectious Disease Plan                1/31/15
                                  ISOLATION PRECAUTIONS
  4    CO-IC-02-01     2/1/2012   Standard Precautions                                        1/31/15
  4    CO-IC-06-01     2/1/2012   Isolation Precautions (Transmission-Based Precautions)      1/31/15
  4    CO-IC-08-03     2/1/2012   Protective Precautions                                      1/31/15
  4    CO-IC-08-04     2/1/2012   Vancomycin-Resistant Organisms                              1/31/15
  4    CO-IC-08-11     2/1/2012   Emerging MDRO Precautions                                   1/31/15
  4    CO-IC-08-13     5/1/2012   C.difficile Precautions                                      5/1/15
  4    CO-ICP-04-01    2/1/2012   MRSA Precautions                                            1/31/15



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                      Recent                                                                   Date
                      Review                                                                  Due for
Binder Policy No.     Date        Title                                                       Review
                                  DISINFECTION AND ENVIRONMENTAL MANAGEMENT
  4    CO-IC-07-03     2/1/2012   Sharps - Handling And Disposal                              1/31/15
  4    CO-IC-07-04     7/1/2011   Special Medical / Infectious / Regulated Waste              6/30/14
  4    CO-IC-07-05     5/1/2012   Sanitary Storage And Dispensing Of Ice                       5/1/15
  4    CO-IC-07-06     5/1/2012   Environmental Microbiologic Monitoring                       5/1/15
  4    CO-IC-07-07     5/1/2012   Handling And Prevention Of Soiled Documents (Charts)         5/1/15
  4    CO-IC-07-10     6/1/2012   Management Of Contaminated Work Clothes                      6/1/15
  4    CO-ICP-05-01    3/1/2013   Disinfection and Sterilization Plan For Medical Equipme     2/29/16
                                  INFECTION CLASSIFICATION AND REPORTING
  4    CO-IC-03-01     2/1/2012   Determining The Presence Of Health Care-Associated In       1/31/15
  4    CO-IC-05-01     2/1/2012   Reporting Conditions - "Notifiable Conditions" In Texas     1/31/15
  4    CO-IC-05-02     5/1/2012   Reporting Infections-Healthcare Associated Infection, C      5/1/15
  4    CO-IC-05-03     2/1/2012   Notification Of Possible Exposure By A Peace Officer, Fi    1/31/15
  4    CO-IC-05-05     4/1/2012   Autopsy Reports - Undiagnosed Ante Mortem Infections         4/1/15
  4    CO-IC-07-11     5/1/2012   Status / VIP Codes For Infection Control                     5/1/15
                                  INFORMATION MANAGEMENT
                                  INFORMATION SERVICES
                                  PROTECTED HEALTH INFORMATION (PHI)
                                  PUBLIC RELATIONS
  4    CO-PM-04-1      5/1/2011   Communications, Promotions, & Public Relations              4/30/14
  4    CO-PM-04-2      5/1/2011   Release of Information to the News Media                    4/30/14
  4    CO-PM-04-3      5/1/2011   Entertainer/ Media Visitors in Children's Hospital          4/30/14
  4    CO-PM-04-4      5/1/2011   Identity, Graphic Standards, Naming of Entities or Servic   4/30/14
  4    CO-PM-04-5      5/1/2011   News Media / Public Relations                               4/30/14
                                  LABORATORY
  4    CO-LAB-01-01    5/1/2013   Regional Morgue Management                                  4/30/16
                                  MATERIALS MANAGEMENT
  4    CO-FM-03-02     3/1/2001   Capital Budget Policy                                       2/29/04
  4    CO-FM-03-03     3/1/2011   Ordering Business Cards - Santa Rosa Health Care Facil      2/28/14
  4    CO-FM-03-04     8/1/2012   Purchase of Supplies Non-Captial Equipment and Servic        8/1/15
  4    CO-FM-03-05     3/1/2011   Disposal Of Excess Furnishings And Equipment (Assets)       2/28/14
  4    CO-FM-03-07     2/1/2011   Contract Confidentiality                                    1/31/14
  4    CO-FM-03-08     3/1/2011   Guidelines For Inventory Products                           2/28/14


                                                                                                        R. 1:22
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                       Recent                                                           Date
                       Review                                                          Due for
Binder   Policy No.    Date         Title                                              Review
   4     CO-FM-03-09     3/1/2011   Group Purchasing                                   2/28/14
   4     CO-FM-03-19     3/1/2011   Purchase And Management Of Capital Equipment And F 2/28/14
   4     CO-FM-03-21    9/17/2010   Inventory Cycle Counting                           9/16/13
   4     CO-FM-03-22     3/1/2011   Damaged Goods                                      2/28/14
   4     CO-FM-03-23     1/1/2012   Vendor Representative Appointment Process         12/31/14




                                                                                                 R. 1:23
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                    Recent                                                            Date
Binder              Review                                                            Due for
No.    Policy No.   Date        Title                                                 Review
                                NURSING
                                NURSING CLINICAL PRACTICE
  5                 12/1/2011   Transfer of Patients to or from Another Facility        11/30/14
  5    CO-NU-00-01   9/1/2012   Code Blue Response For Clinic Services, Diagnostic And T 9/1/15
  5    CO-NU-00-02   4/1/2013   Use of Restraints                                        3/31/16
  5    CO-NU-00-04   6/4/2012   Tissue Management                                         6/4/15
  5    CO-PM-01-06   5/1/2012   Animal Assisted Therapy                                   5/1/15
  5    CO-PM-07-06 2/28/2012    Closure (Temporary) Of Nursing Unit                      2/27/15
  5    CO-PM-07-08   5/1/2012   Service Animals                                           5/1/15
  5    CO-PM-07-09   5/7/2012   Management Of The Suicide/Overdose Patient                5/7/15
  5    CO-PM-07-10 10/24/2011   Death, Autopsy, And Post - Mortem Care                  10/23/14
  5    CO-PM-07-11   1/1/2012   Discharge Procedure                                     12/31/14
  5    CO-PM-07-13   1/1/2012   Skin Testing                                            12/31/14
  5    CO-PM-07-15   2/1/2012   Sedation During Diagnostic And Therapeutic Procedures 1/31/15
  5    CO-PM-07-17 12/1/2011    Patient Controlled Analgesia (PCA)                      11/30/14
  5    CO-PM-07-17C 8/21/2008   Epidural Analgesia Management                            8/21/11
  5    CO-PM-07-18   2/1/2012   Pain Management                                          1/31/15
  5    CO-PM-07-21   4/1/2012   Nursing Process                                           4/1/15
  5    CO-PM-07-24   6/1/2008   Informed Consent For HIV Testing                          6/1/11
  5    CO-PM-07-25 11/1/2008    Physician Orders, Receiving, and Transcribing            11/1/11
  5    CO-PM-07-27   1/1/2007   Off Unit Privileges for Patients                        12/31/09
  5    CO-PM-07-30   8/7/2009   Latex Sensitivity Program                                 8/6/12
  5    CO-PM-07-32   1/1/2012   Blood Administration                                    12/31/14
  5    CO-PM-07-33 11/12/2008   "Hand Off" Communications                               11/12/11
  5    CO-PM-07-37 10/1/2007    MyTime Extra Shift Program                               9/30/10
  5    CO-PM-07-38 12/1/2010    Critical Test/ Critical Value Reporting                 11/30/13
  5    CO-PM-07-39   4/1/2012   Wound Assessment Using Photography and E-Z Graph          4/1/15
  5    CO-PM-07-40   5/1/2012   Preoperative NPO Status And HCG Testing                   5/1/15
  5    CO-PM-07-41   5/1/2012   Blood Cultures                                            5/1/15
  5    CO-PM-07-43   4/1/2012   Parenteral Nutrition                                      4/1/15
  5    CO-PM-07-45 8/13/2008    Hypo-Hyperthermia Blanket, Use of the                    8/13/11
  5    CO-PM-07-47 8/11/2008    In-Line Filter Use                                       8/11/11
  5    CO-PM-07-48 8/13/2008    Clearing an Occluded Central Venous Catheter             8/13/11


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                        Recent                                                              Date
Binder                  Review                                                              Due for
No.      Policy No.     Date         Title                                                  Review
   5     CO-PM-07-49     7/28/2008   Patient Transport - In Facility                          7/28/11
   5     CO-PM-07-50      4/1/2012   Refrigerator / Freezer Temperature                        4/1/15
   5     CO-PM-07-51     3/20/2008   Medication Extravasation                                 3/20/11
   5     CO-PM-07-52      2/1/2012   Resuscitation Cart Maintenance                           1/31/15
   5     CO-PM-07-53      1/1/2008   Immunizations                                           12/31/10
   5     CO-PM-07-55      5/1/2011   Rapid Response Team (RRT) - Adult and Pediatrics         4/30/14
   5     CO-PM-07-57      6/1/2010   LVN Administration Of IV Bolus Medications               5/31/13
   5     CO-PM-07-59     11/1/2010   Adult Code Blue                                         10/31/13
   5     CO-PM-07-60      5/1/2011   Central Venous Catheter/PICC Management: Insertion       4/30/14
   5     CO-PM-07-65     3/18/2010   Therapeutic Phlebotomy                                   3/17/13
   5     CO-PM-07-68     12/1/2011   Medication Administration Process                       11/30/14
   5     CO-PM-07-72      2/1/2012   Central Venous Catheter/PICC Management: Care and M 1/31/15
   5     CO-PM-07-73      2/1/2012   Central Venous Catheter/PICC Management: Blood Samp 1/31/15
   5     CO-PM-07-153     5/1/2009   Acute MI and STEMI Patients (Heart Alert)                4/30/12
   5     CO-PM-07-162     6/1/2012   Monitoring of Blanket Warmers                             6/1/15
                          6/1/2012   Tissue Supplier Certificates
                                     ADMINISTRATION
  5      CO-NU-01-01     11/1/2012   Peer Review Plan - Incident Based                        11/1/15
  5      CO-NU-01-03     11/1/2012   Peer Review Plan - Safe Harbor                           11/1/15
  5      CO-PM-07-01     12/1/2010   Scopes Of Practice For Registered Nurses (RN) And Licen 11/30/13
  5      CO-PM-07-02      1/1/2012   RN Professional Recognition Program (PReP)              12/31/14
  5      CO-PM-07-03      9/1/2007   Reassignment Of Staff (Floating)                         8/31/10
  5      CO-PM-07-07      1/1/2012   Lifesaver Program In Patient Care Services              12/31/14
  5      CO-PM-07-12      1/1/2012   PRN Pool Program In Patient Care Services               12/31/14
  5      CO-PM-07-19      6/3/2011   Nursing Administration Chain of Command                   6/2/14
  5      CO-PM-07-20    12/15/2010   Standards Of Nursing Practice                           12/14/13
  5      CO-PM-07-26      8/5/2009   Student Nurses                                            8/4/12
  5      CO-PM-07-29      4/1/2012   Required School Support For Patients                      4/1/15
  5      CO-PM-07-36      5/1/2012   Resuscitation Training Expectations Of Personnel          5/1/15
  5      CO-PM-07-42      5/1/2012   Use of Nursing Procedure Manuals                          5/1/15
  5      CO-PM-07-58     4/27/2010   Nurse Staffing Committee                                 4/26/13
                                     CARDIOLOGY - CATH LAB
  5                                  Heart Alert - Flow Chart


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                        Recent                                                              Date
Binder                  Review                                                              Due for
No.      Policy No.     Date      Title                                                     Review
   5                              Heart Alert - Transfer Flow Chart
   5     CO-PM-07-95     1/1/2012 Assessment / Reassessment Of The Cath Lab Patient         12/31/14
   5     CO-PM-07-96     1/1/2012 Equipment In The Cath Lab                                 12/31/14
   5     CO-PM-07-97     1/1/2012 Hours Of Operation                                        12/31/14
   5     CO-PM-07-98     1/1/2012 Traffic Patterns - Infection Control                      12/31/14
   5     CO-PM-07-99     1/1/2012 Dress Code For Cath Lab Staff                             12/31/14
   5     CO-PM-07-100    1/1/2012 Intra Procedure Montoring                                 12/31/14
   5     CO-PM-07-101    1/1/2012 Pediatric Cardiac Catheterization Laboratory Scheduling   12/31/14
   5     CO-PM-07-102    1/1/2012 Recovery Of The Invasive Procedure Patient                12/31/14
   5     CO-PM-07-103    1/1/2012 Contrast Reaction                                         12/31/14
   5     CO-PM-07-104    1/1/2012 Education / Competency In The Cardiac Cath Lab            12/31/14
   5     CO-PM-07-105    1/1/2012 Arterial And Venous Sheath Removal                        12/31/14
                                  CARDIOLOGY - NON INVASIVE
                                  ECHOCARDIOGRAPHY
  5           E04        4/1/2012 Adult Transthoracic Echocardiogram:2D and M-Mode Vie        4/1/15
  5           E05        4/1/2012 Dobutamine Stress Echocardiogram                            4/1/15
  5           E07        4/1/2012 Bubble Contrast Study                                       4/1/15
  5           E08        5/1/2012 Transesophagel Echocardiogram                               5/1/15
  5           E13        4/1/2012 Processing of Echocardiogram Procedures                     4/1/15
  5           E15        5/1/2012 Guidelines for Echocardiogram Interpretations               5/1/15
  5           E16        4/1/2012 Definity Contrast Echocardiogram                           4/1/2015
                                  ELECTRODIAGNOSTICS
  5           A01        2/1/2011 Cardio-Neurodiagnostics Scope of Care                     1/31/2014
  5           A02        2/1/2011 EKG Administrative Procedure                              1/31/2014
  5           A03        2/1/2011 Electrocardiogram Adult - Pediatric Lead Placement        1/31/2014
  5           A04        3/1/2011 Process for Performing EKG's                              2/28/2014
  5           A05       3/10/2011 Critical Test Values                                       3/9/2014
  5           A06        3/1/2011 Cleaning EKG machines and Stress Equip                    2/28/2014
  5           A07        3/1/2011 Isolation Technique for EKG and EEG                       2/28/2014
  5           A08        3/1/2011 Ordering Procedures for Non-Invasive Cardiology Exams     2/28/2014
  5           A09        3/1/2011 Scheduling Outpatient Cardiovascular Neurodiagnostic E    2/28/2014
  5           A10       11/1/2008 Inpatient Scheduling                                      11/1/2011
  5           A11        3/1/2011 Procedure of Ordering Supplies                            2/28/2014


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                     Recent                                                              Date
Binder               Review                                                              Due for
No.    Policy No.    Date        Title                                                   Review
   5        A12       3/1/2011   ER and EKG Reading Roster Qualifications                 2/28/2014
   5        A13       3/1/2011   Responsibilities of the EKG Weekly Reader                2/28/2014
   5        A14       3/1/2011   STAT EKG Interpretations                                 2/28/2014
   5        A15       3/1/2011   Cardiology Department EKG Discrepancy Reporting          2/28/2014
   5        A16       3/1/2011   Department Disaster plan for Non-Invasive Cardiology     2/28/2014
   5        A17       3/1/2011   Code Blue                                                2/28/2014
   5        B01       3/1/2011   Transportation of Patients                               2/28/2014
   5        B02       2/1/2011   Exercise Adenosine Stress with Nuclear isotope           1/31/2014
   5        B03       2/1/2011   Adenosine Stress with Nuclear Medicine Imaging           1/31/2014
   5        B04       2/1/2011   Dobutamine Stress with Nuclear Medicine Imaging          1/31/2014
   5        B05       2/1/2011   Elective Electrical Cardioversion                        1/31/2014
   5        B06       2/1/2011   Lexiscan Stress Test with Nuclear Medicine Imaging       1/31/2014
   5        B07       2/1/2011   Metabolic Exercise Test without Nuclear Imaging          1/31/2014
   5        B08       2/1/2011   Persantine Stress Test with Nuclear Medicine Imaging     1/31/2014
   5        B09       2/1/2011   Tilt-Table Testing                                       1/31/2014
   5        B10       2/1/2011   Exercise Stress Test with Radio-Isotope Nuclear Medicine 1/31/2014
   5        B11       2/1/2011   Exercise Stress Test without Nuclear Medicine Imaging    1/31/2014
   5        B12       2/1/2011   Standing Delegation Orders for Nuclear Stress Testing    1/31/2014
   5        B13       2/1/2011   Thirty Minute Rule                                       1/31/2014
   5        B14       3/1/2011   Crash Cart                                               2/28/2014
                                 NEURODIAGNOSTICS
  5       A02        5/20/2010   General Policies, Neurodiagnostics                       5/19/2013
  5       A06        5/26/2010   Routine Adult EEG for Inpatients and Outpatients         5/25/2013
  5       A08        5/20/2010   Scheduling for Long-Term Video EEG                       5/19/2013
  5       A09        5/25/2010   Long-Term Monitoring with Video EEG                      5/24/2013
  5       A10        5/20/2010   Editing Video EEG's                                      5/19/2013
  5       A12        5/26/2010   Record Storage and Retrieval                             5/25/2013
  5       A15        6/23/2010   On-Call, Call-Back, STAT, and Routine Orders             6/22/2013
  5       A16        5/25/2010   Cleaning Gold Disc Electrodes for Neurodiagnostic Proce 5/24/2013
  5    CO-NU-03-01    6/1/2013   Designation of Interpreting Physician                    5/31/2016
  5    CO-NU-03-02    6/1/2013   Brain Death EEG Procedures (ECS)                         5/31/2016
  5    CO-NU-03-03    6/1/2013   International 10-20 System of Measurement                5/31/2016
  5    CO-NU-03-04    6/1/2013   Unattended Patient Policy                                5/31/2016


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                   Recent                                                              Date
Binder             Review                                                              Due for
No.    Policy No.  Date       Title                                                    Review
   5    CO-NU-03-05 6/1/2013  Technical Standards of EEG Recordings for Nonates up to 5/31/2016
   5    CO-NU-03-06 6/1/2013  Therapeutic Hypothermia for Infants                      5/31/2016
   5    CO-NU-03-07 6/1/2013  Routine Pediatric EEG for Inpatient and Outpatient       5/31/2016
   5        F11     5/25/2010 Interpretation of Long-Term Video EEG                    5/24/2013
                              EMERGENCY SERVICES
  5   CO-NU-04-01   12/1/2012 Emergency Department Medical Screening Examination 12/1/15
  5   CO-PM-07-77    3/1/2012 Admission to Emergency Services                             3/1/15
  5   CO-PM-07-78    9/1/2012 Blood Alcohol Sample For Medical And/Or Legal Purpose 9/1/15
  5   CO-PM-07-79    3/1/2012 Care Of The Sexual Assault Victim                           3/1/15
  5   CO-PM-07-80    3/1/2012 Culture Reports and Lab Discrepancies                       3/1/15
  5   CO-PM-07-81    3/1/2012 Post Exposure Prophylaxis and Reporting Of Rabies Expo 3/1/15
  5   CO-PM-07-82    3/1/2012 Emergency Services Computer Downtime                        3/1/15
  5   CO-PM-07-83    3/1/2012 Emergency Services Patient Flow (EDM Tracker)               3/1/15
  5   CO-PM-07-84    3/1/2012 Exposures To EMS and Public Safety Officers                 3/1/15
  5   CO-PM-07-85    3/1/2012 Management Of Boarded Patients In The Emergency Depa 3/1/15
  5   CO-PM-07-86    9/1/2012 Notification Of Private Physician                           9/1/15
  5   CO-PM-07-87    3/1/2012 Patient Belongings                                          3/1/15
  5   CO-PM-07-88    3/1/2012 Emergency Services Pediatric Reference Texts                3/1/15
  5   CO-PM-07-89    3/1/2012 Rapid Medical Examination and Discharge                     3/1/15
  5   CO-PM-07-90    1/1/2012 Visitors In The Emergency Department                      12/31/14
                              FAMILY MEDICINE, HYPERBARICS AND WOUND CARE
                              INTENSIVE CARE UNIT
  5   CO-NU-06-01    8/1/2012 Patient Care Standards - Intensive Care Units               8/1/15
  5   CO-NU-06-02    8/1/2012 Continuous Telemetry and Bedside Cardiac Monitoring         8/1/15
  5   CO-NU-06-03    8/1/2012 Standard Of Care: Care Of The Patient With An Arterial Li 8/1/15
  5   CO-NU-06-04    8/1/2012 Normal Saline Use In Disposable Transducer Systems          8/1/15
  5   CO-NU-06-05    8/1/2012 External Cardiac Pacing                                     8/1/15
  5   CO-NU-06-06    8/1/2012 Temporary Transvenous Pacing                                8/1/15
  5   CO-NU-06-07    8/1/2012 Standard Of Care: Care Of The Patient Receiving Continuo 8/1/15
                              MEDICAL , SURGICAL
                              NEONATAL SERVICES
  5   CO-NU-08-01    3/1/2013 Misadministration of Expressed Breast Milk(EBM)            2/29/16



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                      Recent
Binder                Review                                                                   Date Due for Former
No.    Policy No.     Date         Title                                                          Review    Policy No.   Extra #1
                                   NURSING
                                   SENIOR BEHAVIORAL HEALTH CENTER
  6    CO-NU-09-01     6/1/2013    Admission Criteria                                            5/31/16
  6    CO-NU-09-02     6/1/2013    In-House Transfers to and from Senior Behavioral Health C     5/31/16
  6    CO-NU-09-03     6/1/2013    Assault on Patients and Staff                                 5/31/16
  6    CO-NU-09-04     6/1/2013    Patient Orientation to Community Rules                        5/31/16
  6    CO-NU-09-05     6/1/2013    Continuity of Care                                            5/31/16
  6    CO-NU-09-06     6/1/2013    Contraband and Search of Patient Belongings and Visitors'     5/31/16
  6    CO-NU-09-07     6/1/2013    Crisis Management                                             5/31/16
  6    CO-NU-09-08     6/1/2013    Denial of a Patient's Rights                                  5/31/16
  6    CO-NU-09-09     6/1/2013    Discharge Criteria                                            5/31/16
  6    CO-NU-09-10     6/1/2013    Duty to Warn                                                  5/31/16
  6    CO-NU-09-11     6/1/2013    Nutritional Assessment                                        5/31/16
  6    CO-NU-09-12     6/1/2013    Patient Dress Code                                            5/31/16
  6    CO-NU-09-13     6/1/2013    Patient Grievance Process                                     5/31/16
  6    CO-NU-09-14     6/1/2013    Patient Laundry Service                                       5/31/16
  6    CO-NU-09-15     6/1/2013    Patient Mail                                                  5/31/16
  6    CO-NU-09-16     6/1/2013    Levels of Observation                                         5/31/16
  6    CO-NU-09-17     6/1/2013    Meal Supervision                                              5/31/16
  6    CO-NU-09-18     6/1/2013    Medical Rehabilitation Services                               5/31/16
  6    CO-NU-09-19     6/1/2013    Multidisciplinary Treatment Planning                          5/31/16
  6    CO-NU-09-20     6/1/2013    Neurological Examination                                      5/31/16
  6    CO-NU-09-21     6/1/2013    Patient Orientation                                           5/31/16
  6    CO-NU-09-22     6/1/2013    Patient's Rights                                              5/31/16
  6    CO-NU-09-23     6/1/2013    Program Safety                                                5/31/16
  6    CO-NU-09-24     6/1/2013    Therapeutic Treatment Schedule                                5/31/16
  6    CO-NU-09-26     6/1/2013    Documentation                                                 5/31/16
                                   PERIOPERATIVE, TRANSPLANT
                                   GI LAB
                                   OPERATING ROOM
  6    CO-NU-10-01     1/1/2012    Respiratory Airborne and Droplet Precautions For Patients     12/31/14
  6    CO-NU-10-02     1/1/2012    Aseptic Technique And Applications                            12/31/14
  6    CO-NU-10-03     1/1/2012    Procedure For Use Of Biological Monitoring System             12/31/14
  6    CO-NU-10-04     7/1/2012    Blanket And Fluid Warmer Monitoring                            7/1/15
  6    CO-NU-10-05     4/1/2011    Modified Block Scheduling Of Perioperative Procedures         3/31/14
  6    CO-NU-10-06     1/1/2012    Code Blue / Cardiopulmonary Arrest In The Operating Roo 12/31/14
  6    CO-NU-10-07     4/1/2012    Duties And Responsibilities Of The On-Call Personnel           4/1/15
  6    CO-NU-10-08     4/1/2012    Duties Of The Circulating Nurse                                4/1/15
  6    CO-NU-10-09     4/1/2012    Duties Of The Scrub Personnel                                  4/1/15
  6    CO-NU-10-10    12/1/2011    Emergency "Bump" Guidelines                                   11/30/14
  6    CO-NU-10-11     6/1/2012    Environmental Cleaning Of The Operating Room                   6/1/15
  6    CO-NU-10-12     4/1/2012    Event Related Sterility                                        4/1/15
  6    CO-NU-10-13     6/1/2012    Hair Removal At Operative Site                                 6/1/15
  6    CO-NU-10-14     4/1/2012    Handling Of Sharps                                             4/1/15
  6    CO-NU-10-15    12/1/2011    Implant Record                                                11/30/14
  6    CO-NU-10-16    12/1/2011    Latex Allergy Precautions                                     11/30/14
  6    CO-NU-10-17    12/1/2011    Malignant Hyperthermia                                        11/30/14
  6    CO-NU-10-18     4/1/2012    Monitoring The Local Anesthesia Patient In The OR              4/1/15
  6    CO-NU-10-19    12/1/2011    New Perioperative Associate Unit Specific Information         11/30/14
  6    CO-NU-10-20    12/1/2011    Organ Harvest                                                 11/30/14
  6    CO-NU-10-21     3/1/2012    Perioperative Metrics - Co Management                          3/1/15
  6    CO-NU-10-22     4/1/2012    Perioperative Patient Care Standards                           4/1/15
  6    CO-NU-10-23     4/1/2012    Personal Protective Equipment                                  4/1/15
  6    CO-NU-10-24     4/1/2012    Philosophy                                                     4/1/15
  6    CO-NU-10-25     4/1/2012    Positioning The Surgical Patient                               4/1/15
  6    CO-NU-10-26     4/1/2012    Resterilization Of Single-Use Items                            4/1/15
  6    CO-NU-10-27     3/1/2012    Smoke Evacuation                                               3/1/15
  6    CO-NU-10-28     4/1/2012    Special Precautions (Oxygen Cylinders & Manifolds)             4/1/15
  6    CO-NU-10-29     4/1/2012    Standard Precautions                                           4/1/15
  6    CO-NU-10-30     4/1/2012    Standards Of Perioperative Clinical Practice                   4/1/15
  6    CO-NU-10-31     4/1/2012    Steam Sterilization - Use Of The Autoclave                     4/1/15
  6    CO-NU-10-32     6/1/2012    Surgical Attire - Dress Code (Sterile Environment)             6/1/15
  6    CO-NU-10-33     9/1/2011    Care And Disposition Of Surgical Specimens                    8/31/14
  6    CO-NU-10-34    12/1/2011    Transplant Protocol                                           11/30/14
  6    CO-NU-10-53     8/1/2013    Surgical Lasers, Use of                                       7/31/16
                                   PACU
  6    CO-PM-07-106    1/1/2012    Discharge Criteria From PACU                                  12/31/14
  6    CO-PM-07-109    1/1/2012    Criteria For Discharging Patient From PACU And Admitting 12/31/14
  6    CO-PM-06-110    1/1/2012    Emergency Transfer of Patients from PACU to an ICU            12/31/14
  6    CO-PM-07-112    1/1/2012    Criteria For Post - OP Admit To An ICU Bypassing PACU         12/31/14
  6    CO-PM-07-113    1/1/2012    ICU Overflow Patients In PACU                                 12/31/14
  6    CO-PM-07-114    1/1/2012    Visitors In PACU                                              12/31/14
  6    CO-PM-07-115    1/1/2012    Call Guidelines / Call Back Implementation                    12/31/14
                                   PSU
  6    CO-NU-10-46     1/1/2012    Admissions To The Perioperative Support Unit (PSU)            12/31/14
  6    CO-NU-10-47     1/1/2012    PSU Charges                                                   12/31/14
  6    CO-NU-10-48     1/1/2012    Discharge Instructions                                        12/31/14
  6    CO-NU-10-49     1/1/2012    Post Operative Follow-Up Evaluation / Post OP Calls           12/31/14
  6    CO-NU-10-50     1/1/2012    Post-Op Nursing Care For SDS Patients                         12/31/14
  6    CO-NU-10-51     1/1/2012    Pre-operative Work Up                                         12/31/14
  6    CO-NU-10-52     1/1/2012    Receiving The Patient Directly From Surgery                   12/31/14
  6    CO-NU-10-54     1/1/2012    Transfer From Outpatient To Inpatient Status                  12/31/14
  6    CO-NU-10-55     1/1/2012    Visitors In PSU                                               12/31/14
                                   SPD
                                   TELEMETRY, INTERMEDIATE CARE
  6    CO-PM-07-156    5/1/2012    Admissions and Discharge Guidelines For Telemetry And          5/1/15
                                   TRANSPORT SERVICES
                                   TRAUMA SERVICES
  6    CO-TS-01-01     6/1/2011    Burn Protocol For Trauma Care In Emergency Department         5/31/14
  6    CO-TS-01-02     5/1/2011     Patient Who Presents to the Emergency Department That i      4/30/14
  6    CO-TS-01-03     7/1/2011    Resuscitation and Treatment of the Trauma Patient             6/30/14
  6    CO-TS-01-04     5/1/2011    Santa Rosa System Trauma Services Performance Improvem 4/30/14
  6    CO-TS-01-05     6/1/2011    Spinal Cord Trauma Care In Emergency Department               5/31/14
  6    CO-TS-01-06     5/1/2011    Utilization Of Medcom For Trauma Transfer Cases               4/30/14
  6    CO-TS-02-01     5/1/2011    Acceptance Of Trauma Patients By Transfer To Santa Rosa C 4/30/14
  6    CO-TS-02-02     5/1/2011    Acceptance Of Trauma Patients By Transfer To Santa Rosa L     4/30/14
  6    CO-TS-02-03     5/1/2011    Admission Of Injured Patients To Santa Rosa Healthcare Le     4/30/14
  6    CO-TS-02-05     6/1/2011    Trauma Team Activation Policy-City Centre                     5/31/14
  6    CO-TS-02-08     5/1/2011    Trauma Team Roles And Responsibilites - Level IV Facilitie    4/30/14
  6    CO-TS-02-09     5/1/2011    Trauma Team Roles And Responsibilites - Level III Facilitie   4/30/14
  6    CO-TS-03-01     6/1/2011    Pediatric Trauma Care In Emergency Department                 5/31/14
                                   WOMEN'S SERVICES
  6    CO-NU-14-01    1/31/2012    Obstetrics Emergencies                                        1/30/15
  6    CO-NU-14-03    12/1/2011    Operating Room Responsibilites                                11/30/14
  6    CO-NU-14-04    8/31/2012    Intermediate Care of the Newborn                              8/31/15
  6    CO-NU-14-05    8/31/2012    Antepartum Care                                               8/31/15
  6    CO-NU-14-06    8/31/2012    Care of the Post Partum Patient                               8/31/15
  6    CO-NU-14-07    8/31/2012    Care of the Patient in the OR-Preoperative nad Postoperati    8/31/15
  6    CO-NU-14-08    8/31/2012    Care Of Patients With Post Partum Complications               8/31/15
  6    CO-NU-14-09    3/31/2012    Discharge of the Well Newborn                                 3/31/15
  6    CO-NU-14-10    8/31/2012    Admission, Physician Notification And Discharge Criteria O    8/31/15
  6    CO-NU-14-11    8/31/2012    Hypoglycemia Protocol                                         8/31/15
  6    CO-NU-14-12    8/31/2012    Patient Care Standards - Obstetric Patient                    8/31/15
  6    CO-NU-14-13    8/31/2012    Patient Care Standards: Newborn                               8/31/15
  6    CO-NU-14-14    4/30/2012    Newborns Requiring Transfer                                   4/30/15
  6    CO-NU-14-15    8/31/2012    Management of Pre-eclampsia and Magnesium Sulfate             8/31/15
  6    CO-NU-14-16    8/31/2012    Intrapartum Care Of Patient With Vaginal Delivery             8/31/15
  6    CO-NU-14-17    8/31/2012    Visitation In Women's Services                                8/31/15
  6    CO-NU-14-18    11/1/2013    Fetal Demise                                                  10/31/16
  6    CO-NU-14-19    12/1/2012    Induction Of Labor                                            12/1/15
  6    CO-NU-14-20    1/21/2013    Fetal Monitoring                                              1/21/16
  6    CO-NU-14-21     9/1/2012    Newborn Procedures                                             9/1/15
  6    CO-NU-14-22     8/1/2012    Admission of Newborn to Level I Nursery                        8/1/15
  6    CO-NU-14-23     2/1/2013    Breastfeeding Policy For Late Preterm Infants                  2/1/16
  6    CO-NU-14-24    2/28/2011    Limited Third Trimester Ultrasound in the OB Setting          2/27/14
  6    CO-NU-14-25    2/28/2011    Nursing Competency for Third Trimester Ultrasound in the      2/27/14
  6    CO-NU-14-26    4/15/2010    Surrogacy/Gestational Agreement Cases                         4/14/13
  6    CO-PM-07-61     7/1/2011    Labor Epidural Anesthesia                                     6/30/14
  6    CO-PM-07-63    7/31/2011    Infant Security (Code Pink) Policy                            7/30/14
  6    CO-PM-07-64    6/30/2011    Medical Screening Exam for the Obstetrical Patient            6/29/14
  6    CO-PM-07-66    12/30/2011   Breastfeeding Policy For Full Term Infants                    12/29/14
  6    CO-PM-07-69    11/30/2011   Operative Assistive Delivery                                  11/29/14
  6    CO-PM-07-70    11/30/2011   VBAC (Vaginal Birth after Cesarean)                           11/29/14
                                   NEONATAL INTERMEDIATE CARE
  6    CO-NU-08-02     6/1/2013    Administration of Blood Products in High-Risk Infants         5/31/16
  6    CO-NU-08-03     6/1/2013    Guidelines for Infants and Families with CPS Involvement      5/31/16
  6    CO-NU-08-04     6/1/2013    Hearing Screening                                             5/31/16
  6    CO-NU-08-05     6/1/2013    Hepatitis B Prophylaxis and Management                        5/31/16
  6    CO-NU-08-06     6/1/2013    Kangaroo Care                                                 5/31/16
  6    CO-NU-08-07     6/1/2013    Neonatal Circumcision                                         5/31/16
  6    CO-NU-08-08     6/1/2013    Newborn Car Seat Angle Challenge                              5/31/16
  6    CO-NU-08-09     6/1/2013    Newborn Screening in Neonatal Intermediate Care               5/31/16
  6    CO-NU-08-10     6/1/2013    Neonatal Intermediate Care Admission and Discharge            5/31/16
  6    CO-NU-08-11     6/1/2013    Phototherapy Administration                                   5/31/16
  6    CO-NU-08-12     6/1/2013    Placement and Use of Gastric Tube in NIMC                     5/31/16
  6    CO-NU-08-13     6/1/2013    Pulse Oximetry Screening for Congenital Heart Disease         5/31/16
  6    CO-NU-08-14     6/1/2013    Referrals to Pediatrix Developmental Services and Clinic      5/31/16
  6    CO-NU-08-15     6/1/2013    Re-warming Hypothermic Infants(using Infant Warmer)           5/31/16
  6    CO-NU-08-16     6/1/2013    Safe Sleep for Infant in Neonatal Intermediate Care           5/31/16
  6    CO-NU-08-17     6/1/2013    Sucrose Use in Infants                                        5/31/16
  6    CO-NU-08-18     6/1/2013    Teaching Parents/Caregivers Cardiopulmonary Resuscitat        5/31/16
  6    CO-NU-08-19     6/1/2013    Thermoregulation and Weaning to an Open Crib                  5/31/16
                                   HEMATOLOGY, ONCOLOGY
                                   FORENSIC NURSE EXAMINER
  6    CO-NU-16-01     9/1/2012    Patient Declining Forensic Examination                         9/1/15
  6    CO-NU-16-02     9/1/2012    Consent for Medical Forensic Examination                       9/1/15
  6    CO-NU-16-03     9/1/2012    Digital Photography Of Physical Injuries                       9/1/15
  6    CO-NU-16-04     9/1/2012    FNE Quality Improvement Process                                9/1/15
  6    CO-NU-16-05     9/1/2012    FNE Nursing Process                                            9/1/15
  6    CO-NU-16-06     9/1/2012    Physician Consultation                                         9/1/15
  6    CO-NU-16-07     9/1/2012    Medical Forensic Examination Policy                            9/1/15
  6    CO-NU-16-08     1/1/2012    Chain of Custody - Release of Medical Forensic Evidence       12/31/14
  6    CO-NU-16-09     4/1/2012    Laboratory Test Standards                                      4/1/15
  6    CO-NU-16-10     2/1/2012    Post-Exposure Prophylaxis for Patients of Sexual Abuse or     1/31/15
  6    CO-NU-16-11     4/1/2012    Standard Medication Orders for Prophylaxis Related to Sex      4/1/15




                                                                                                                                    R. 1:29
                      Most
                      Recent
Binder                Review                                                           Date Due
No.    Policy No.     Date        Title                                                for Review
                                  PHARMACY
  7    CO-PM-03-00      9/1/11    Medication Management Policy                           8/31/14
  7    CO-PM-03-01     1/1/2012   Administration And Handling Of Medications            12/31/14
  7    CO-PM-03-02    7/31/2011   Antidote and Poison Control                            7/30/14
  7    CO-PM-03-03     7/1/2011   Automatic Stop Of Medication Orders                    6/30/14
  7    CO-PM-03-04     3/1/2012   Controlled Sustance Distribution Administration         3/1/15
  7    CO-PM-03-05     7/1/2011   Crash Cart Medication Re-Supply                        6/30/14
  7    CO-PM-03-06     9/1/2010   Medication Orders                                      8/31/13
  7    CO-PM-03-07     2/1/2012   Controlled Substance Infusion - Documentation          1/31/15
  7    CO-PM-03-08    9/30/2011   Drug Use Evaluation Process                            9/29/14
  7    CO-PM-03-10     1/1/2012   Formulary Process                                     12/31/14
  7    CO-PM-03-11    9/30/2011   Generic And Therapeutic Substitution                   9/29/14
  7    CO-PM-03-13     2/1/2012   Floor-Stock Medication Distribution                    1/31/15
  7    CO-PM-03-14     1/1/2012   Potassium Chloride (KCL) Administration Guidelines    12/31/14
  7    CO-PM-03-15    9/30/2011   Investigational Medications                            9/29/14
  7    CO-PM-03-16     9/1/2011   Medication Information Services                        8/31/14
  7    CO-PM-03-17     2/1/2012   Medication Delivery Process                            1/31/15
  7    CO-PM-03-18     9/1/2011   Medication Error Reporting                             8/31/14
  7    CO-PM-03-19    12/1/2011   Drug Product Problem Reporting                        11/30/14
  7    CO-PM-03-20     7/1/2011   Automated Medication Dispensing Systems (PYXIS)        6/30/14
  7    CO-PM-03-20B    9/1/2011   Medication Override Guidelines                         8/31/14
  7    CO-PM-03-21    7/31/2011   Adverse Drug Reaction Reporting Process                7/30/14
  7    CO-PM-03-22     7/1/2011   Reconciliation Of Medications                          6/30/14
  7    CO-PM-03-23     9/1/2011   Methadone Use                                          8/31/14
  7    CO-PM-03-24    12/1/2011   Nurse / Pharmacy Medication Communication Form        11/30/14
  7    CO-PM-03-25    12/1/2011   Outpatient Prescription Services                      11/30/14
  7    CO-PM-03-26     1/1/2012   Medication Labeling                                   12/31/14
  7    CO-PM-03-27     2/1/2012   Patient Own Medications                                1/31/15
  7    CO-PM-03-29     9/1/2011   Medication Management - Minimum Patient Data Set       8/31/14
  7    CO-PM-03-30     1/1/2012   Medication Adminstration Record                       12/31/14
  7    CO-PM-03-31     5/1/2012   Storage Of Pharmaceuticals                              5/1/15
  7    CO-PM-03-32    12/1/2011   Pharmacy & Therapeutic Committees                     11/30/14
  7    CO-PM-03-33    12/1/2011   Recall Of Medications                                 11/30/14
  7    CO-PM-03-34     2/1/2012   Safe Handling Of Cytotoxic Drugs                       1/31/15

                                                                                                    R. 1:30
                       Most
                       Recent
Binder                 Review                                                                      Date Due
No.      Policy No.    Date         Title                                                          for Review
   7     CO-PM-03-35    12/1/2011   Pharmaceutical Sales Representatives                            11/30/14
   7     CO-PM-03-36    9/30/2011   Medication Samples                                               9/29/14
   7     CO-PM-03-37    12/1/2011   Security Of Medications In Patient Care Areas                   11/30/14
   7     CO-PM-03-38     3/1/2012   Medication Administration Time Standards                          3/1/15
   7     CO-PM-03-39    12/1/2011   Standarized Concentrations For Medications                      11/30/14
   7     CO-PM-03-40     1/1/2012   Food-Medication Interaction Monitoring and Education            12/31/14
   7     CO-PM-03-41     2/1/2012   High Alert Medications                                           1/31/15
   7     CO-PM-03-44    12/1/2011   Vincristine (Intravenous) Preparation, Delivery, And Adm        11/30/14
   7     CO-PM-03-45     2/1/2011   Look-alike, Sound-alike Medication Names (a.k.a. Confuse         1/31/14
   7     CO-PM-03-47    12/1/2011   Contrast Media As Medication                                    11/30/14
   7     CO-PM-03-48    12/1/2011   Pharmacy Closure                                                11/30/14
   7     CO-PM-03-49    12/1/2011   Surgery Pharmacy Services                                       11/30/14
   7     CO-PM-03-50     5/1/2012   Pharmacist-Managed Drug Therapy Protocol For Vancomy              5/1/15
   7     CO-PM-03-51     5/1/2012   Hospital Protocol. For Parenteral Nutrition (PN) in Adult Pa      5/1/15
   7     CO-PM-03-52    7/31/2011   Anticoagulation Management Program                               7/30/14
   7     CO-PM-03-53      1/1/12    Storage and Use of Concentrated Potassium Chloride and          12/31/14
                                    PHYSICIAN SERVICES
                                    MEDICAL STAFF ADMINISTRATION
  7                       1/16/09   Membership, Credentialing, Privileging, And Due Proces           1/16/12
  7                       1/16/09   Organizational Manual                                            1/16/12
  7                       3/26/12   Rules and Regulations                                            3/26/15
  7                     1/14/2011   Medical Staff Bylaws                                             1/13/14
  7      CO-AD-02-05   11/30/2011   Sexual Harassment Involving Medical Staff                       11/29/14
  7      CO-AD-02-10   11/30/2011   Disclosure Of Medical Errors                                    11/29/14
  7      CO-AD-02-14   11/30/2011   Disclosure Of Unanticipated Outcomes                            11/29/14
  7      CO-AD-02-15   11/30/2011   Emergency Room On-Call Schedule Process                         11/29/14
  7      CO-AD-02-16   11/30/2011   Emergency Room On-Call Physician Response                       11/29/14
  7      CO-AD-02-20   11/30/2011   Professional Practice Evaluation Policy                         11/29/14
  7      CO-AD-02-21   11/30/2011   Conflict Of Interest For Medical Staff Policy                   11/29/14
  7      CO-AD-02-25       4/1/12   Physician Attribution Policy                                      4/1/15
  7      CO-MS-01-01    11/1/2012   Practitioner Peer Review Guidelines                              11/1/15
  7      CO-MS-01-02    11/1/2012   Professional Code Of Conduct Policy                              11/1/15
  7      CO-MS-01-03       5/1/13   Medical Staff Chain of Command                                   4/30/16


                                                                                                                R. 1:31
                     Most
                     Recent
Binder               Review                                                       Date Due
No.    Policy No.    Date       Title                                             for Review
                                PHYSICIAN RECRUITMENT
                                MEDICAL EDUCATION (CME)
                                QUALITY, PI, & NPSG
  7    CO-PI-01-03       7/1/11 Performance Improvement and Patient Safety Plan    6/30/14
  7    CO-PI-01-26    3/26/2009 Patient Flow and Bed Capacity                      3/25/12




                                                                                               R. 1:32
                     Most
                     Recent                                                             Date
Binder               Review                                                             Due for
No.    Policy No.    Date         Title                                                 Review
                                  RADIOLOGY
                                  ADMINISTRATION
  8    CO-PM-08-02    12/1/2011   Assessment for Central Venous Device Insertion            11/30/14
  8    CO-PM-08-03     2/6/2012   Care of Critically Ill Patients                             2/5/15
  8    CO-PM-08-04   12/29/2011   Diagnostic Imaging Guidelines                             12/28/14
  8    CO-PM-08-14   12/31/2011   Diagnostic Imaging Quality Control                        12/30/14
  8    CO-PM-08-15     7/1/2012   Use of Power Injectors in the Radiology Department          7/1/15
  8    CO-PM-08-16    2/13/2012   Rectal Tube Insertions                                     2/12/15
  8    CO-PM-08-17     2/6/2012   Radiology Medical Records                                   2/5/15
  8    CO-PM-08-18    2/13/2012   Radiology Department Chairperson                           2/12/15
  8    CO-PM-08-19    2/13/2012   Radiology Services Provided by Outside Agency              2/12/15
  8    CO-RD-01-01     4/1/2013   Reporting Patient Complaing and/or Grievance in Radiolo   3/31/16
  8    CO-RD-01-06    1/31/2013   Radiation Safety Program and Procedures                   1/31/16
                                  CAT SCAN (CT)
                                  INTERVENTIONAL RADIOLOGY (IR)
                                  MAGNETIC RESONANCE IMAGING (MRI)
  8    CO-PM-08-07   1/31/2012    Patient Protection in MRI                                 1/30/15
  8    CO-PM-08-08   1/31/2012    MRI Associates/Non-MRI Associate Zone Restriction         1/30/15
  8    CO-PM-08-09    2/1/2012    Time Varying Gradient and Radiofrequency Magnetic Fie     1/31/15
  8    CO-PM-08-10   1/31/2012    Monitoring Critically Ill Patients                        1/30/15
  8    CO-PM-08-12   1/31/2012    Safety in the MRI Suite due to an Emergent Situation      1/30/15
  8    CO-PM-08-13    2/9/2012    Cyrogen Safety                                             2/8/15
                                  MAMMOGRAPHY
                                  NUCLEAR MEDICINE (NM)
                                  NM - ADMINISTRATION
  8    CO-PM-08-36   2/14/2012    Medical Director of the Nuclear Medicine Department       2/13/15
  8    CO-PM-08-51   2/17/2012    Radiation Safety Committee Responsibilites                2/16/15
  8    CO-PM-08-52    3/6/2012    Radiation Safety Officer                                   3/6/15
                                  NM - OPERATIONS
  8    CO-PM-08-20   2/13/2012    Administration of Radionuclides by Non-Physician          2/12/15
  8    CO-PM-08-21   2/13/2012    Assurance of Correct Injections in Nuclear Medicine       2/12/15
  8    CO-PM-08-24   2/13/2012    Collection and Re-Injection of Blood Products             2/12/15
  8    CO-PM-08-25   2/13/2012    Compliance with Regulatory Agencies                       2/12/15


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                       Recent                                                               Date
Binder                 Review                                                               Due for
No.      Policy No.    Date         Title                                                   Review
   8     CO-PM-08-27    2/13/2012   Disposition of Examination Report                        2/12/15
   8     CO-PM-08-31    2/14/2012   General Instructions for Obtaining Nuclear Medicine Proc 2/13/15
   8     CO-PM-08-32    2/14/2012   Informed Consent to Nuclear Medicine Procedures          2/13/15
   8     CO-PM-08-33    2/14/2012   Leaking or Contaminated Source                           2/13/15
   8     CO-PM-08-34    2/14/2012   Lost or Stolen Radiation Sources                         2/13/15
   8     CO-PM-08-35    2/14/2012   Mandatory Review for I-131 RX Physician Ordered Proced 2/13/15
   8     CO-PM-08-37    2/15/2012   Nuclear Medicine Hours of Operation                      2/14/15
   8     CO-PM-08-42    2/17/2012   Ordering and Receipt of Radiopharmaceuticals             2/16/15
   8     CO-PM-08-43    2/17/2012   Orientation and Review                                   2/16/15
   8     CO-PM-08-46    2/17/2012   Venous Blood Collection, Policy and Procedure for        2/16/15
   8     CO-PM-08-54    2/21/2012   Records Maintenancefor Nuclear Medicine                  2/20/15
   8     CO-PM-08-57    2/21/2012   Supervision of Therapeutic Neclear Medicine Procedures 2/20/15
                                    NM - QUALITY CONTROL
  8      CO-PM-08-22   2/13/2012    Calibration of Nuclear Medicine Intstruments             2/12/15
  8      CO-PM-08-28   2/14/2012    Dose Calibrator Quality Control                          2/13/15
  8      CO-PM-08-45   2/17/2012    Performance Monitoring in Nuclear Medicine               2/16/15
  8      CO-PM-08-48   2/17/2012    Quality Control Program                                  2/16/15
                                    NM - RADIATION SAFETY
  8      CO-PM-08-38   2/15/2012    Nursing Instructions for Gold Seed Implants              2/14/15
  8      CO-PM-08-39   2/15/2012    Nursing Instructions for I-131 Therapy                   2/14/15
  8      CO-PM-08-40   2/17/2012    Nursing Instructions for Permanent Radioactive Seed Impl 2/16/15
  8      CO-PM-08-49   2/17/2012    Radiation Protection in Nuclear Medicine                 2/16/15
  8      CO-PM-08-50   2/17/2012    Radiation Protection Principles for Attending Personnel  2/16/15
  8      CO-PM-08-53   2/21/2012    Radiation Safety Program Review                          2/20/15
                                    NM - SAFETY
  8      CO-PM-08-23   2/13/2012    Care of Critically Ill Patients                          2/12/15
  8      CO-PM-08-26   2/13/2012    Equipment Safety Guidelines, Nuclear Medicine            2/12/15
  8      CO-PM-08-55   2/21/2012    Sharps Disposition and Disposal                          2/20/15
                                    Picture Archive Communications System (PACS)
  8      CO-PM-08-58   2/13/2012    Archiving of Studies                                     2/12/15
  8      CO-PM-08-59   2/10/2012    CHRISTUS Network Downtime Procedures                      2/9/15
  8      CO-PM-08-60     2/1/12     Control Station Operation in PACS                        1/31/15
  8      CO-PM-08-61    2/9/2012    Diagnostic Imaging CR System                              2/8/15


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                       Recent                                                                  Date
Binder                 Review                                                                  Due for
No.      Policy No.    Date         Title                                                      Review
   8     CO-PM-08-62     2/9/2012   Digitizing of Hard Copy Radiographs                          2/8/15
   8     CO-PM-08-63     2/9/2012   ER Physician User Role                                       2/8/15
   8     CO-PM-08-64    2/10/2012   Exporting of Exams to CD-ROM                                 2/9/15
   8     CO-PM-08-65    2/10/2012   Hospital Information System Downtime Procedures              2/9/15
   8     CO-PM-08-66    2/10/2012   ICU - Ward Staff User Role                                   2/9/15
   8     CO-PM-08-67    2/10/2012   Outside Physician User Role                                  2/9/15
   8     CO-PM-08-68     2/9/2012   Audit Procedures                                             2/8/15
   8     CO-PM-08-69     2/9/2012   Downtime Procedures                                          2/8/15
   8     CO-PM-08-70    2/10/2012   Quality Assurance                                            2/9/15
   8     CO-PM-08-71    2/10/2012   User Account Inactivation                                    2/9/15
   8     CO-PM-08-72    2/10/2012   User Account Request                                         2/9/15
   8     CO-PM-08-73    2/10/2012   Purpose and Philosophy of PACS                               2/9/15
   8     CO-PM-08-74    2/10/2012   Radiologist User Role                                        2/9/15
                                    ULTRASOUND
                                    X-RAY
                                    REHAB SERVICES
                                    PROCEDURES
  8      CO-RE-00-01   8/31/2012    Prosthetic/Orthotic Services for Rehabilitation Patients    8/31/15
  8      CO-RE-00-02   8/31/2012    Traction Pelvic-Motorized                                   8/31/15
  8      CO-RE-00-03   8/31/2012    VitalStim Electrical Stimulation                            8/31/15
  8      CO-RE-00-04   8/31/2012    Bedside Swallowing Evaluations                              8/31/15
  8      CO-RE-00-05   8/31/2012    Tilt Table                                                  8/31/15
  8      CO-RE-00-06   8/31/2012    Deep Pharyngeal Neuromuscular Stimulation (DPNS)            8/31/15
  8      CO-RE-00-07   8/31/2012    Referral For Audiological Assessment                        8/31/15
  9      CO-RE-00-08   8/31/2012    Phonophoresis                                               8/31/15
  8      CO-RE-00-09   8/31/2012    Cryotherapy                                                 8/31/15
  8      CO-RE-00-10   8/31/2012    Joint Mobilization                                          8/31/15
  8      CO-RE-00-11   8/12/2012    Biofeedback Myofeedback                                     8/12/15
  8      CO-RE-00-12   8/31/2012    Driving                                                     8/31/15
  8      CO-RE-00-13   8/31/2012    Treatment Procedure: Fluidotherapy                          8/31/15
  8      CO-RE-00-14   8/31/2012    Hydrocollator - Hot Packs-Moist Heat Packs                  8/31/15
  8      CO-RE-00-15   8/31/2012    Intermittent Compression Unit - Instructions                8/31/15
  8      CO-RE-00-17   8/31/2012    Cleaning Of Equipment & Supplies Used For Patient's         8/31/15


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                       Recent                                                                   Date
Binder                 Review                                                                   Due for
No.      Policy No.    Date         Title                                                       Review
   8     CO-RE-00-18    1/31/2012   Pain Management                                              1/30/15
   8     CO-RE-00-19    1/31/2012   Treatment Plan Development                                   1/30/15
   8     CO-RE-00-20    1/31/2012   PCS Documentation: General Guidelines                        1/30/15
   8     CO-RE-00-21    1/31/2012   Written Documentation: General Guidelines                    1/30/15
   8     CO-RE-00-22    8/31/2012   Use of Safety Devices                                        8/31/15
   8     CO-RE-00-23    8/31/2012   Ultrasound                                                   8/31/15
   8     CO-RE-00-24    8/31/2012   Ultrasound And Electrical Stimulations - Combined            8/31/15
   8     CO-RE-00-25    8/31/2012   Patient Transportation                                       8/31/15
   8     CO-RE-00-26    8/31/2012   Neuromuscular Electrical Stimulation (Vital Stimulation)     8/31/15
   8     CO-RE-00-27    8/31/2012   Contrast Baths, Procedure                                    8/31/15
   8     CO-RE-00-28    8/31/2012   Electrical Stimulation                                       8/31/15
   8     CO-RE-00-29    8/31/2012   Monitoring of Modality Safe Temperatures                     8/31/15
                                    ACUTE CARE
  8      CO-RE-01-01   1/31/2012    Discharge Criteria For Acute Therapy Services                1/30/15
  8      CO-RE-01-02   1/31/2012    Assessment: Initial/Discharge                                1/30/15
  8      CO-RE-01-03   1/31/2012    Acute Hospital Patient Reassessment                          1/30/15
                                    OUTPATIENT REHAB
  8      CO-RE-02-01   2/28/2012    Patient Safety/Fall Prevention Program                       2/27/15
  8      CO-RE-02-02   1/31/2012    Admission Criteria                                           1/30/15
  8      CO-RE-02-03   1/31/2012    Discharge Criteria                                           1/30/15
  8      CO-RE-02-04   1/31/2012    Discharge Planning                                           1/30/15
  8      CO-RE-02-05   1/31/2012    Discharge Summary                                            1/30/15
  8      CO-RE-02-06   1/31/2012    Exclusionary Criteria                                        1/30/15
  8      CO-RE-02-07   1/31/2012    Initial Evaluation - PT/OT/ST                                1/30/15
  8      CO-RE-02-08   1/31/2012    Medical and Therapeutic Holds                                1/30/15
  8      CO-RE-02-09   1/31/2012    Patient Admission Information                                1/30/15
  8      CO-RE-02-10   1/31/2012    Patient And Family Education                                 1/30/15
  8      CO-RE-02-11   1/31/2012    Patient Case Conferences                                     1/30/15
  8      CO-RE-02-12   1/31/2012    Patient Referrrals For Outpatient Rehabilitation Services    1/30/15
  8      CO-RE-02-13   1/31/2012    Plan Of Care                                                 1/30/15
  8      CO-RE-02-14   1/31/2012    Reassessment                                                 1/30/15
  8      CO-RE-02-15    8/1/2012    OFF Grounds Treatment with Patient/Therapist                 8/1/15
  8      CO-RE-02-16    8/1/2012    Multidisciplinary Community Re-Entry Outings                 8/1/15


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                     Recent                                                              Date
Binder               Review                                                              Due for
No.    Policy No.    Date         Title                                                  Review
                                  INPATIENT REHAB
  8    CO-RE-03-01   8/31/2012    Discharge Planning Inpatient                               8/31/15
  8    CO-RE-03-02   8/31/2012    Ordering Special Equipment - Other Than Prosthetics and    8/31/15
  8    CO-RE-03-03   8/31/2012    Family Conferences                                         8/31/15
  8    CO-RE-03-04   8/31/2012    Treatment for Patients Who Have Experienced A Change       8/31/15
                                  CARDIAC REHAB
  8    CO-RE-04-01     5/1/2011   Cardiac Rehab Services And Referral Process                4/30/14
  8    CO-RE-04-02     5/1/2011   Cardiac Rehab Program Goals                                4/30/14
  8    CO-RE-04-03     5/1/2011   Cardiac Rehab Safety                                       4/30/14
  8    CO-RE-04-04     5/1/2011   Cardiac Rehab Termination Of Exercise Session              4/30/14
  8    CO-RE-04-05     5/1/2011   Cardiac Rehab Patient Risk Stratification                  4/30/14
  8    CO-RE-04-06     5/1/2011   Cardiac Rehab Patient Education Program                    4/30/14
  8    CO-RE-04-07     5/1/2011   Cardiac Rehab Initial Assessment And Orientation           4/30/14
  8    CO-RE-04-08     5/1/2011   Cardiac Rehab Inclusionary & Exclusionary Criteria         4/30/14
  8    CO-RE-04-09     5/1/2011   Cardiac Rehab Exercise Prescription                        4/30/14
  8    CO-RE-04-10     5/1/2011   Cardiac Rehab Assessment                                   4/30/14
  8    CO-RE-04-11     5/1/2011   Discharge Criteria, Cardiac Rehab                          4/30/14
  8    CO-RE-04-12     5/1/2011   Cardiac Rehab Patient Assessments                          4/30/14
  8    CO-RE-04-13     5/1/2011   Phase I Cardiac Rehab Services                             4/30/14
  8    CO-RE-04-14     5/1/2011   Role Of The Medical Director                               4/30/14
  8    CO-RE-04-15     5/1/2011   Cardiac Rehab Guidelines For Exercise In Diabetic Patien   4/30/14
                                  PULMONARY REHAB
  8    CO-RE-05-01     6/1/2011   Pulmonary Rehab Patient Referral                           5/31/14
  8    CO-RE-05-02     6/1/2011   Pulmonary Rehab Admission Criteria                         5/31/14
  8    CO-RE-05-03     6/1/2011   Pulmonary Rehab Initial Assessment                         5/31/14
  8    CO-RE-05-04     6/1/2011   Pulmonary Rehab Six Minute Walk Assessment                 5/31/14
  8    CO-RE-05-05     6/1/2011   Pulmonary Rehab Reassessment                               5/31/14
  8    CO-RE-05-06     6/1/2011   Pulmonary Rehab Patient Safety                             5/31/14
  8    CO-RE-05-07     6/1/2011   Pulmonary Rehab Patient Exercise Prescription              5/31/14
  8    CO-RE-05-08     6/1/2011   Pulmonary Rehabilitation Patient & Family Education        5/31/14
  8    CO-RE-05-09     6/1/2011   Pulmonary Rehab Goals                                      5/31/14
  8    CO-RE-05-10     6/1/2011   Pulmonary Rehab Documentation                              5/31/14
  8    CO-RE-05-11     6/1/2011   Pulmonary Rehab Discharge Guidelines                       5/31/14


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                     Recent                                                               Date
Binder               Review                                                               Due for
No.    Policy No.    Date        Title                                                    Review
   8   CO-RE-05-12      6/1/2011 Pulmonary Rehab Individualized Treatment Plan             5/31/14
                                 General Administration
  8   CO-RE-06-01     8/31/2012 Pool Rules and Regulations                                 8/31/15
  8   CO-RE-06-02     1/31/2012 Educating Patient And Family                               1/30/15
  8   CO-RE-06-03     8/31/2012 Scheduling Patients for Therapy Treatments                 8/31/15
  8   CO-RE-06-04     8/31/2012 Safety - Limited Use Of Extension Cord in the Therapy Dep 8/31/15
  8   CO-RE-06-05     8/31/2012 Safety - IV's, Oxygen, Catheter Bags - Guidelines for Ther 8/31/15
  8   CO-RE-06-06     8/31/2012 Safety Guidelines And Records                              8/31/15
  8   CO-RE-06-07     8/31/2012 Infection Control With Kitchen Activities                  8/31/15
  8   CO-RE-06-08     8/31/2012 Infection Control: Cleaning Of Modality Equipment          8/31/15
  8   CO-RE-06-09     8/31/2012 Infection Control : Sanitizing of Adaptive Eating Equipmen 8/31/15
  8   CO-RE-06-10     8/31/2012 Wheelchair and Seating Clinic Services                     8/31/15
                                 PEDIATRICS
                                 FORMS




                                                                                                     R. 1:38
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                      Recent                                                                         Date
Binder                Review                                                                         Due for
No.    Policy No.      Date      Title                                                               Review
                                 RESPIRATORY CARE
                                 ADMINISTRATION
  9    CO-RC-01-01   7/1/2012    Medical Direction Of Respiratory Care                                 7/1/15
  9    CO-RC-01-02   8/1/2012    Performance Improvement for Respiratory Care                          8/1/15
  9    CO-RC-01-03    9/1/2012 Orientation, Training & Education Of Respiratory Therapy Associates     9/1/15
  9    CO-RC-01-04    9/1/2012 State License And CPR Certification                                     9/1/15
  9    CO-RC-01-05    9/1/2012 Responsibilities of the Cardiopulmonary Department                     9/1/15
  9    CO-RC-01-06    9/1/2012 General Responsibilities Of The Respiratory Care Department            9/1/15
  9    CO-RC-01-07   11/1/2013 Staffing, Absences and Punctuality                                     3/31/16
  9    CO-RC-01-08    9/1/2012 Management of External Agrency Respiratory Care Practitioners          9/1/15
                               Documentation and Meditech Downtime Procedures For Respiratory
  9    CO-RC-01-09    9/1/2012 Care                                                                    9/1/15
  9    CO-RC-01-10    9/1/2012 Respiratory Student Policy                                              9/1/15
                               RESPIRATORY CARE
  9                   4/1/2012 Safe Handling - Use of Metricide OPA PLUS Solution and Test Strips      4/1/15
  9    CO-RC-02-01    9/1/2012 Criteria For Undesirable Therapeutic Side Effects                       9/1/15
  9    CO-RC-02-03    9/1/2012 Respiratory Care Services Respiratory Care Plan                         9/1/15
  9    CO-RC-02-04    9/1/2012 Initiation & Timelines Of Therapy                                       9/1/15
  9    CO-RC-02-05    9/1/2012 Respiratory Care Orders                                                 9/1/15
  9    CO-RC-02-06    9/1/2012 Shift Report                                                            9/1/15
  9    CO-RC-02-07    9/1/2012 Transfers of RC Patients Between ICU's, General Floors And ER's         9/1/15
  9    CO-RC-02-08    9/1/2012 Pulse Ox Monitoring on the Floors                                       9/1/15
  9    CO-RC-02-09    9/1/2012 Oxygen Rounds                                                           9/1/15
  9    CO-RC-02-10    9/1/2012 Oxygen Administration                                                   9/1/15
  9    CO-RC-02-11    9/1/2012 Continuous Aersol Therapy                                               9/1/15
  9    CO-RC-02-12    5/1/2012 Aersol Therapy Treatments                                               5/1/15
  9    CO-RC-02-13    9/1/2012 Pentamidine Isethionate Aersol Therapy Treatments                      9/1/15
  9    CO-RC-02-14    9/1/2012 Pulse Oximeter Trending                                                 9/1/15
  9    CO-RC-02-15   10/1/2012 Intermittent Positive Pressure Breathing                               10/1/15
  9    CO-RC-02-16    7/1/2012 Sputum Specimen Collection                                              7/1/15




                                                                                                           R. 1:39
                       Most
                      Recent                                                                        Date
Binder                Review                                                                        Due for
No.    Policy No.      Date       Title                                                             Review

  9    CO-RC-02-17     7/1/2012   Aerosol Medication Delivery Via Meter Dose Inhaler And Aero-chamber  7/1/15
  9    CO-RC-02-18     7/1/2012   Nasal Wash For The Detection Of Respiratory Syncytial Virus           7/1/15
  9    CO-RC-02-19     7/1/2012   Chest Physical Therapy                                                7/1/15
  9    CO-RC-02-20     7/1/2012   Nasopharyngeal Or Oropharyngeal Suctioning                            7/1/15
  9    CO-RC-02-21     7/1/2012   Suctioning Endotracheal Tube Or Tracheotomy Tube                      7/1/15
  9    CO-RC-02-22     7/1/2012   Use Of The Demistifier Scavenging Isolation Unit                      7/1/15
  9    CO-RC-02-23     7/1/2012   Initiation Of Pulse Oximeter                                          7/1/15
  9    CO-RC-02-24     7/1/2012   Cystic Fibrosis Therapy Protocol                                      7/1/15
  9    CO-RC-02-25     7/1/2012   Administration of Pulmozyme(Dornase Alpha)                           7/1/15
  9    CO-RC-02-26     7/1/2012   Administration of Aerosolized Tobi(Tobramycin Solution)              7/1/15
  9    CO-RC-02-27    7/27/2012   Use of The Vest Percussive Unit                                       7/1/15
  9    CO-RC-02-28    12/1/2012   Acapella(airway mucus clerance device)                               12/1/15
  9    CO-RC-02-29   12/23/2012   EzPAP(Positive Airway Pressure System)                              12/1/15
  9    CO-RC-02-30   12/23/2012   Surfactant Administration in Nicu                                    12/1/15
  9    CO-RC-02-31   12/23/2012   Intrapulmonary Percussive Ventilation                                12/1/15
  9    CO-RC-02-32    12/1/2012   Administration of Hypertonic Saline                                  12/1/15
  9    CO-RC-02-33   12/23/2012   Pediatric Asthma Protocol                                            12/1/15
  9    CO-RC-02-34    12/1/2012   Colistin Antibiotic Aerosol Therapy                                  12/1/15
  9    CO-RC-02-35    12/1/2012   Cough Assist Mechanical In-Exsufflator Device                        12/1/15
  9    CO-RC-02-36    11/1/2013   Bronchiolitis Protocol                                               12/1/15
  9    CO-RC-02-37   12/12/2012   Reactive Airway Disease Protocol                                    12/12/15
  9    CO-RC-02-39    12/1/2012   Mechanical Ventilation                                               12/1/15
  9    CO-RC-02-40    1/17/2013   Use of the Passy-Muir Tracheostomy Speaking Valve(Pmtsv)              1/1/16
  9    CO-RC-02-41    1/17/2013   Evita 4 Mechanical Ventilator Set-Up & Implementation                 1/1/16
  9    CO-RC-02-42    1/17/2013   Tracheostomy Replacement                                              1/1/16
  9    CO-RC-02-43    1/17/2013   Endotracheal Intubation                                               1/1/16
  9    CO-RC-02-45     1/1/2013   Bilevel Positive Airway Pressure Ventilation                          1/1/16
  9    CO-RC-02-46    1/17/2013   Bronchoscopy Assistance                                               1/1/16
  9    CO-RC-02-47    1/17/2013   Continuous Bronchodilator Therapy Administration                      1/1/16
  9    CO-RC-02-48     1/1/2013   Plumonetic System LTV Ventilator                                      1/1/16
  9    CO-RC-02-60    11/1/2013   Bunnell Jet Ventilator                                              10/31/16
  9    H-18            3/1/2012   Negative Pressure Ventilation                                         3/1/15


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                        Most
                       Recent                                                                             Date
Binder                 Review                                                                             Due for
No.    Policy No.       Date     Title                                                                    Review
                                 BLOOD GASES
                                 PULMONARY FUNCTION TESTS
                                 SLEEB LAB
                                 RISK MANAGEMENT
  9                              Risk Management and Loss Prevention Regional Plan FY2013
  9    CO-PI-01-07      7/1/2012 Informed Consent                                                          7/1/15
  9    CO-PI-01-12      1/1/2012 Authorized Drivers of CSRHC Owned Vehicles Policy                        12/31/14
  9    CO-PI-01-16      9/1/2012 Records Retention and Destruction Policy                                  9/1/15
  9    CO-PI-01-17    10/19/2012 RM and Loss Prevention Management Plan                                   10/19/15
  9    CO-PI-01-18      1/1/2012 Patient Personal Property And Valuables                                  12/31/14
                                 Emergency Medical Treatment & Active Labor Act (EMTALA) And
  9    CO-PI-01-23      9/1/2012 Patient Transfer Policy                                                    9/1/15
  9    CO-PI-01-24      1/1/2012 EMTALA Violation Reporting                                               12/31/14
  9    CO-PM-01-33     12/1/2009 Response to Patient Abuse Allegations Made Against Staff                 11/30/12
  9    CO-RM-01-02      4/1/2013 Variance Reporting (Risk Management Notification)                         3/31/16
  9    CO-RM-01-03      7/1/2013 Associates Serving As Notary Public To Legal Instruments                  6/30/16
  9    CO-RM-01-06      7/1/2013 Elopement Policy                                                          6/30/16
  9    CO-RM-01-15      1/1/2014 Against Medical Advice-Refusal of Treatment and Discharge(AMA)           12/31/16
                                 Sequestering of Medical Devices, Equipment, and Products Following
  9    CO-RM-01-25      6/1/2013 an Actual or Potential Adverse Event                                      5/31/16
                                 Associates Witnessing Signatures on Wills, Deeds for Asset or Property
  9     CO-RM-01-26    7/1/2013 Transfers, and Durable Power of Attorney                                   6/30/16
      9 CO-RM-01-27     9/1/2013 Emergency Detention and Involuntary Mental Health Services                8/31/16
                                 SAFETY
  9    CO-EC-01-02      1/1/2012 Electrical Safety                                                        12/31/14
  9    CO-EC-01-03      1/1/2012 Extension Cords and Adaptors                                             12/31/14
  9    CO-EC-01-04      1/1/2012 Portable Heating Devices                                                 12/31/14
  9    CO-EC-01-11      1/1/2012 Safe Medical Device Act Reporting                                        12/31/14
                                 Construction Related Environmental Safety And Infection Control
  9    CO-EC-01-14     12/1/2010 Procedures                                                               11/30/13
  9    CO-EC-01-15      7/1/2012 Eyewash Stations and Emergency Showers                                     7/1/15
  9    CO-EC-03-04      5/1/2013 Respiratory Protection Program                                            4/30/16
  9    CO-EC-05-02      1/1/2012 Report on Open Flame Fires - Code Red                                    12/31/14


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                       Recent                                                                            Date
Binder                Review                                                                             Due for
No.    Policy No.       Date    Title                                                                    Review
   9   CO-EC-05-04    1/1/2012  Portable Fire Extinguisher Inspection                                     12/31/14
                                Flammability / Combustibility of Purchased Furniture, Furnishings, and
  9   CO-EC-05-05      1/1/2012 Decorations                                                              12/31/14
  9   CO-EC-05-07      1/1/2012 General Fire Prevention Duties                                           12/31/14
  9   CO-EC-05-08      4/1/2012 Compressed Gas Cylinders                                                   4/1/15
  9   CO-SA-01-06      4/1/2013 Fire Alarm and Fire Drills                                                3/31/16
  9   EC.02.03.01 LS. 7/1/2012 Fire and Life Safety Management Plan                                        7/1/15
  9   EC.01.01.01      7/1/2012 Environmental Safety Management Plan                                      7/1/15
                                SECURITY
  9   EC-02.01.01       7/1/12  Security Management Plan                                                   7/1/15
  9   CO-EC-02-02       3/1/11  Parking At Christus Santa Rosa Health Care Facilities                     2/28/14
  9   CO-EC-02-08      4/1/2011 Package Inspection                                                        3/31/14
  9   CO-EC-02-17      5/1/2013 Patient Valuables Policy                                                  4/30/16
  9   CO-EC-02-20     11/1/2010 Patient (Forensic) Prisoner Policy                                       10/31/13
  9   CO-EC-02-21     2/28/2013 Mobile Telephone and Pager Service                                        2/28/16
  9   CO-SC-01-02      7/1/2013 Key Control                                                               6/30/16
  9   CO-SC-01-03      7/1/2013 Helipad Procedure                                                         6/30/16
  9   CO-SC-01-05      7/1/2013 Prevention of Workplace Violence                                         6/30/16
  9   CO-SC-01-06      7/1/2013 Disoderly Conduct                                                         6/30/16
  9   CO-SC-01-07      7/1/2013 Bomb Threat (Code Black)                                                  6/30/16
  9   CO-SC-01-08      7/1/2013 Closed Circuit Television (CCTV)                                          6/30/16
  9   CO-SC-01-09      7/1/2013 Regional Access Control                                                   6/30/16
  9   CO-SC-01-10      7/1/2013 Regional Weapons                                                          6/30/16
  9   CO-SC-01-12      8/1/2011 Active Shooter Policy (Code White)                                        7/31/14
  9   CO-SC-01-13      7/1/2013 Identification Badges                                                     6/30/16
  9   CO-SC-01-16     7/26/2013 Disaster Phone Procedures                                                 7/25/16
  9   CO-SC-01-17      7/1/2013 Management of Dangerous or Combative Patients                             6/30/16
  9   CO-EC-02.01.0 7/1/2012 Security Program Management Plan                                              7/1/15
                                SPIRITUAL CARE




                                                                                                               R. 1:42
REQUEST FOR PRODUCTION NOs. 3, 4, 5




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R. 1:54
                                 Cause No. C-2013-0566-C

LESLIE BAIRD                                  §                 IN THE DISTRICT COURT
                                              §
v.                                            §             OF COMAL COUNTY, TEXAS
                                              §
GERALD MARCUS FRANKLIN, MD AND                §
G. MARCUS FRANKLIN, MD                        §
ASSOCIATES, P.A. D/B/A THE ENT                §
CENTER OF NEW BRAUNFELS                       §                 274th JUDICIAL DISTRICT



  DEFENDANTS CHRISTUS HEALTH AND CHRISTUS SANTA ROSA HEALTH SYSTEM
          D/B/A CHRISTUS SANTA ROSA HOSPITAL — NEW BRAUNFELS’
OBJECTIONS AND ANSWERS TO DEFENDANTS GERALD MARCUS FRANKLIN, MD AND
   G. MARCUS FRANKLIN, MD & ASSOCIATES, PA D/B/A THE ENT CENTER OF NEW
                    BRAUNFELS’ FIRST INTERROGATORIES

TO:    Gerald Marcus Franklin, MD and G. Marcus Franklin, MD & Associates, P.A. d/b/a The
       ENT Center of New Braunfels, by and through its attorney of record, Richard J. Kasson,
       Gonzalez, Chiscano, Angulo & Kasson, PC, 613 N.W. Loop 410, Suite 800, San Antonio,
       Texas 78216.

       CHRISTUS Health and CHRISTUS Santa Rosa Health System d/b/a CHRISTUS Santa

Rosa Hospital — New Braunfels, pursuant to the Texas Rules of Civil Procedure, make the

following Objections and Answers to Defendants Gerald Marcus Franklin, MD And G. Marcus

Franklin, MD & Associates, PA D/B/A The ENT Center Of New Braunfels’ First Interrogatories.




                                                                                     R. 1:55
    Respectfully submitted,

    KROGER | BURRUS


    By: ___________________________
        Edward J. Kroger
        State Bar No. 11729700
        Kroger@krogerlaw.com
        Leah A. Greene
        State Bar No. 24012729
        Greene@krogerlaw.com
    3100 Weslayan, Suite 300
    Houston, Texas 77027
    Telephone:     713.961.7952
    Telecopier:    713.961.7953

    Counsel for Defendants
    CHRISTUS Health and CHRISTUS Santa
    Rosa Health System d/b/a CHRISTUS Santa
    Rosa Hospital – New Braunfels




2
                                      R. 1:56
                                    CERTIFICATE OF SERVICE

This Pleading was served in compliance with the Texas Rules of Civil Procedure by the
methods designated, or if not designated, by United States Postal Service First Class Mail, on
this, the 4th day of April 2014.

Mr. Michael Sawicki                                      Via CM-RRR and Fascimile
Sawicki & Lauten, LLP                                    (214) 468-8845
4040 N. Central Expressway, Suite 850
Dallas, Texas 75204

Mr. Charles Soechting                                    Via CM-RRR and Fascimile
Soechting Law Firm                                       (512) 392-6204
3331 Ranch Rd., 12, Suite 107
San Marcos, Texas 78666

Mr. Richard Kasson                                       Via CM-RRR and Fascimile
Gonzalez Chiscano Angulo & Kasson, PC                    (210) 569-8490
613 NW Loop 410, Suite 800
San Antonio, Texas 78216




                                                         ____________________________
                                                                 Leah A. Greene




                                              3
                                                                                      R. 1:57
  DEFENDANTS CHRISTUS HEALTH AND CHRISTUS SANTA ROSA HEALTH SYSTEM
          D/B/A CHRISTUS SANTA ROSA HOSPITAL — NEW BRAUNFELS’
OBJECTIONS AND ANSWERS TO DEFENDANTS GERALD MARCUS FRANKLIN, MD AND
   G. MARCUS FRANKLIN, MD & ASSOCIATES, PA D/B/A THE ENT CENTER OF NEW
                    BRAUNFELS’ FIRST INTERROGATORIES

INTERROGATORY NO. 1: Identify by name, address and phone number each and every
employee, including but not limited to, all nurses, surgical coordinators, surgical assistants,
pathology department technicians, of the Hospital who worked in the surgical department and
the pathology department within the Hospital on March 5, 2012.

ANSWER:       The health care providers whose names, signatures, or initials appear in the
              medical records for Leslie Baird’s March 5, 2012 procedure at CHRISTUS Santa
              Rosa Hospital — New Braunfels include but may not be limited to:

CHRISTUS Santa Rosa Hospital — New Braunfels                     Treating Facility
c/o Counsel Edward J. Kroger and Leah A. Greene
Kroger | Burrus
3100 Weslayan, Suite 300
Houston, Texas 77027
Telephone: 713.961.7952
Custodian of Records, employees, agents, physicians, nurses, aides, therapists, and affiliated
healthcare providers currently employed and/or employed at the time of the incident made the
basis of this lawsuit, including but not limited to:

Angleton, Gareth G., RN                                          PACU
Bonner, Joe, RN                                                  OR Supervisor
Brammeier, Vanessa, RN
Farrow, Martha
Garcia, Carmela
Holden, Pamela                                                   Lab Supervisor
La Roque, B.,                                                    Nerve stimulator
McKeen, Cassie, RN                                               Circulator
Moya, Susie S., RN
Path-Jente, Lori A., RN
Phillips, Patricia                                               Certified Scrub Tech
Skehan, Laura S, RN                                              Post Op

Physicians on staff at CHRISTUS Santa Rosa Hospital — New Braunfels
Franklin, Gerald Marc, MD                                         ENT Surgeon
Hensley, Richard, MD                                              Pathologist
Perches, David, MD                                                Anesthesiologist
Rodriguez, Richard                                                First Assistant



                                              4
                                                                                        R. 1:58
INTERROGATORY NO. 2: Identify each and every Hospital employee you contend informed
Dr. Franklin BEFORE he started his thyroidectomy surgery on Plaintiff on March 5th, 2012, that
the cryostat a/k/a frozen section machine was not available and/or out of service for Plaintiff’s
surgery.

ANSWER:

CHRISTUS Santa Rosa Hospital — New Braunfels                       Treating Facility
c/o Counsel Edward J. Kroger and Leah A. Greene
Kroger | Burrus
3100 Weslayan, Suite 300
Houston, Texas 77027
Telephone: 713.961.7952
Custodian of Records, employees, agents, physicians, nurses, aides, therapists, and affiliated
healthcare providers currently employed and/or employed at the time of the incident made the
basis of this lawsuit, including but not limited to:

Bonner, Joe, RN                                                    OR Supervisor
McKeen, Cassie, RN                                                 Circulator



INTERROGATORY NO. 3: Identify by name, address and phone number of each pathologist
who was on duty and in charge/supervising the operations of the pathology department of the
Hospital on March 5, 2012 and indicate the start and ending time of each pathologist.

ANSWER:

Berardo, Melora, MD                                                Chief Pathologist
600 N. Union Ave
New Braunfels, Texas 78130
830.643.5189

Dr. Berardo was responsible for Clinical Pathology services from 5:00 PM on March 5, 2012
through the conclusion of her shift on March 6, 2012.

Hensley, Richard, MD                                               Pathologist
600 N. Union Ave
New Braunfels, Texas 78130
830.606.9111

Dr. Hensley was responsible for the Histology Department from 7:45 AM to 5:00 PM on March
5, 2012.




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INTERROGATORY NO. 4: Identify by name, address and phone number who was serving as
Chief of Pathology for the Hospital on March 5, 2012.

ANSWER:

Berardo, Melora, MD                                              Chief Pathologist
600 N. Union Ave
New Braunfels, Texas 78130
830.643.5189



INTERROGATORY NO. 5: Identify by name, address and phone number Chief of Surgery for
the Hospital on March 5, 2012.

ANSWER:

Metzger, Nicholas, MD                                            Chief of Surgery
191 N. Union Avenue
New Braunfels, Texas 78130
830.627.9229



INTERROGATORY NO. 6: Identify by name, address and phone number the pathology
department personnel, technician and/or pathologist who you contend called and/or informed
the surgical department on March 5, 2012 to tell them the cryostat a/k/a frozen section
equipment was down due to contamination and need for cleaning.

ANSWER:

CHRISTUS Santa Rosa Hospital — New Braunfels                     Treating Facility
c/o Counsel Edward J. Kroger and Leah A. Greene
Kroger | Burrus
3100 Weslayan, Suite 300
Houston, Texas 77027
Telephone: 713.961.7952
Custodian of Records, employees, agents, physicians, nurses, aides, therapists, and affiliated
healthcare providers currently employed and/or employed at the time of the incident made the
basis of this lawsuit, including but not limited to:

Bonner, Joe, RN                                                  OR Supervisor
Holden, Pamela, HT                                               Lab Supervisor
McKeen, Cassie, RN                                               Circulator




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                                                                                      R. 1:60
INTERROGATORY NO. 7: Identify any and all Pathology Policies and Procedures manuals
and/or guidelines that were in effect on March 5, 2012, which address and/or pertain in any
manner to proper communication to various departments/personnel within the Hospital if any
pathology equipment, including but not limited to cryostat a/k/a frozen section machine(s) are
not available for use for any reason.

ANSWER:       Please see the attached CHRISTUS Santa Rosa Hospital — New Braunfels
              Guidelines. Please highlight the sections you would like to review, and
              Defendant will forward the same to you.



INTERROGATORY NO. 8: Identify any and all Surgical Department Policies and Procedures
manuals and/or guidelines that were in effect on March 5, 2012, which address and/or pertain in
any manner to the proper course of action and/or communication to physicians, surgeons
and/or surgical technicians if any pathology equipment, including but not limited to cryostat
a/k/a frozen section machine(s) are not available for use for any reason.

ANSWER:       Please see the attached CHRISTUS Santa Rosa Hospital — New Braunfels
              Guidelines. Please highlight the sections you would like to review, and
              Defendant will forward the same to you.




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                                                                                       R. 1:61
Pamela Holden                                                                               1

                 1                             NO. C-2013-0566-C

                 2   LESLIE BAIRD,                          ) IN THE DISTRICT COURT
                                                            )
                 3              Plaintiff,                  )
                                                            )
                 4   VS.                                    ) COMAL COUNTY, TEXAS
                                                            )
                 5   GERALD MARCUS FRANKLIN,                )
                     M.D., AND G. MARCUS                    )
                 6   FRANKLIN, M.D. &                       )
                     ASSOCIATES, P.A. D/B/A THE             )
                 7   ENT CENTER OF NEW                      )
                     BRAUNFELS, CHRISTUS                    )
                 8   HEALTH; AND CHRISTUS SANTA             )
                     ROSA HEALTH CARE                       )
                 9   CORPORATION D/B/A CHRISTUS             )
                     SANTA ROSA HOSPITAL - NEW              )
                10   BRAUNFELS,                             )
                                                            )
                11              Defendants.                 ) 274TH JUDICIAL DISTRICT

                12
                                   -----------------------------------
                13
                                    ORAL AND VIDEOTAPED DEPOSITION OF
                14
                                                  PAMELA HOLDEN
                15
                                                  JULY 16, 2014
                16
                                 -----------------------------------
                17         ORAL AND VIDEOTAPED DEPOSITION OF PAMELA HOLDEN,

                18   produced as a witness at the instance of the DEFENDANT,

                19   and duly sworn, was taken in the above-styled and

                20   numbered cause on July 16, 2014 from 9:08 o'clock a.m.

                21   to 1:46 o'clock p.m., before DEBBIE S. LONGORIA, CSR in

                22   and for the State of Texas, reported by machine

                23   shorthand, at the COURTYARD MARRIOTT NEW BRAUNFELS,

                24   pursuant to the Texas Rules of Civil Procedure and the

                25   provisions stated on the record or attached hereto.


                      DepoTexas, Inc. / Sunbelt Reporting & Litigation Services   R. 1:62
Pamela Holden                                                                                  158

                 1        A.     I've just always called directly to the OR and

                 2   told them that the cryostat will be down, no more

                 3   frozens.

                 4        Q.     Generally, that's usually all the cryostat is

 01:09           5   used for is by the OR department, correct?

                 6        A.     Correct.      Well, we also get tissue from the

                 7   surgery center on Commons and we drive down there, pick

                 8   it up as fast as we can, get it back and perform a

                 9   frozen.

 01:09          10        Q.     But, within regards to the hospital setting,

                11   it's -- cryostat is used by the pathologists when

                12   requested by surgeons in the OR?

                13        A.     Correct.

                14        Q.     And do you -- do you remember what you did in

 01:10          15   this case with respect to this particular tissue and who

                16   you contacted?

                17        A.     For this one, as soon as I handed it to

                18   Dr. Hensley, he said, "Possible granulomas," and I said,

                19   "Okay.    What does that mean possible?               Yea or nay, are

 01:10          20   we shutting it down?"          And he said, "Yes."           I said,

                21   "Okay."    I called directly into the OR and I said, "The

                22   cryostat will be down."           I spoke with Joe Bonner on

                23   this.

                24        Q.     All right.       And is it your testimony you made

 01:10          25   that phone call immediately after getting instructions

                      DepoTexas, Inc. / Sunbelt Reporting & Litigation Services      R. 1:63
Pamela Holden                                                                                    159

                 1   or information from Dr. Hensley that the cryostat is to

                 2   be shutdown?

                 3        A.     Yes, sir.

                 4        Q.     And this is a phone call that you had with

 01:11           5   him, you didn't tell him in person, correct?

                 6        A.     Correct.

                 7        Q.     And am I right to assume that this is a phone

                 8   call that lasted a very short period of time?

                 9        A.     Correct.

 01:11          10        Q.     Do you know for a fact that you specifically

                11   remember sitting here today making that phone call?

                12        A.     Yes, sir.

                13        Q.     And what was Mr. Bonner's response?

                14        A.     He -- he repeated what I said.                   I said, "The

 01:11          15   cryostat's shutdown, no more frozens."                 And he said, "No

                16   more frozens?"       And I said, "No, sir.            We are down for

                17   the day."

                18        Q.     Did you tell him because of suspected TB?

                19        A.     Yes.

 01:11          20        Q.     Any other information you gave him other than

                21   what you've told me already?

                22        A.     No, not that I remember.

                23        Q.     Not that you remember?

                24        A.     Correct.

 01:11          25        Q.     All right.       Did you have any subsequent

                      DepoTexas, Inc. / Sunbelt Reporting & Litigation Services        R. 1:64
R. 1:65
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R. 1:67
Cassie McKeen                                                                             1

  1                                 NO. C-2013-0566-C

  2     LESLIE BAIRD,                              ) IN THE DISTRICT COURT
                                                   )
  3                 Plaintiff,                     )
                                                   )
  4     VS.                                        ) COMAL COUNTY, TEXAS
                                                   )
  5     GERALD MARCUS FRANKLIN,                    )
        M.D., AND G. MARCUS                        )
  6     FRANKLIN, M.D. &                           )
        ASSOCIATES, P.A. D/B/A THE                 )
  7     ENT CENTER OF NEW                          )
        BRAUNFELS, CHRISTUS                        )
  8     HEALTH; AND CHRISTUS SANTA                 )
        ROSA HEALTH CARE                           )
  9     CORPORATION D/B/A CHRISTUS                 )
        SANTA ROSA HOSPITAL - NEW                  )
 10     BRAUNFELS,                                 )
                                                   )
 11                 Defendants.                    ) 274TH JUDICIAL DISTRICT

 12
                      -----------------------------------
 13
                       ORAL AND VIDEOTAPED DEPOSITION OF
 14
                                       CASSIE McKEEN
 15
                                       JULY 16, 2014
 16
                      -----------------------------------
 17             ORAL AND VIDEOTAPED DEPOSITION OF CASSIE McKEEN,

 18     produced as a witness at the instance of the DEFENDANT,

 19     and duly sworn, was taken in the above-styled and

 20     numbered cause on July 16, 2014 from 2:22 o'clock p.m.

 21     to 4:59 o'clock p.m., before DEBBIE S. LONGORIA, CSR in

 22     and for the State of Texas, reported by machine

 23     shorthand, at the COURTYARD MARRIOTT NEW BRAUNFELS,

 24     pursuant to the Texas Rules of Civil Procedure and the

 25     provisions stated on the record or attached hereto.


                    DepoTexas, Inc. / Sunbelt Reporting & Litigation Services   R. 1:68
Cassie McKeen                                                                              69

  1             A.   I don't really understand that.

  2             Q.   Sure.

  3             A.   It went on too long.

  4             Q.   You -- you are -- you are testifying under

  5     oath that you told Dr. Franklin, prior to him doing the

  6     surgery, that the cryostat was down?

  7             A.   That's correct.

  8             Q.   And that he proceeded, despite knowing that

  9     information, that's your testimony, correct?

 10             A.   Yes.

 11             Q.   My question is, have you ever had that

 12     experience before with another physician on a

 13     thyroidectomy where, for whatever reason, the cryostat

 14     was down, you informed that surgeon that it was down,

 15     yet, that surgeon went forward with the thyroidectomy,

 16     even though it wasn't -- even -- even though that

 17     equipment was not available to them?

 18             A.   I cannot.

 19             Q.   This is the only case that you can remember?

 20             A.   This is the only case I can remember a

 21     thyroidectomy.         Other cases, I can remember where we

 22     proceeded.

 23             Q.   I'm sorry, what?

 24             A.   Where we proceeded if there wasn't frozen

 25     available.

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