Committee forwards a slate of clinic policies to full board, flags HRSA and wording concerns

At its May 12 meeting, the Dahl Memorial Clinic Planning Committee voted to forward a large group of clinic policies to the full board for approval, while discussing clarifications needed to meet HRSA requirements and to reflect current operations.

The committee moved policies including the clinic volunteer policy, scope-of-project document, quality improvement policy, peer review, safety and health, controlled substance policy, medical-staff on-call, drug drop box, obstetrical care, chaperone, medical records, behavioral health procedures and medical assistant policy to the full board; motions and seconds for each were recorded and each motion passed without objection.

Why it matters: Several policies intersect with federal grant compliance (HRSA) and daily clinic operations. Committee members pressed for clearer language where practice has diverged from written materials — for example, references to an existing senior center in the scope form that the committee said no longer exists and a safety-plan attachment last revised in February 2019 that does not include active‑shooter protocols recently trained at the clinic.

Volunteer policy: The committee approved forwarding a revised volunteer policy. The policy adds a definition that distinguishes an on-call professional (who would provide care under their license and protections such as the Samaritan’s Law) from routine volunteers, and clarifies which volunteer activities require background checks. Director Wahl told the committee she would have a nursing student complete the municipality’s volunteer application because the student will work near protected health information.

Scope and HRSA: Members discussed accepting the scope document by reference (as done previously with a legislative mandate policy) to avoid repeatedly copying federal text into local policy. The committee noted the clinic’s scope has changed often — “we've had 10 changes in scope in the last 3 years,” a committee member said — and agreed that keeping the official form (Form 5 A, B, C) as the operative record would reduce errors.

Titles and HRSA recognition: Committee members debated whether to use “medical director” (an MD requirement under HRSA) or “health director” (a term used locally for a supervising nurse practitioner). The committee resolved to add clear language listing the health director in review roles while noting HRSA’s requirement that a medical director term is MD‑specific.

Controlled substances and procedures: The committee flagged a draft change shortening a period from 60 to 30 days for certain controlled‑substance prescriptions and asked staff to confirm whether that change reflects CDC or state requirements; staff said Britney drafted the edit and would verify the source. The committee also noted that procedures would need updating to reflect any policy changes.

Other operational items: The safety and health policy will be updated to include active‑shooter protocol and a communicable‑disease point person; the obstetrical policy attachments need updates to reflect current providers and the transfer agreement with Bartlett; and a new chaperone policy is being renewed following recent law changes.

Ending: Each policy will go to the full board for final reading after the committee’s requested clarifications are incorporated.