Office Policies and Procedures

Security Statement

Carrie Tingley Hospital Foundation has taken measures to guard against unauthorized or unlawful processing of personal data and against accidental loss, destruction or damage.  This includes:

  • Adopting this information security policy
  • Taking steps to control physical security (projects and staff records are all kept in a locked filing cabinet)
  • Putting in place controls on access to information (password protection on files and server access)
  • Training all staff on security systems and procedures
  • Detecting and investigating breaches of security should they occur

 


Policy
Foundation Office – 700 Lomas Blvd NE, #2-200, Albuquerque, NM 87102

Bellamah Warehouse – 1224 Bellamah Ave NW, Albuquerque, NM 87104

Name of Procedure Building Access, Maintenance
Reference Number 0.00
Applicable Parties All Carrie Tingley Hospital Foundation Employees
Effective Date 7/22/24
Supporting Documentation Key Request Form
Procedures 0.01         Foundation Building Access

  • The Call Box number is 059. Upon arrival at the building once the call box number has been entered it will call the foundation main line to initiate access.
  • To request an access card fill out the Research Park Card & Key Signature Form. Once the form is completed email it to keys@unm.edu once the form has been emailed go to https://fm.unm.edu/services/lock-shop.html and schedule an appointment to pick up a key.

0.02       Foundation Maintenance Requests

  • Contact The Property Management Office at (505) 272-7313 or by email stpark@unm.edu

0.03      Bellamah Warehouse Access

There are three sets of keys to the building and utility trailers. The keys are in the possession of the Executive Director, Director of Programs, and Michael Chamberlain. Keys should not be duplicated or given to any other individual especially not employed by the Carrie Tingley Hospital Foundation without Executive Director approval.

Approved by / Date

 


Policy
Building – 700 Lomas Blvd NE, #2-200, Albuquerque, NM 87102
Name of Procedure Information Technology
Reference Number 1.00
Applicable Parties All Carrie Tingley Hospital Foundation Employees
Effective Date 7/22/24
Supporting Documentation Help Desk Request Form
Procedures 1.01         Information Technology Support

1.02        Critical Malfunction

  • Advise the Executive Director for next steps.
Approved by / Date

 


Policy
Building – 700 Lomas Blvd NE, #2-200, Albuquerque, NM 87102
Name of Procedure Telephones
Reference Number 2.00
Applicable Parties All Carrie Tingley Hospital Foundation Employees
Effective Date 7/22/24
Supporting Documentation Teams User Guide Get started with Microsoft Teams phones - Microsoft Support
Procedures 2.01      Telephone Setup and Repair

  • The phones are set up through Iron Edge Group and part of the Microsoft Teams platform. Users have access through their company issued computer or personal data device. Iron Edge Group can be contacted at 1-913780-0494 or email helpdesk@ironedgegroup.com

2.02       Answering Phones

  • Utilize the standard greeting of: “Thank you for calling Carrie Tingley Hospital Foundation this is (NAME) how may I assist you?” Messages should be sent via email to the intended recipient.

2.03       Phone Call Routing

  • Phones are routed in the following order prior to going to voicemail the Administrative Assistant, Director of Programming, Director of Development
Approved by / Date

Policy
Building – 700 Lomas Blvd NE, #2-200, Albuquerque, NM 87102
Name of Procedure Copy Machine, Fax and Printing
Reference Number 3.00
Applicable Parties All Carrie Tingley Hospital Foundation Employees
Effective Date 7/22/24
Supporting Documentation Lanier IM C3000 User Manual IM C3000/C3500 download page (ricoh.com)
Procedures 3.01 Copy Machine

  • The copy machines are set up through Iron Edge Group. Iron Edge Group can be contacted at 1-913780-0494 or email helpdesk@ireonedgegroup.com
  • The Fax machine e-fax is set up through Iron Edge Group. Iron Edge Group can be contacted at 1-913780-0494 or email helpdesk@ironedgegroup.com Our fax number is (505) 738-5444.

3.02       Printing Codes

  • Utilize the following to allocate printing costs to the correct department:
    • Management and General 10
    • Quality of Life 30
    • Patient and Family 33
    • Fundraising 40
    • Pickleball 41
    • Golf 42
    • Day of the Tread 43
    • Trees 44

3.03       Service Requests

  • RICOH Aficio SP C400DN PCL 6 is not under a service contract.
  • LANIER IM C3000 PCL 6 is maintained by DocTech.com (505) 888-3005 and provide ID#D0BL1616
Approved by / Date

 


Policy
Building – 700 Lomas Blvd NE, #2-200, Albuquerque, NM 87102
Name of Procedure Postage and Post Office Box
Reference Number 4.00
Applicable Parties All Carrie Tingley Hospital Foundation Employees
Effective Date 7/22/24
Supporting Documentation Postbase Vision user manual: FP POSTBASE VISION REFERENCE MANUAL Pdf Download | ManualsLib

Current Postage Rates: Retail Postage Price Calculator (usps.com)

Non-Profit USPS Guidelines: How to Prepare Nonprofit Mail | Postal Explorer (usps.com)

Procedures 4.01        Postage Machine

  • The postage machine is a Postbase Vision use the above user for operation instructions.

4.02       Postage Account

  • Login to usps.com to login the username is: CTHF2020 Password: CTHF4thekids
    • You may Request Pickup from the site
    • You can access all postage transactions

4.03       Supplies

  • Login to stamps.com username CTHF2020 Password: CTHF4thekids! to order click and ship labels. All other materials can be ordered through the USPS site or by picking supplies up at the closest USPS.

4.04      Postage

  • On an annual and, at times, semi-annual basis, the Post Master General may change the base rate for postage. To ensure accurate postage pricing, please use the above retail postage price calculator and compare it to the pricing listed on the Postbase Vision.

4.05       Post Office Box

  • Our PO Box number is PO BOX 25424, Albuquerque, NM 87125 located at 1135 Broadway Blvd NE, Albuquerque, NM 87101. The Director of Development has the PO Box key and checks the mail regularly.
Approved by / Date

 


Policy
Automatic External Defibrillator
Name of Procedure AED
Reference Number 5.00
Applicable Parties All Carrie Tingley Hospital Foundation Employees
Effective Date 7/22/24
Supporting Documentation NM Department of Health: Microsoft Word - EMS-AED-CARP-ApplicationForm.docx (nmhealth.org)

AHA Protocols: Your On-site AED Program: An Implementation Guide (heart.org)

PALS: PALS Precourse Self-Assessment and Precourse Work (heart.org)

Procedures 5.01      AED Machine

  • The AED Machine is a

5.02       AED Login

  • Login username: CTHF4thekids Password: QOL$

5.03       Usage

  • Before operating the AED you must be trained to do so. Please contact ABQ Fire Rescue Administration HQ at (505) 833-7300 for training. Eryn Bialey
  • The State of New Mexico requires administrative and operational requirements on AED oversight such as maintenance, training, program oversight, AED placement reporting, EMS activation, post-event reporting, program documentation, AED program registration.
  • AED participants are protected under The Good Samaritan Law. Students must not utilize the foundation AED. Please see NMStatues Annotated 24-10C-7, 7.27.8.2, 7.27.8.3, 7.27.8.6, 7.27.8.7, 7.27.8.8, 7.27.8.9, 7.27.8.11.

A. AED program supervising trained targeted responder shall:

(1) Oversee the AED program, assuming responsibility for how the AED program is planned and conducted.

(2) Select and identify other participating persons as trained targeted responders.

(3) Maintain AED training records for all trained targeted responders while they are active in the program, and for at least three years thereafter.

(4) Maintain AED program records including AED maintenance records, trained targeted responder training records, and AED usage records.

(5) Ensure that all trained targeted responders are trained using a training program which has been approved by the department.

(6) Provide evidence of coordination of the AED program with local EMS services and emergency dispatch agencies, including 911 dispatch agencies.

(7) Register the AED program with the department and pay registration fees, as detailed in this regulation.

(8) Report all operational uses of the AED to the department.

(9) Perform quality assurance review of all operational defibrillations; and.

(10) Ensure AED equipment is maintained in accordance with the manufacturer's guidelines.

B. Trained targeted responders: Individuals selected by the supervising trained targeted responder that are trained in CPR and use of an AED and understand how to activate the local emergency medical system for any sudden collapse or cardiac arrest victim:

(1) Prior to participating in an AED program, trained targeted responders shall complete an initial AED training course from a Department approved training program. The course shall include both cardiopulmonary resuscitation (CPR) and AED training.

(2) At least every two years, trained targeted responders shall recertify in CPR and AED training, by successfully completing a department approved AED training course.

(3) Activate the emergency medical system during any operational response to a victim of cardiac arrest, and advise that AED is being used.

(4) Comply with program protocols for operational response to victims of cardiac arrest.

(5) Report all operational responses to victims of cardiac arrest to the supervising trained targeted responder and complete a defibrillation report. A copy of the report shall be submitted to the department within 20 calendar days.

(6) Ensure AED's are maintained and used in accordance with the manufacturer's guidelines, and inspect AED equipment at least monthly.

C. Registration: All AED programs shall be registered with the department:

(1) Initial registration: The initial registration period shall be for a period of four years. The supervising trained targeted responder for the AED program shall complete the application provided by the bureau and submit it to the department, along with the appropriate fees.

(2) Renewal: AED programs shall renew the AED program every four years, with a renewal application provided by the bureau submitted to the department, along with the appropriate fees.

(3) Notification of changes in registration: The department shall be notified when there is a:

(a) change in AED supervising trained targeted responder;

(b) change in physical address or telephone number; or

(c) stoppage or cancellation of the AED program.

D. Fees: The bureau shall establish a fee schedule for AED programs. Seventy-five ($75) dollars shall be paid by the AED program to the department for initial registration. For renewal, AED programs shall pay a fee of fifty ($50) dollars to the department.

E. Notification: Local EMS services and emergency dispatch agencies shall be notified of the activation and existence of the AED program. The notification shall include the name of the AED program supervising trained targeted responder, location of the program, telephone number, a copy of the program protocols, location of the placement of AED(s), and the operational area where the AED(s) will be used. The local emergency services and dispatch agencies shall also be notified if an existing AED program stops or cancels the AED program.

F. AED Selection and Maintenance:

(1) AED Selection: AED programs shall acquire and use semi-automated cardiac defibrillators. These devices require the responder to deliver the shock by pushing the shock button. AED programs that want a fully automated defibrillator (analyzes and shocks without operator input) may petition the bureau for a waiver to use an automated defibrillator.

(2) Maintenance: AED programs shall maintain the AED(s) and associated supplies and batteries in accordance with the manufacturer's suggested guidelines.

G. Record Keeping: Establish and maintain a record keeping system. Include the following information:

(1) List of trained targeted responders.

(2) Dates of training for trained Targeted Responders including CPR training and AED training.

(3) Copy of program protocols.

(4) Copy of registration and EMS service notification forms.

(5) AED usage reports/Data collection forms; examples may be obtained from the bureau.

(6) Quality assurance review documentation.

(7) AED equipment purchase and maintenance records.

Approved by / Date

 


Policy
Purchasing
Name of Procedure Purchasing
Reference Number 6.00
Applicable Parties All Carrie Tingley Hospital Foundation Employees
Effective Date 7/22/24
Supporting Documentation General Ledger Code Matrix (GL Code)
Procedures 6.01      Purchasing Procedure

  • All purchase requests for any program must be requested through the Director of Programs via itemized email with vendor information, item number, item name, item price, and item quantity.
  • All requests will be sourced by the Director of Programs and must be budget-friendly.
  • All purchase requests must be approved by the Executive Director.
  • All purchases must be made utilizing the Director of Programs credit card.
  • Receipts for each transaction must be retained. The receipt must be accompanied by a Department Cost Center Name and General Leger Code.
  • Purchases must never be cross-departmental or cross-program.
  • Receipts are provided to SJT Group weekly.

6.02       Lunches

  • Lunch may be ordered utilizing a company credit card. All attendees must be listed on the receipt.

6.03       Personal Purchases

  • All purchases requiring foundation reimbursement must be approved prior to purchase by the Executive Director. Personal purchases are limited and could lead to disciplinary action or termination.
Approved by / Date

 


Policy
Accounts Receivable
Name of Procedure Accounts Receivable
Reference Number 7.00
Applicable Parties All Carrie Tingley Hospital Foundation Employees
Effective Date 7/22/24
Supporting Documentation  Donor Perfect Learning Center User Manual: DonorPerfect Nonprofit Software User Learning Center
Procedures 6.01      Donor Perfect

  • Safe Save handles all Donor Perfect financial transactions and payment is distributed to the Carrie Tingley Hospital Foundation Account.

6.02       Fundraising

  • Utilize Donor Perfect for all sales transactions. Donor Perfect Processing Gateway allows for credit card, electronic check, and TXT2Pay.
  • Cash transactions should be recorded in Donor Perfect and deposited into the Carrie Tingley Hospital Foundation Account.
Approved by / Date

 


Policy
Accounts Payable
Name of Procedure Accounts Payable
Reference Number 8.00
Applicable Parties All Carrie Tingley Hospital Foundation Employees
Effective Date 7/22/24
Supporting Documentation  Approved Vendor List
Procedures 8.01      Accounts Payable Invoices and Statements

  •  Invoices and Statements are received via mail or email. Once received, review the vendor list to ensure this is a regular vendor. If it is not a usual or customary vendor, engage with the Executive Director to see if the vendor is approved and add them to the vendor list.
  • Attach the invoice or statement and correctly apply the Department Cost Center Name and General Leger Code. Once this step has been completed, attach the invoice or statement to a Check Request Form and provide the document to the Executive Director on a weekly basis for review and approval of payment.
  • Once the invoice or statement has been approved by the Executive Director, provide all documents to SJT Group for final accounting and issuance of a check.
  • SJT Group will provide the Director of Programs with a check to issue payment.
  • Scan all documents into SharePoint monthly.
Approved by / Date

 


Policy
Risk Identification and Assessment
Name of Procedure Risk Identification and Assessment
Reference Number 9.00
Applicable Parties All Carrie Tingley Hospital Foundation Employees
Effective Date 7/22/24
Supporting Documentation Fiscal Management Policy

Employee Compensation Policy

Gift Acceptance Policy

Records Retention and Destruction Policy

Conflict of Interest Policy

Whistleblower Policy

Fraud, Waste, and Abuse Prevention Policy

Incident Reporting Policy

Procedures 9.01  Risk Identification and Assessment

  • Please see the above referenced policies for process, procedure, and reporting.
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