MedStar Health Policy and Procedure Updates March, 2021

MedStar Health regularly updates, revises and creates new policies and procedures for the operational efficiency of the organization.

Please be advised, the following policies and procedures are now in effect.

Effort Commitment and Certification

The Effort Commitment and Certification policy was updated to incorporate changes mandated in the Uniform Guidance to match MHRI Office of Contract & Grants processes in our current accounting system, and to provide a tool for collecting effort information for those staff employed by MedStar but external to MHRI.

There are no substantial changes to our business practices. However, one change does close the loop on a known audit gap regarding the reconciliation of the committed effort and the actual effort expending on a federal award or any award that invokes the federal regulations regarding effort commitment.

• OCG.O-007.01 Effort Commitment and Certification
• OCG.O-007 Effort Commit and Certification 
• OCG.O.007.01 FM1 Effort Allocation Report 

Government Inquiries

These policies have been updated as part of the three year periodic review.

• ORG.O-007.01 Responding and Managing Government Inquiries
• ORG.O-007 Responding to Government Inquiries

Emergency Response Management

It is recommended by MedStar Health ER One Institute that ERM policies are reviewed annually. During the annual review, we work with ER One and they inform us of any MedStar Health changes. In addition, we confirm all contact information (e.g., telephone numbers) are still accurate.

• ERM O-001 Active Shooter and Hostage Plan Code Silver
• ERM O-002 Bomb Threat Suspicious Package Code Gold
• ERM O-003 Bad Weather Emergency Response
• ERM O-004 Fire Prevention and Fire Emergency Code Red
• ERM O-005 Telephone IS Failure
• ERM O-006 Utilities Failure

Any questions regarding the new policy and procedure should be directed to MHRI-OCGM@medstar.net.