Mail and Packages

To assure mail is handled in the quickest and most secure manner, to assure adequate segregation of duties and to assure HIPAA laws are adhered to, the following policy is applicable to the distribution of mail.

The processes are to be followed by all NKY Health staff who process and receive postal materials.

Please note that this system's success is predicated on the addressee fulfilling her/his responsibility in a timely manner.

Division support staff responsible for mail distribution (including adequate back-ups) are assigned and approved by the administrative/managerial staff at each location, and must NOT be staff responsible for depositing checks into NKY Health accounts.

Immediately after receipt of mail, the front desk staff will contact the “mail person” who will process the mail.

Normal processing includes:

1. Open it.

2. Date stamp it.

3. Distribute it.

Special processing is needed as follows:

• CHECKS received:  Date stamp paperwork accompanying checks.  ALL checks are to be logged onto the Check Log database and hand delivered to the recipient.

• CONFIDENTIAL MEDICAL INFORMATION from medical facilities will not be opened.  It will be date stamped on the outside of the envelope and distributed to the Clinical Services billing staff.

• OPEN RECORDS REQUESTS: Date stamp and give to Director of Environmental Health & Safety.

• REQUESTS FOR MEDICAL RECORDS: Date stamp and give to Support Services Supervisor.

• PUBLIC INFORMATION REQUESTS: Date stamp and give to Public Information Officer.

Do NOT open mail if any of the following is true:

1. • It is suspicious.

   • It is marked “CONFIDENTIAL.” 

   • It is intended for Human Resources.  (Give this item to the Clinic/Site Manager or her/his designee.  S/He will open it and scan it to the HR Administrator if it's anything other than "junk mail" and will discard it if it appears to be "junk mail.")

   • It appears to be personal (i.e. card).

   • It meets criteria suggesting it contains potential confidential medical information (see below for criteria.) In this case, the outside of the envelope will be date stamped.

Procedures

Follow these steps:

1. Open all DPH/CHFS mail.

2. Date stamp top right hand corner of document. 

3. Route stamp bottom right hand corner of document and enter who the document was addressed to and who will receive a copy(s).  Enter Division under “Central Files” (i.e. CS = Clinical Services, A&A = Administrative & Accounting, etc.) as this is where the original copy will be filed.

4. Make copies and distribute.

5. Original document goes to the District Executive Assistant for logging and filing. Addressee(s) are responsible to route/send copies in a timely manner to other individuals in their Division as appropriate.

Reasons for Procedures

These procedures are put in place for the following reasons:

• Mail sent from Frankfort is to a position, not to an individual.  This mail needs to be opened and disseminated regardless of to whom it is addressed.

• These procedures will help to ensure all concerned parties receive the information and that there is easy access to correspondence from Frankfort.

• All incoming business mail is date stamped per internal control requirements established by federal, state, and local auditing standards.

• All incoming potential privileged medical information from medical facilities is handled according to HIPAA Guidelines and Medical Record Documentation located in the DPH Administrative Reference Manual.

When sending potential confidential non-medical information through interdepartmental mail, use the regular interdepartmental envelopes and mark it "CONFIDENTIAL."

When sending potential confidential medical information through interdepartmental mail, always use the BLUE interdepartmental envelopes.

When receiving potential confidential medical information date stamp the outside of the envelope but do not open the envelope.

When sending potential confidential medical information through interdepartmental mail, always use the BLUE interdepartmental envelopes.

Please assume mail contains confidential medical information when any of the following is true:

• • The envelope is marked "Attention: Medical Records Custodian" or something similar.

  • The mail is from:

    • Department of Public Health Laboratory Services

    • St. Elizabeth Hospital (birth certificates) – to be given to Deputy Registrar

    • Medical Facility Departments of:

      • Medical Records

      • Laboratory Services

      • Infection Control

      • Radiology

      • Avesis Company

Some characteristics of suspicious packages and envelopes include the following:

• Inappropriate or unusual labeling

  • • Excessive postage

    • Handwritten or poorly typed addresses

    • Misspellings of common words

    • Strange return address or no return address

    • Incorrect titles or title without a name

    • Not addressed to a specific person

    • Marked with restrictions, such as "Personal", "Confidential" or "Do Not X-Ray"

    • Marked with any threatening language

    • Postmarked from a city or state that does not match the return address

• Appearance

  • • Powdery substance felt through or appearing on the package or envelope

    • Oily stains, discolorations, or odor

    • Lopsided or uneven envelope

    • Excessive packaging material such as masking tape, string, etc.

• Other suspicious signs

  • • Excessive weight

    • Ticking sound

    • Protruding wires or aluminum foil

When a package or envelope appears suspicious and/or has any substance spilling out follow these steps immediately:

1. Isolate item as safely as possible (shut doors, keep individuals away.)

2. Notify your supervisor immediately.

3. Your supervisor may clear the area, contact others, call 9-1-1, or take other actions deemed necessary.

When a package or envelope appears suspicious and/or has any substance spilling out:

DO NOT:

• Handle it.

• Move it.

• Clean it up.

• Shake or empty the contents of it. 

• Carry it, show it to others or allow others to examine it. 

• Sniff, touch, taste, or have prolonged proximity to it or any contents which may have spilled.

DO:

• Immediately notify your supervisor.

• Alert others in the area about the suspicious package or envelope.

• Isolate item as safely as possible (shut doors, keep individuals away).

• Wash hands with soap and water to prevent spreading potentially infectious material to face or skin. 

• Create a list of persons who were in the room or area when the suspicious package or envelope was recognized and give this list to your supervisor. 

Staff must not receive personal mail/packages at work.

10/3/2022

• Updated policy header. 

• Added How to Identify Suspicious Packages / Envelopes section