Employee Assessment Manual

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					         Employee Assessment Manual
Hold Ctrl and L Click on the Subject Title to take you to that area of Study:

Abuse and Neglect                                                        Go To Test
Advance Directives                                                       Go To Test
Benefits                                                                 Go To Test
Customer Satisfaction                                                    Go To Test
Disaster Preparedness/Fire Safety                                        Go To Test
Haz Mat                                                                  Go To Test
HIPAA                                                                    Go To Test
Hospital Incident Command System (HICS)                                  Go To Test
Infection Control                                                        Go To Test
    Infection Control 2                                                  Go To Test
Bloodborne Pathogens                                                     Go To Test
Lifting and Body Mechanics                                               Go To Test
Phone and FAX Usage                                                      Go To Test
Resident and Patient Rights                                              Go To Test
Risk Management/Performance Improvement                                  Go To Test

Hold Ctrl and L Click the “Go Home” option at the beginning or the end of each study guide area
or test page to bring you back to this page.

You may access the assessment tests through the links given above, or choose the one provided
at the end of each study guide section. Hold down the Ctrl key and left click the mouse to access
the links.

Printed manuals containing the study guides, tests, answer sheet, Handwashing
Competency Checklist and Cleaning Product Use Review Sheet are located at the hospital
nurses station, CLC nurses station, dietary department, or are available for checkout from
the Public Relations office.

When you are ready to begin testing, get a printed answer sheet from your department OR
hold Ctrl and L Click here to go to the Answer Sheet. Choose FILE > Print from the tool bar at
the top of the computer screen and specify to print ONLY pages 146-147 on the Page
Range given on the printer screen if you choose to print your own answer sheet. Choose
to print page 148 for the Handwashing Comptency Checklist Sheet or print page 149 for
the Cleaning Product Use Review Sheet.

Record your answers on your printed answer sheet using a pen or pencil by circling the
best answer choice. BE SURE to write your full name, date and last 4 digits of your SS #
on your answer sheet. When you are finished with all 15 assessment tests, place your
answer sheet in the Public Relations mailbox in the front office. Your test will be graded
within a few days. If it is necessary for you to retake a test to reach the 80% passing
score, you will be notified by your department manager.

If you would like to know which questions you missed, please contact Becky Wilson in
Public Relations.
           ***********************************************************

Abuse & Neglect                                                          Go Home
      DECATUR HEALTH SYSTEMS PURPOSE AND POLICY
                  REGARDING ABUSE
DHS PURPOSE:

To ensure the facility has in place an effective system that will prevent mistreatment, abuse,
and neglect of residents/patients or misappropriation of their property.

The facility will promptly investigate and report all identified incidents of alleged or suspected
abuse/neglect of patients or misappropriation of their property.

To ensure all identified incidents involving injury of unknown origin are promptly investigated
to determine the cause of injuries and reported to the Charge Nurse.

To ensure a review of incidents are investigated and documented.

To review suspicious bruising of resident/patient, occurrences, or trends that may be abuse.

To determine the direction of the investigation.

To ensure the resident/patient is not subjected to abuse by anyone including, but not limited
to, facility staff, another resident or patient, consultant, volunteer, family member, legal
guardian, friends or others.

DECATUR HEALTH SYSTEMS ABUSE POLICY:

Each resident/patient at Decatur County Hospital/Cedar Living Center has the right to be free
from abuse, corporal punishment, and involuntary seclusion. Residents/patients must not be
subjected to abuse by anyone, including, but not limited to, facility staff, other
residents/patients, consultants or volunteer staff of other agencies serving the
resident/patient, family members or legal guardians, friends or other individuals.

             SCREENING AND TRAINING OF EMPLOYEES
SCREENING POLICY
Decatur County Hospital/Cedar Living Center will not knowingly hire any individual who has a
history of abusing other persons. This facility will conduct pre-employment reference checks,
abuse registry and other registry checks as deemed necessary on individuals making
application for employment within this facility.
SCREENING PROCEDURE:
1. Department Manager will conduct reference checks on persons making application for
employment. Reference checks will be completed prior to employment offer.
2. For all certified nurse aide applicants, the state nurse aide registry will be contacted to
determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of
property have been entered into the applicant’s file.
3. For any licensed professional individual applying for a position, his/her respective licensing
board will be contacted to determine if any sanctions have been assessed against the
applicant’s license.
4. Human Resource Department will conduct an O.I.G. check on each new employee.
5. Prior convictions of offenses other than abuse, neglect, mistreatment of individuals, and/or
theft of property may not necessarily disqualify an applicant from employment with our
facility. Serious consideration will be given to the position applied for, the seriousness of the
offense, and how recently the offense was committed.
6. Employment drug screening will be conducted on all new employees.

EMPLOYEE TRAINING:
All Decatur County Hospital/Cedar Living Center employees will receive periodic in-service
training relative to residents/patient rights and the facility’s abuse prevention policies and
procedures. This in-service training shall be held annually, but may be done more often if
deemed necessary.

TRAINING PROCEDURE:
1. All new employees will receive a copy of the residents/patient rights and facility abuse
prevention policy during orientation.
2. All employees are required to complete an annual in-service. In-service on abuse
prevention will be provided which will include:
   Appropriate interventions to deal with aggressive and/or catastrophic reactions of
residents
   How staff should report their knowledge related to allegations without fear of reprisal
   How to recognize signs of burnout, frustration and stress which may lead to abuse
   What constitutes abuse, neglect and misappropriation of resident/patient property

ABUSE PREVENTION:
Decatur County Hospital/Cedar Living Center will strive to provide a safe environment for all
residents/patients.

PROCEDURE:
1. Family, residents, patients, and staff will be provided information on how and to whom
they may report concerns, incidents and grievance without fear of retribution.
2. Residents/patients who are cognitively impaired or who do not have active family or friend
involvement will be assessed to assure their needs and behaviors are properly monitored
and appropriate interventions are reflected in the care plan.
3. Case Management at Cedar Living Center will meet weekly to review all resident issues
and make recommendations. Discharge Planning will meet three times a week to review all
Decatur County Hospital Patients.
4. The Performance Improvement Committee will meet weekly to review all resident/patient
incidents and make recommendations where appropriate.

IDENTIFICATION OF ABUSE:
Decatur County Hospital/Cedar Living Center will not condone any form of resident/patient
abuse or neglect. To aid in abuse prevention, all personnel are to report any signs of
abuse/neglect to their supervisor, Case Managers, or Chief Nursing Officer immediately.
PROCEDURE:
1. Sign of Actual Physical Abuse:
   · Welts or bruises
   · Abrasions or lacerations
   · Fractures, dislocations or sprains of questionable origins
   · Black eye or broken teeth
   · Improper use of restraints
   · Sexual exploitation
   · Rape
   · Excessive exposure to heat or cold
   · Involuntary seclusion
   · Any burns or human bites
2. Signs of Actual Physical Neglect:
   · Malnutrition and dehydration (unexplained weight loss)
   · Poor hygiene
   · Inappropriate clothing
      (soiled, tattered, poor fitting, lacking, inappropriate for season)
   · Decayed teeth
   · Improper use/administration of medication
   · Inadequate provision of care
   · Caregiver indifferent to resident/patient personal care and needs
   · Failure to provide privacy
   · Left alone but needs supervision
3. Signs/Symptoms of Psychological Abuse/Neglect:
   · Resident/patient clings to abuser/caregiver
   · Paranoia
   · Depression
   · Confusion
   · Disorientation
   · Withdrawal
   · Inconsistent injury explanation
   · Low self esteem
   · Anger
   · Suicidal

INVESTIGATION OF ABUSE:
The Performance Improvement Committee will review all abuse or neglect incidents involving
a resident/patient. The Committee will determine the level of follow up required based on the
answers to the Reportable Incident Checklist on the back of the Incident Report and upon
the initial investigation. All alleged abuse situations would be investigated and reported as
follows:

PROCEDURE:
1. The Social Service Director will coordinate the investigation. In the event of his/her
absence, the CEO will appoint a Coordinator. The Coordinator will report the event to the
Kansas Department of Health and Environment at the earliest possible time.
2. An investigation team, made up of the Chief Nursing Officer and Social Service Director
and Department Manager will investigate the report.
3. The investigation team will interview any person(s) with information of knowledge of the
incident. Appropriate clinical records will be researched. Accurate notes will be taken during
each interview. The team will interview witnesses separately, in order to accurately assess
the information.
4. The facility may, at its own discretion, involve the local police and/or its own attorney to
assist with the investigation.
5. Before completion of the investigation, the CEO will be notified of the team’s conclusion
and recommendations.


If such an investigation involves an employee, on conclusion of the investigation, the
employee(s) will be notified of the results. The Decatur Health Systems Personnel Policy
Manual will be used to determine appropriate disciplinary actions.




          STAFF PROCEDURES IF ABUSE IS SUSPECTED:

1. In cases of suspected sexual abuse:

   · Contact your supervisor immediately. In the absence of your supervisor, report to the
nurse on duty.
   · The nurse on duty will assess the resident/patient for possible injuries and document
appropriately.
   · Provide the resident/patient with emotional support.
   · Do not disturb the area where sexual abuse is suspected to have occurred.
   · The supervisor will contact the attending physician, responsible party, Chief Nursing
Officer and CEO immediately. The CEO or designee will determine the need to contact the
police department.
   · Do not attempt to bathe the resident/patient and do not douche the female
resident/patient.
   · Do not change the resident/patients clothing or linens so as not to disturb or lose
evidence.
   · Attempt to keep staff or potential witnesses from leaving the facility. If witnesses insist
on leaving, get names, addresses and phone numbers.
   · Assist the resident/patient in preparation to be transported to the hospital or other
designation as instructed by law enforcement. Local authorities will direct further follow-up
and investigation as needed.
   · Complete an Incident Report.

2. In cases of Resident /Patient Abuse:
    · Remove aggressor from the situation if the aggressor is still in the area in which the
incident occurred.
    · Contact your supervisor immediately. In the absence of your supervisor, report to the
nurse on duty.
    · The supervisor will contact the Chief Nursing Officer immediately; the CEO will be
contacted as needed.
    · Provide medical attention, as indicated.
    · Counsel the resident/patient involved to determine the cause of the behavior.
    · Notify each resident/patient representative and attending physician.
    · Evaluate the circumstances leading up to the incident.
    · Complete an Incident Report; document the incident, findings and any corrective
measures taken in the resident/patient medical record.
    · If any resident/patient is determined to be a danger to himself or others, contact the
attending physician immediately for alternative placement.
3. In cases of suspected physical abuse (other that of resident to resident):
    · Contact your supervisor immediately. In the absence of your supervisor, report to the
nurse on duty.
    · The supervisor will contact the Chief Nursing Officer and CEO immediately.
    · The nurse will contact the:
       a) Physician -if injury requires medical attention
       b) Responsible party of each resident/patient involved
       c) Police department-as directed by the CEO/designee
    · Follow physician’s orders or provide comfort and care. If police are involved, follow all
instructions.
    · Attempt to keep staff or potential witnesses from leaving the facility. If witnesses insist
on leaving get name, address and phone number.
    · Complete the Incident Report.
    · Local authorities will direct further follow-up and investigation as needed.

4. In cases of suspected misappropriation of resident/patient property:
    · Contact your supervisor immediately. In the absence of your supervisor, report to the
nurse on duty.
    · Two staff members may need to thoroughly search the resident/patient room, with
permission, and possibly search the entire facility.
    · Complete Incident Report.
    · The supervisor will contact the Chief Nursing Officer and the CEO/designee.
    · The police department will be notified when directed to do so by the CEO.
5. In cases of suspected verbal abuse:
    · Contact your supervisor immediately. In the absence of your supervisor, report to the
nurse on duty.
    · The supervisor will contact the Chief Nursing Officer and /or CEO.
    · Complete an Incident Report.
6. In cases of injury of unknown origin:
    · Contact your supervisor immediately. In the absence of your supervisor, report to the
nurse on duty.
    · The supervisor is to contact the Chief Nursing Officer and/or CEO.
    · Contact physician and responsible party.
    · Provide medical attention as directed.
    · Complete an Incident Report.

PROTECTION FROM ABUSE:
During an investigation of alleged abuse the resident/patient will be protected from further
potential harm.

PROCEDURE:
· During abuse investigations, resident/patients will be protected by the following measures:
   a) Employees accused of participating in alleged abuse may be immediately reassigned
to duties that do not involve resident/patient contact or will be suspended without pay until
the findings of the investigation have been reviewed by the CEO.
   b) If the alleged abuse involves a resident/patient’s family or visitor, such person(s)will not
be permitted to have unsupervised visits with the resident/patient until the findings has been
reviewed by the CEO.

ABUSE REPORTING/RESPONSE:
Decatur County Hospital/ Cedar Living Center will report all alleged violations and all
substantial incidents to the Kansas Department of Health and Environment and to all other
agencies as required.

PROCEDURE:
1. Risk Manager will notify the Kansas Department of Health and Environment at the earliest
possible convenience of the alleged incident via phone.
2. Upon the completion of the investigation a written report will be sent to the Kansas
Department of Health and Environment.
3. Other regulatory agencies will be notified of their results as necessary and indicated by the
Kansas Department of Health and Environment.
4. The State nurse aide registry or licensing authority will be contacted at the time the facility
has any knowledge of any actions by a court of law-which would indicate an employee is
unfit for service.
5. The Performance Improvement Committee will analyze occurrence of incidents to
determine appropriate changes in policy and procedures or other intervention to prevent
further occurrences.
6. Residents involved in anything that is a reasonable suspicion of a crime and reportable to
the State of Kansas will also be reported to the local law enforcement officers during normal
daytime working hours in accordance with Section 1150B of the Social Security Act. This
includes employee theft, employee battery or any illegal transactions, resident theft, resident
battery, or any suspicious deaths.
7. Family complaints of possible theft or battery should also be reported to the local law
enforcement officers.


Reporting number: 1-800-842-0078-Resident Issues
Kansas Department of Health and Environment

1-800-922-5330-Patient Issues (ER, OP and IP)
Adult Protective Services

1-785-475-2627-Oberlin Law Enforcement
1-785-470-7025-cellular

Glossary of Terms:
“Abuse”:
The willful infliction of injury, unreasonable confinement, deprivation, intimidation or
punishment with resulting physical harm, pain or mental anguish. This includes deprivation of
goods or services that are necessary to attain or maintain physical, mental well-being. This
presumes that instances of abuse of all resident/patient (regardless of physical or mental
condition) cause harm, pain or mental anguish.

“Neglect”:
Failure to provide goods and services necessary to avoid physical harm, mental anguish or
mental illness. Neglect occurs on an individual basis when a resident/patient does not
receive care in one or more areas.

“Mistreatment”:
To treat wrongly or badly contrary to facility policy and compromise the resident/patient’s
physical or emotional integrity.

“Injury of Unknown Source”:
Injury of unknown origin or suspicious circumstances. This includes any injury which is not
clearly explained by a witness and corresponding event. If source of injury is not clear, the
investigation must proceed.

“Serious Injury”:
Serious injuries are defined as an injury resulting in medical intervention/follow-up /treatment
which are beyond standing protocols and customary nursing.

“Verbal Abuse”:
Any use of oral, written or gestured language that willfully includes disparaging and
derogatory terms to residents/patients or their families or within their hearing distance,
regardless of their age, ability to comprehend or disability.



“Sexual Abuse”:
Includes, but is not limited to: sexual harassment, sexual coercion or sexual assault.

“Physical Abuse”:
Includes hitting, slapping, pinching and kicking. It also may include controlling behavior
through corporal punishment.

“Mental Abuse”:
Includes, but is not limited to: humiliation, harassment, threats of punishment or deprivation,
name-calling and use of foul language toward and in regard to a resident/patient.

“Involuntary Seclusion”:
Defined as separation of a resident/patient from other residents/patients or from his/her room
or confinement to his/her room (with or without roommates) against the resident’s/patient’s
will or the will of the resident’s/patient’s legal representative. Emergency or short term
monitored separation from other resident/patients will not be considered involuntary
seclusion and may be permitted if used for a limited period of time as a therapeutic
intervention to reduce agitation until professional staff can develop a plan of care to meet the
resident’s/patient’s needs.

“Misappropriation of Resident/Patient Property/Funds”:
The patterned or deliberate misplacement, exploitation or wrongful, temporary or permanent
use of a resident/patient’s belongings or money without the resident/patient’s consent.

“O.I.G.”:
Office of the Inspector General.


Go Home                                 Take the Abuse and Neglect Test
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Advance Directives                                                              Go Home

What are Advance Directives?

They are legal documents that allow you to give directions for your future medical care. They
could be:
   A Living Will and/or
   A Durable Power of Attorney for Health Care Decisions.

The Patient Self-Determination Act passed by Congress became effective December 1,
1991. This act requires all facilities that receive Medicare and Medicaid funds such as
hospitals, nursing homes, home health agencies, hospices, and HMOs to inform patients and
residents about Living Will and Durable Power of Attorney for Health Care Decisions.

It’s your right to accept or refuse medical care. Advance Directives can protect this right if
you ever become mentally or physically unable to choose or communicate your wishes due
to an injury or illness. Advance Directives are valuable tools. They can help YOU to protect
your right to make medical choices that can affect your life, YOUR FAMILY to avoid the
responsibility and stress of making difficult decisions; and YOUR PHYSICIAN by providing
guidelines for your care.

All patients have rights.
These rights include:
    Privacy
Your personal and medical information is confident. Medical records and communications
with your physician must be kept private.
    Informed Consent
Your physician must clearly explain the advantages and risks of any procedures, tests, or
treatments. You must give your permission for such care. You have the right to refuse any
treatment.
    Information about your condition
You must be kept up to date about your medical condition, treatments, and chances for
recovery.
    Information about Advance Directives
Advance Directives must be explained in writing when you’re admitted if you wish to receive
the information.

Advance Directives help protect your rights.

They can “speak” for you when you can’t make your wishes known due to:
  · Irreversible brain damage or brain disease
  · Coma or other unconscious states
  · Terminal illness when death is expected within a short time
There are two types of Advance Directives:
   Living Will-These written instructions explain your wishes for health care if you can’t
communicate as a result of a terminal condition or irreversible coma.
   Durable Power of Attorney for Health Care Decisions—This is sometimes called a
“health care proxy.” This is a document that lets you name a person or two or three to make
medical decisions for you if you become unable to do so.

It’s a good idea to have both kinds, if possible.

Advance Directives can limit life-prolonging measures when there’s little or no chance of
recovery. For example, Advance Directives may enable you to make your feelings known
about:
   · Surgery
   · Cardiopulmonary Resuscitation (CPR)—used to restore stopped breathing and/or
heartbeat
   · Antibiotics
   · Dialysis—cleaning the patient’s blood when kidneys are no longer working
   · Mechanical ventilator (respirator)—machines used to keep patients breathing
   · Intravenous (IV) therapy—providing food, water, and/or medication through a tube in a
vein
   · Feeding Tubes—food and water delivered through a tube in the nose, throat, or stomach
   · Organ tissue or donation
   · Pain relief and comfort care

What's Important to You?
Let your values be your guide when creating Advance Directives. Consider what’s important
to you. Which of these statements express how you think you’d feel if you were near death?

It’s important for me to:
    · Die without pain or suffering
    · Prolong life, regardless of the chances for recovery
    · Leave my family with good memories
    · Have my religious beliefs respected
    · Have others honor my decisions
    · Not burden my family with difficult decisions
    · Be with my loved ones at death

How to create Advance Directives:
1. Check the laws in your state regarding Living Will and Durable Power of Attorney for
Health Care Decisions; you may consult with your attorney if you wish.
2. Put your wishes in writing and be as specific as possible. Forms are available at the
hospital.
3. Sign and date your Advance Directives, and have them notarized.
4. Keep a card in your wallet, stating you have Advance Directives and where to find them.
5. Give your physician a copy to be kept as part of your medical records. Bring a copy to
your hospital as well. If you use a Durable Power of Attorney for Health Care Decisions, be
sure to give that person a copy.
6. Discuss your Advance Directives with your family and friends. Give copies to a relative or
friend who is likely to be notified in an emergency.
7. Review your Advance Directives. You can always change or even cancel Advance
Directives. Make sure to update copies you’ve given out.

What is a “do not resuscitate” (DNR) order?
A DNR order is a set of written instructions from a physician telling health-care providers not
to perform CPR or related procedures.

Advance Directives do not replace DNR orders.
Help and information are available. If you need help in preparing Advance Directives, or
you’d like more information, contact:
   A lawyer
   Hospitals, hospices, home health agencies, and long term care facilities
   Your state Attorney General’s office
   Choice in Dying (1-800-989-9455

Go Home                         Take the Advance Directives Test
            ***********************************************************

EMPLOYEE BENEFITS                                                              Go Home
Paid Time Off

Paid Time Off (PTO) provides benefit eligible employees with paid time off to use for
personal reasons, the occasional sick day, vacations, bereavement, holidays and any
unscheduled work absence of 15 minutes or more. Therefore, time away from work for these
reasons requires that you use PTO if available. PTO must be used for all scheduled work
hours unless you are on management requested leave. PTO is also a means for you to
accumulate time to use during the waiting period for Short Term Disability (STD) benefits.
Employees may use available PTO as an income source before or after the full pay period of
STD is exhausted, but will not be allowed to draw both STD and PTO at the same time. All
employees are required to take at least one consecutive week off each year using PTO.

PTO is earned for each hour worked by an eligible employee. PTO is calculated on a
percentage of each hour worked, based on the length of service of each individual employee.
PTO hours may be used after the first six months of employment. Use of PTO requires your
supervisor's approval. No more than 80 hours of PTO can be carried over into the next year.
You will not be paid for PTO that is not used and is in excess of the 80 hours that may be
carried over. If you have more than 80 hours PTO accumulated as your anniversary date
approaches, you may choose to cash out some of the PTO hours. In the month prior to your
anniversary date a PTO cash out form must be filled out. This form may be obtained from the
front office. Full time employees may cash out up to a maximum of 40 PTO hours per year.
Part time workers may cash out up to a maximum of 20 PTO hours per year.

Short Term Disability

Short Term Disability is provided to the employee by Decatur Health Systems at no extra
cost. This benefit is for maternity leave, or when an employee has been injured or sick and
cannot work. There is a seven-day waiting period for STD. After the 7th day the employee
will be reimbursed at 60% of his/her normal wage up to $500.00 per pay period. An
employee may elect to take time off through PTO or through STD, but not both at the same
time. To apply for Short-Term Disability the employee should pick up the paperwork in the
Business Office. Claim form sections for the employee, the employer and the physician need
to be completed. After everything is filled out, return the form to the business office and the
paperwork will be sent in. Benefit checks will be mailed to the hospital and the Business
Office Manager, Natasha Weishapl, will send the checks to the employee’s home. If there
are any changes in disability status the employee should notify Natasha immediately.

Freedom Claims Management Medical Insurance

All full time and part time employees are eligible to apply for medical insurance coverage
under Freedom Claims Management. If a newly hired employee is eligible for benefits he/she
may apply for Medical insurance immediately on the hire date, but coverage is subject to a
90-day waiting period to take effect.
If an employee has a change of status and needs to change the medical benefit, no 90 day
waiting period is required if the employee has been employed for 3 months. Changes in
medical coverage will take effect on the first of the month following the status change.


The open enrollment period for Freedom Claims Management Medical Insurance is some
time during March for an effective date of April 1st.

AFLAC Insurance

The employee may choose to enroll in AFLAC’s many benefits. A new hire employee is
eligible after a 90-day waiting period. All other employees may make changes at open
enrollment, which is some time during March, or if a qualifying event occurs in which
changes can be made.

401K

Employees may enroll in the 401K plan on the first enrollment date after reaching one year of
service. The employer will contribute to the plan on a tier level basis depending on years of
service. Enrollment dates for the 401k are quarterly. During these times employees may
change the amount of their contributions.

Checking In and Out on the Soft Time Clocks

Soft Time Clocks are posted at five locations throughout the facility. They are located in the
Family Practice Clinic, at the CLC nurses desk, the front office, in the small dining room
beside the kitchen area, and in the room next to the nursery in the hospital. Employees may
select any of these locations to check in or out.

Check In Procedure:
Check in with the last four digits of your social security number using either the mouse or the
keypad. Select "Enter". The first screen will ask you to select which department you are
checking in or whether you have been called in. You will then be asked to verify by selecting
Continue for the next two screens. When you are checked in, the following screen will verify
you are now checked in.

Check Out Procedure:
Check out with the last four digits of your social security number using either the mouse or
the keypad. Select "Enter". The first screen will ask you whether you are checking out. Select
the Continue button, and the next screen will verify that you are checked out.


Reviewing Your Punch History:
You may check the time you have worked by reviewing your Punch History. This can be
done at any time, whether you are checked in or out. Enter the last four digits of your social
security number and select the Review button. A page appears which shows your work
history for the past month. A different color background designates each 2-week pay period.
When you are finished viewing your Punch History, select the HOME button and you will
return to the main screen.
REMINDER:
At the end of each pay period the following changes need to be written on the Time
Correction Forms which are found by the Soft Time Clocks:

   Corrections to the time posted on the Soft Time Clocks
   Hours for On-Call Pay
   Reimbursement for Education Time
   Request for PTO hours

Paycheck Distribution
Employees who elect to have their paycheck direct deposited in their bank account will have
their advice statements available from their Department Manager on the Friday before the
pay date. The money is also direct deposited into their bank account on Friday.

Employees who elect to receive a regular paycheck will have them mailed out on payday
Mondays. If Monday is a holiday, the check will be mailed out on the following Tuesday.


Go Home                               Take the Benefits Test
                  ***************************************************

Customer Satisfaction                                                   Go Home

Focus on Customer Needs
Customer focus is the cornerstone of a business’s success. Customer focus or
service is everyone’s job. Your customers may be external to the organization or
they may be internal. Customer focus includes--but goes beyond--customer
service. It means listening to customers; identifying, meeting, and exceeding their
needs; and anticipating their future needs. It means aligning what you do and
how you do it with what the customers need.

Listen Actively
Personally take time to ask customers, “How are you doing?” Actively listen to
what they say. Communicate these findings to the appropriate people in your
organization.

If you hear it, you own it, which means you need to inform the appropriate person
to handle the issue at hand.

Identify With Your Customer
Look “outside in” not “inside out”- look at things from your customer’s viewpoint.

Treat your internal customers with the same care and respect as you treat your
external customers.

External customers purchase your products and services and internal customers
are your employees and co-workers.

Who is a customer?
Someone who receives:
  Your information
  Your product or
  Your service.

What is customer service?
The customer’s perception of how well needs and wants are met, meeting or
exceeding the customer’s expectations or providing continuous improvement of
our services.

QUALITY SERVICE = CUSTOMER SATISFACTION
   Quality customer service is an integral part of our jobs.
   Satisfied customers are essential to our success.
   Quality customer service is learned, not inherited.



Why do we provide quality service?
  ~Customers expect it.
  ~Competition demands it.
  ~It is a key to the success of the business.


Whether you are a custodian, a physician, or a healthcare worker, you have
customers who want:
  Reassurance that they matter to you
  To enjoy the experience of contact with you

The Hostess Role
   Assess the environment
   Welcome guests
   Take care of their needs
   Acknowledge them when they are leaving

Give Out Plenty of Free Stuff!
A smile and a friendly hello don't cost us anything, in fact they add to our value!
Pass out plenty of this "Free Stuff."

Handling Complaints
   Listen carefully
   Be understanding
   Apologize
   Identify the problem
   Determine a solution
   Thank them

Never
   Argue
   Criticize
   Ignore
   Challenge

On the Phone
Communication is measured 16% by the words you use and 84% by the tone of
the voice.

Five Basic Needs of Our Customers
   *Need for personal attention
   *Need to feel comfortable and relaxed
   *Need to belong
   *Need to feel important
   *Need to be recognized

OUR CUSTOMER SERVICE PHILOSOPHY
Our organization is known for going above and beyond the call of duty to care for
patients, residents and customers’ needs. Providing quality care is so important.
However, this cannot be accomplished if we provide inadequate customer
service.
RULE # 1:

       IF WE DO NOT TAKE CARE OF OUR CUSTOMERS….

SOMEONE ELSE WILL!!!
Make your choice now. The difference between professional and non-professional health
care providers is a matter of sensitivity, sincerity and selling skills. All of which can be
learned.

OUR GOLDEN RULE OF SERVICE

Treat people as you would like to be treated. Be responsible for your own attitude and
actions.

The pay off for good customer service is to work in a pleasant environment where stress is
minimal.




                                What is a Customer?

   A customer is the most important person in any business.
   A customer is not dependent on us. We are dependent on them.
   A customer is not an interruption of our work. They are the purpose of it.
   A customer does us a favor when they come in. We aren’t doing them a favor
by waiting on them.
   A customer is part of our business- not an outsider.
   A customer is not just money in the cash register. They are human beings with
feelings, like our own.
   A customer is a person who comes to us with their needs and their wants. It is
our job to fill them.

A customer deserves the most courteous attention we can give them. They are the
life-blood of this and every business. They pay our salary.

Without them we would have to close our doors.         Don’t ever forget it.
Go Home   Take the Customer SatisfactionTest
              *******************************************************

Disaster Preparedness                                                 Go Home
Definition of Disaster Preparedness
Disaster preparedness is the facility’s master plan for saving lives when disaster strikes.
The plan enables the facility personnel to respond quickly and effectively, provide first
aid to minimize loss of life, and treat the injured and care for existing patient load.

What is a medical disaster?
A medical disaster is a sudden event that overloads a health care facility’s ability to
deliver emergency services.

Potential disasters are:


Natural Disasters
  Snowstorms
  Floods
  Tornadoes
  Earthquakes


National Emergencies
  Terrorist attacks
  Wars


Mass Casualty Disasters
  Fires
  Explosions
  Building collapse
  Hazardous chemical spills
  Transportation accidents
  Power losses
  Fuel shortages and water shortages
  Mass food poisonings

Medical disasters are classified into two types:

External Disasters
These require a healthcare facility to admit and treat many casualties, but doesn’t damage
the facility itself or threaten personnel, patients, or residents.



Internal Disasters
These cause (or threaten to cause) injury or damage to the healthcare facility and its
patients, residents and staff. Examples are:

-Fires
-Water shortages
-Fuel shortages
-Loss of power
-Bomb threats


                                 The Disaster Plan
The Disaster Plan addresses both internal and external disasters. It covers:
Admission of casualties
Securing the facility
Traffic control
Communicating with the public and families
Tornado
Fire
Loss of Utilities
Bomb Threat
Snow Storm
Evacuation

Before Disaster Strikes, Be Prepared!
  Know the plan for responding to internal and external disasters.
  Know your role and responsibilities in the plan.

Practice via drills
   Monthly fire drills
   Annual tornado drills
   Annual disaster drills

                   EMERGENCY AND DISASTER CODES
Code “Triage” - Disaster Plan Activation
Code “Red” - Fire
Code “Orange” - Hazardous Materials Release
Code “Blue” - Cardiac Arrest
Code “Black” - Bomb Threat
Code “Pink” - Infant Abduction
Code “Grey” - Resident or Patient Missing
Inclement Weather Alerts:
Code “Tornado Watch” - Weather Conditions Such That Tornadoes Could Form
Code “Tornado Warning” - A Tornado Has Been Sighted in the Area: Take Cover


                         Response To Discovery Of Fire
Employee Responsibility In Case Of Fire

All employees need to respond appropriately upon discovery of a fire.
Any individual discovering a fire must remain calm and do the following:

R - Rescue any person that is in immediate danger.
A - Announce alarm. Call out "Code Red-location" and pull the nearest Fire alarm station if
alarm is not already activated.
C - Confine the fire.
E - Extinguish the fire if reasonable. Evacuate as needed, following the Evacuation Plan for
your department. Evacuation Plans are in a red binder located in each department. Be sure
you know where this information is and acquaint yourself with it so you will be
prepared in case of an emergency.

Work as a team. You and/or others must do all of the above within the first 30 seconds of
discovery.


GENERAL INSTRUCTIONS:
  Remain calm, do not run or panic.
  Smoke kills. Stop the spread of smoke, stay low and crawl below smoke level.
  Do not open HOT DOORS. If closed doors are touchable, open slowly.
  Place a wet towel at the base of the door where the fire is located.
  If clothing catches on fire, smother flame by rolling in blanket.
  Smother small fires with a pillow, towel or blanket.
  Never leave an extinguished fire unattended. Stay until fire department arrives.
  Apply extinguishing agent even after the flames are extinguished.

                 Fire Drills and Fire Alarm System Testing
DHS Policy on Fire Drills
Fire drills and testing of the fire alarm system will be conducted monthly, on alternating shifts.

Procedure for Fire Drills
Fire drills will be conducted in a manner to simulate an actual fire situation, conducted
simultaneously in both units and will activate the fire alarm system during each drill. If the fire
alarm system is not activated during a drill (i.e.: patient/resident convenience between 9pm
and 6am), the fire alarm system will be tested within 24 hours of the silent drill. The drill will
be documented on an approved form by the person conducting the drill.

1. Prior to initiating the drill, dispatch must be notified by the person conducting the drill that a
drill is being conducted.
2. A red and white flag is used to indicate location of the fire. Different locations are used to
gain a variety of possible fire situations.
3. The person finding the flag will respond according to the “Fire Response Procedure (R-
A-C-E)”. Observer calls Dispatch and informs them that a fire drill is to be conducted.
Observer announces drill after fire alarm has been activated.
4. All others respond according to the department specific guidelines outlined in the
“Response to a Fire Emergency” procedure.
5. Supervisors evaluate staff response and educate as needed. Fire drill participation forms
are kept at the Nurses Stations and are to be signed by all participants and delivered to the
Plant Operations Supervisor when completed.
6. Person conducting drill will announce “all clear” over the intercom at the end of drill. At
the completion of the drill, dispatch is notified that the drill has been completed and verifies
that the monitoring party has responded.


                Fire Prevention-Employee Responsibility
DHS Policy on Employee Responsibility in Fire Prevention:
All employees shall observe good fire prevention and life safety practices.

Fire Prevention Procedure
1. Always keep areas near fire doors clear.
2. Maintain clear and unobstructed hallways and exits. When using carts in hallways place
carts on odd numbered room sides only to maintain an unobstructed exit path.
3. Dispose of trash and rubbish properly.
4. Report any known electrical, fire or life safety hazards
to your supervisor or the maintenance department.
5. Enforce and obey established smoking rules.
6. Know the location and proper use of fire extinguishers; pull stations and oxygen shut off
valves in assigned work area.
7. Report, immediately, any suspicious sounds, smoke, or smell to your supervisor or the
Maintenance Department.

All facility fire extinguishers are ABC multipurpose dry chemical and can be used on all
types of fires.

Using an Extinguisher:

P - Pull the pin between the two handles.
A - Aim nozzle at the base of the fire.
S - Squeeze handles together.
S - Sweep from side to side.

Always, extinguish the fire with your back to an exit door, in case you have to leave the area.
If safe, you should remain at fire location until the fire department arrives.




Go Home                         Take the Disaster Preparedness Test
                 ****************************************************

HAZ MAT                                                                   Go Home
(HAZARDOUS MATERIAL SAFETY)
Some of the things we use around our workplace can be classified as hazardous substances.
Generally, we’re talking about chemicals used in different procedures throughout the facility.
Hazardous substances include everyday things like cleaners, radiation, noise levels, ergonomics,
etc. Here are some simple guidelines to follow regarding general hazardous material safety:

1. If there is anything you don’t understand about the chemical hazards associated with your job,
be sure to ask!!

2. Be sure you know where the company’s written hazard communication plan is stored.

3. Be sure you have received appropriate hazard communication training before working with
potentially dangerous substances.

4. Understand how to read chemical labels and review them before using any chemical.

5. Never use a substance in an unlabeled or unauthorized container.

6. Wear appropriate protective equipment when working
with hazardous substances.

7. Make sure you know where material safety data sheets (MSDSs) are located and how to read
them.

8. Always follow proper procedure when handling hazardous substances.

9. Store chemicals in closed containers and in accordance with instructions on the label.

10. Wash thoroughly after using a hazardous substance.

11. Clean any tools, clothing or equipment that have been exposed to a hazardous substance.

12. Be sure you understand potential emergencies that could arise with chemicals you use at
work.

Remember: According to OSHA regulations, you have a right to know about the hazardous
substances you work with. Taking advantage of this right is your responsibility. Please participate
in all hazard communication training; read and follow all instructions on chemical labels and
material safety data sheets (MSDSs); and if you are unsure about something, ASK !!!!!

PRACTICE CHEMICAL SAFETY
More than 10,000 people die from on-the-job accidents every year—and a worker is injured every
18 seconds.
Your company does much to protect you from accidents—from special training and protective
equipment-to providing printed information for you to read.
But there’s one key to safety only YOU can control: YOUR OWN SAFETY ATTITUDE.
Use Your Safety Sense
Carelessness is the main cause of accidents. People get careless about safety for several
reasons:
· Complacency—going on “automatic pilot” because you’ve done the job so often
· Emotions—being angry or upset by something that happened at home, an argument with
someone else at work, etc.
· Fatigue—too little rest or too many hours on the job
· Not appreciating risks—not enough training, not wearing protective equipment, or not paying
enough attention when you are being trained
· Reckless or know-it-all attitude—thinking that safety isn’t important or doesn’t apply to you.

The bottom line: Don’t allow these factors to set you up for a painful accident. Take safety
seriously—all the time!!!!!

Plan Your Job for Safety
Before you start any job, use the following safety checklist:
   Look around for anything that could go wrong.
   Eliminate the risks before you start.
   Check and read labels and MSDSs.
   Use the correct protective clothing and equipment.
   Remove from the workspace anything you could trip over or that creates a hazard—ignition
sources, reactive chemicals, combustibles, etc.
   Be sure equipment is in good working order. If it’s not, DON’T USE IT. REPORT IT TO YOUR
SUPERVISOR.
   Don’t eat or smoke in the work areas.
   Use proper ventilation if it’s called for.
   Respect electricity and power equipment. Turn off equipment when it’s not in use.
   Use the right tool or equipment for the job. For instance, don’t use a pile of boxes instead of a
ladder.
   Follow all job procedures. Don’t do a job if you’re not sure how.
   Have a buddy around if you’re assigned to a hazardous task such as working in a confined
space.
   Keep focused on what you’re doing.

The most important rule: When it comes to safety, there are no dumb questions!!

                  RIGHT TO KNOW TRAINING PROGRAM
The Occupational Safety and Health Administration (OSHA) created the Hazard Communication
Standard (HazCom) to protect you, the employee. You have the RIGHT TO KNOW about the
potential hazards you face on the job, and how to protect yourself from those potential hazards.

   Your employer is required to provide you with the information, training and equipment you
need to protect yourself and others when working with the potential hazards in your work area.

   You, the employee, are required to use your RIGHT TO KNOW training to stay safe and
healthy on the job. Our HAZARDOUS MATERIAL (HAZMAT) COORDINATOR is JIM SULLIVAN.

   It is the responsibility of the Department Manager to see that all their employees have
received the in-service on the employee's RIGHT TO KNOW.
Chemicals make your work easier and more effective and they save lives. YET, used carelessly
in ignorance or with poor judgment these same powerful tools become destructive.



WHAT YOU DON’T KNOW ABOUT CHEMICALS OR IGNORING
THE POTENTIAL HAZARD OF CHEMICALS YOU WORK WITH
CAN QUICKLY HURT YOU.
A chemical can be a physical hazard, a health hazard or both.
   A physical hazard can cause a dangerous situation such as a fire or an explosion.
   A health hazard can damage your health when a chemical is inhaled, eaten, or splashed on
your skin or into your eyes.
   Acute health hazards hurt you rapidly, after short-term exposure, i.e. Poisoning, chemical
burns or rash.
   Chronic health hazards harm you more slowly, after long-term exposure, i.e. Cancer, organ
damage, or allergies.

~Reactive chemicals can burn, explode, or release toxic vapors, if exposed to certain other
chemicals or heat, air or water. (Mixing toilet bowl cleaner and bleach)
~Toxic chemicals cause illness or even death. (Asbestos, coal dust, weed killers, bug dope)
~Corrosive chemicals can burn the eyes or skin. (Lye, oven cleaners) Consider what the
corrosive chemical from poison ivy does to your skin.
~Flammable chemicals catch fire easily. (Some paints)
~Some chemicals can explode or emit harmful radiation. (Gas containers, oxygen cylinders,
radiology procedures)
~Chemicals aren’t just liquids in a container. They may be solids, liquids, gases, vapors, fumes
and/or mists.

Below are some chemicals which appear in these different forms:
   Lye
   Car gas
   Anhydrous
   Carbon monoxide
   Welding fumes
   Spray paints
   What about the fumes released when mixing toilet bowl cleaner and bleach?

Chemicals can enter your body by three routes:
  Skin and eye contact
  Inhaling
  Swallowing

Swallowing hazardous chemicals (easy to do if you eat or smoke after handling chemicals without
washing first) can poison you or damage your internal organs.

How do we find out which products contain potentially hazardous chemicals?

Chemical manufacturers must determine the physical and health hazards of their products. This
information is passed on to users of the chemical by container labels and material safety data
sheets. (MSDSs)

Manufacturers are not required to use a standard format for their warning labels or MSD sheets
but the labels and MSD sheets must contain the required information as set by the Hazard
Communications Standard.
Product Warning Labels

Warning labels on containers alert you to the dangers of the chemicals you are about to handle.
The label states:
   The products chemical name
   Any hazardous ingredients
   Physical and health hazards
   The name, address and emergency phone number of the company that manufactured or
imported the chemical
   Important storage and handling instructions
   Basic protective clothing, equipment and procedures that should be used to work safely with
the chemical might also be listed.


MATERIAL SAFETY DATA SHEETS

Each hazardous product has its own MATERIAL SAFETY DATA SHEET (MSDS).
Read it before you start any job where you will be using a product containing a chemical if you
have not been trained in the use of the product. You will learn:

    What the chemical is
    What its hazardous ingredients are
    What its physical and chemical characteristics are
    Why the chemical is hazardous
    How to work safely with the chemical
Remember: Not all MSD Sheets have the same format BUT they do contain the following
information:

IDENTITY
~ The name of the chemical on the product container, its chemical name and any common
names, such as “formalin” for formaldehyde.
~ The manufacturer name, address, phone number, plus an emergency phone number you
can use to get immediate information on specific chemical hazards.


HAZARDOUS INGREDIENTS
~ Any hazardous ingredients of a chemical
~ Safe exposure limits, such as Permissible Exposure Limits (PELs) and Threshold Limit
Values (TLVs)


PHYSICAL and CHEMICAL CHARACTERISTICS
~ Physical information to help you identify the chemical and its characteristics, such as
appearance, odor, boiling point, vapor pressure, vapor density, solubility in water, melting
point and evaporation rate.


PHYSICAL HAZARDS
~ Fire and explosion information
~ The chemical flash point, or temperature at which it ignites
~ What to put on the fire to extinguish it safely
~ Special fire fighting techniques and equipment
~ Any unusual fire or explosion hazards

REACTIVITY
~ Dangers from chemical reactions with the material
~ Conditions or other materials that can cause reactions with chemicals you are using.
~ Any dangerous substances that can be produced in relation with other chemicals or in
atmospheric change.

HEALTH HAZARDS
~ Health hazards caused by the chemical itself
~ Symptoms of overexposure, both acute and chronic
~ Medical conditions that may be aggravated by exposure
~ How the chemical can enter your body
~ Whether the chemical can cause cancer
~ First-aid and emergency procedures – sometimes listed separately at the beginning of the
form for quick reference

HANDLING PRECAUTIONS
~ How to deal with spills and leaks
~ Clean-up techniques
~ Personal protective equipment to be used during clean up
~ How to dispose of waste materials properly

    Always notify your supervisor of a chemical spill immediately. Make sure you are
trained and wearing appropriate protective gear before you attempt clean up.

CONTROL MEASURES

~ Special protection information on the MSDS includes any personal protective equipment
you will need to work safely with the chemical

DIFFERENT CHEMICALS AND JOBS REQUIRE DIFFERENT PROTECTION. FOLLOW
THE PROCEDURES ESTABLISHED BY YOUR FACILITY. YOU MAY BE REQUIRED TO
WEAR:
~ Safety glasses and/or goggles
~ Protective clothing or suits
~ Gloves
~ Special boots or shoes
~ A respirator

For your safety use these protective items when you are required to.



Be sure to:
   Follow the manufactures directions
   Read the MSDS for warning information
   Make sure the protective items fit snugly yet allows you to do your job
   Make sure the protective items have no rips or tears
   Check that all fasteners are secure
   Remove protective items carefully after the job to prevent contaminating yourself and the
surrounding area
   Dispose of contaminated protective items according to facility procedures


SPECIAL PRECAUTIONS
  Additional special precautions to follow when handling the chemical may include:
   ~ What you need to clean up a spill or extinguish a fire
   ~ Other health and safety information

POSTERS SHOWING SOME SAMPLES OF LABELS AND HOW TO READ THEM ARE
LOCATED IN CLC AND THE HOSPITAL
A Color and Number coded label system has been developed by the National Fire Protection
Association (NFPA) and other organizations.

This system uses the following codes:
COLORS – represent the KIND OF HAZARD

   · Blue = Health Hazards
   · Yellow = Reactivity
   · Red = Flammability
   · White = Specific Hazard


NUMBERS – show the “DEGREE” of HAZARD
  · 0 = minimal hazard
  · 1 = slight hazard
  · 2 = moderate hazard
  · 3 = serious hazard
  · 4 = severe hazard

Hazard warning information such as organs of the body that may be affected by the chemical
will usually be shown.
By law every chemical container must have a label attached to it. If you find a damaged,
incomplete or missing label, notify your supervisor immediately. It must be replaced. A new
container must be labeled when a chemical is transferred to another container.

Labels are not required when you transfer a chemical from a labeled container to a portable
container if you plan to use that chemical immediately yourself. NEVER leave an unmarked
container of a hazardous chemical unattended. NEVER assume that an unlabeled container
has contents that are harmless. DO NOT SMELL, TASTE or TOUCH an unknown liquid.
Always read the label before you use a chemical. Read the MSD Sheet. Use the information
to work safely with the chemical.

Your safety training along with label and MSDS information can protect you and others when
working with chemicals.

  KNOW WHAT CHEMICALS ARE USED IN YOUR WORK AREA
  FOLLOW LABEL AND MSDS INSTRUCTIONS and FACILITY PROCEDURES
  KEEP INCOMPATIBLE CHEMICALS APART
  STORE AND USE FLAMMABLES AND EXPLOSIVES AWAY FROM HEAT SOURCES
  BE SURE THERE IS ENOUGH VENTILATION
  KEEP FOOD, DRINK, CIGARETTES, AND COSMETICS OUT OF WORK AREAS
WHERE CHEMICALS ARE USED.
Your facility provides you with training programs and equipment to protect you. BUT it is up
to you to use this help to stay safe around chemicals you use in your work area. Get to know
the MSD Sheets for the chemicals you work with now – before a problem occurs.

YOUR “RIGHT TO KNOW” DOES YOU NO GOOD UNLESS YOU EXERCISE IT!


                                  RIGHT TO KNOW
Good Housekeeping is Important
§ Keep your work area clean. Dust, debris, etc. can easily catch fire.
§ Keep aisles and stairs clear. Do NOT leave anything that could be tripped over.
§ Do NOT have more than one file drawer open at a time.
§ Have enough light to see what you’re doing.
§ Make sure tools are clean and in good working order before you put them away.
§ Only smoke where permitted. Use deep ashtrays in any areas where smoking is permitted.
§ Do NOT leave sharp edges sticking out.
§ Clean up spills promptly.
§ Dispose of trash, scrap, and other debris promptly. Use the proper containers.
§ Follow storage procedures to the letter. For instance, Do NOT store flammables near heat
or ignition sources.

Follow Your Common Sense

DO:
§ Treat safety as an important part of your job.
§ Keep asking yourself—what could go wrong here?
§ Keep your full attention on what you’re doing.
§ Know and follow your company’s safety rules.
§ Use required protective clothing and equipment.
§ Remind other workers about safety procedures and equipment.
§ Pay attention during training programs and safety meetings.

DON'T:
§ Fool around or show off on the job.
§ Let anger, frustration, arguments, or personal problems interfere with your work
§ Ignore a safety hazard.
§ Become overconfident with jobs you’ve done many times.
§ Use equipment such as conveyors or forklifts in ways they’re not intended.
§ Get pressured by others into ignoring safety procedures.
§ Take shortcuts on job procedures like machine guarding.
§ Assume safety is someone else’s job.

Develop a Safe Attitude
A safe attitude is your responsibility. And it’s the best thing you can have to prevent
accidents.
When you think an accident can’t possibly happen to you, you may become careless. And
that’s when accidents happen. Develop a Safe Work Attitude.




Go Home                                Take the Haz-Mat Test
          ************************************************************

HIPAA                                                                  Go Home


                               HIPAA Education

PRIVACY AND CONFIDENTIALITY

Why are privacy and confidentiality important?

No matter where you work in healthcare—the hospital, labs, radiology, nursing
homes, doctors’ offices, business units, IT, or right in a patient’s home, it is
important to understand what privacy and confidentiality mean.

Patients have the right to control who will see their protected, identifiable health
information. This means that communications with or about patients involving
patient health information will be private and limited to those who need the
information for treatment, payment, and healthcare operations. Such
communications may involve verbal discussions, written communications, or
electronic communications. Only those people with an authorized need to know
will have access to the protected information.

Hospitals and healthcare organizations have always upheld strict privacy and
confidentiality policies. Unless you are new to healthcare, this idea will be
familiar to you. However, the U.S. government strengthened the laws protecting
privacy and confidentiality in response to situations in which private medical
information has ended up in the wrong hands.

In North Carolina, an employer fired a good employee shortly after learning that
the employee had tested positive for a genetic illness that could lead to lost work
time and increased insurance costs. In New York, a congresswoman who had
battled depression found out her medical history was released to newspaper
reporters.

Not surprisingly, cases of misuse of health information have also caused
lawsuits. A California woman sued a pharmacy that released her medical
information to her husband, who used it to damage her reputation in a divorce.
In another divorce case, a woman threatened to use information about her
husband’s health status that she had obtained from his health records in custody
hearings, forcing him to settle in order to avoid public discussion of his health.
As the number of cases of misuse of health information rises, Congress has
taken action to ensure that hospitals and healthcare providers protect health
information privacy and confidentiality.

With the enactment of the Health Insurance Portability and Accountability Act of
1996, (HIPAA), a patient’s right to have his or her health information kept private
and secure became more than just an ethical obligation of physicians and
hospitals—it became the law.

What is HIPAA?

HIPAA is a broad law dealing with a variety of issues. Its original goal was to
make it easier for people to move from one health insurance plan to another as
they change jobs or become unemployed. This also means they must be able to
move their medical records and information easily, to get the care they need.

To make it easier for healthcare organizations to share medical information, the
law requires that common transactions—such as submitting a claim on the
patient’s behalf—be in a standard format for all healthcare organizations and
payers. But as patient information becomes easier to transmit, it also becomes
easier for information leaks and abuses to happen. This is especially true as
more and more information is shared electronically through e-mail and the
Internet.

Before computerized records, it would have been difficult to remove many
records and make use of the information. Today, with e-mail and electronic
storage of information, in just a few minutes at a computer, thousands of records
can be sent virtually anywhere.

Imagine you wanted to identify patients who had an expensive medical condition
in order to discriminate against them. Using paper records, if you could get
them, the task would take countless hours. But with a computer and
standardized records, it is simple to sort out patients who have expensive
illnesses and potentially use that information to hurt their chances at getting jobs
or insurance. Standardizing and computerizing patient health information has
important benefits, but it also brings risks.

As a result, an important part of HIPAA focuses on patient privacy and
confidentiality. Under HIPAA privacy and information security sections, it is
illegal to release health information to inappropriate parties or to fail to
adequately protect health information from release.
Potential Consequences

The U.S. Department of Health and Humans Services (HHS) enforces HIPAA.
Breaking HIPAA privacy or security rules can mean either a civil or criminal
penalty.

Civil penalties are fines of up to $100 for each violation of the law per person, up
to a limit of $25,000 for each identical requirement of prohibition. For instance, if
a hospital released 100 patient records illegally, it could be fined $100 for each
record, for a total of $10,000. If there are found to be multiple violations, these
fines could increase significantly.

Criminal penalties for wrongful disclosure can include not only large fines, but
also jail time. The criminal penalties increase as the seriousness of the offense
increases. In other words, selling patient information is more serious than
accidentally letting it be released, so it brings stiffer penalties. These penalties
can be as high as a $250,000 fine or a prison sentence of 10 years. For
example:

Knowingly releasing patient information in violation of HIPAA can result in a one-
year jail sentence and a $50,000 fine.
Gaining access to health information under false pretenses can result in a five-
year jail sentence and a $100,000 fine.
Releasing patient information with harmful intent or selling the information can
lead to a 10-year jail sentence and a $250,000 fine.

Your facility is committed to protecting patient privacy and confidentiality. When
you fail to protect patient information and records by not following your
organization’s privacy and security policies, it reflects on your ability to perform
your job. To learn more about the consequences of violating patient privacy and
confidentiality, review our facility’s privacy policy.

PROTECTING PRIVACY

Ways to protect patient privacy
Whether they are in the hospital, physician’s office, lab, or other setting, patients
receiving medical care expect privacy. They expect to be physically separated
from strangers and employees when the consult or interact with their doctors and
nurses, and they expect that their private health information will not be shared
with people who do not have a need to know.

Decatur Health Systems is committed to giving patients privacy. As you work
here, you will see many ways patient privacy is protected.
Patient care or discussion about patient care is kept private by closing doors or
drawing privacy curtains and conducting discussions so that others may not
overhear them. Patient medical records are not left where others can see or gain
access to them. Laboratory, radiology, and other ancillary test results are kept
private.

Privacy is essential to the mission of Decatur Health Systems, and it is important
to patients—many of whom will be uncomfortable in strange surroundings. As
you perform your job, you need to protect patient privacy.

When carrying out your job assignments and meeting deadlines, remember that
you don’t want to interfere with patient privacy or jeopardize the confidentiality of
patient information in the process.

Much of this is common sense. Knock on a door and ask to enter before
entering a room. Keep patient records locked away and out of public areas. If
you find records unattended, return them to the nursing supervisor.

If you need to page a patient, the page should not include information that can
allow others to identify the patient’s condition or reason for being there.

If visitors ask you for information about a patient, direct them to the charge nurse
for assistance rather than giving out patient names or locations yourself. Be sure
the patient has agreed to see visitors or has agreed that information about
his/her location can be released before you disclose any information.

Patients expect privacy when they are receiving healthcare. It is up to everyone
to see that their expectations are met by both respecting their privacy and not
repeating any information that may detract from a patient’s privacy.

Consider what you would choose to do in the following cases to protect patient
privacy:

Case Scenario # 1:

You are called to work in a patient’s room to perform a routine job assignment.
You knock on the door and are invited in. You see that a nurse is in the room,
discussing the patient’s condition or medication.

Q: What should you do? Should you ask if it’s OK to perform your job? Or
should you come back later?

A: If the task is critical to patient care, ask if you can interrupt. Otherwise explain
that you are there to perform a routine job and will return in 15 to 20 minutes.
That protects the patient’s privacy by allowing them to conduct their discussions
without being overheard.

While some patients may say that it’s OK for you to remain in the room during a
consultation, remember that patients might not feel comfortable sharing complete
information about symptoms while you are in the room. Some patients might not
feel comfortable asking you to leave. Some nurses might even forget that you
shouldn’t be in the room while they are discussing treatment with a patient.

That’s why good privacy practices require that you tell them you will return later
to complete your work so that you don’t interfere with the patient’s care.


Case Scenario # 2:

You are working in the emergency department when you see that a neighbor has
just arrived for treatment after a car crash and you hear someone saying that he
will be taken to surgery soon. Your neighbor’s wife works in another part of the
hospital.

Q: Should you notify the neighbor’s wife that her husband has arrived in
the emergency department?

A: No. The correct course of action is for you to tell the nursing staff that you
know the patient and his wife, and let them know if they need to locate her, you
can help by providing information.

When patients are in the hospital, they have the right to decide who should know
they are there. Your neighbor has a right to privacy. Your neighbor may not
want to notify his family of his accident. If he is conscious, the emergency
department staff will allow him to decide who should be notified of his presence
at the hospital.

If he is unconscious, the doctors and nurses will use their professional judgment
about whether to notify his wife and will decide whether you, as a friend, should
be involved in any way. Leaving this decision to the emergency department staff
is essential.

If you are unsure about what to do when a situation arises, consult with your
supervisor or your privacy officer.

Which of the following situations describe proper techniques for protecting a
patient’s privacy and confidentiality?

A doctor brings a patient into an unused room to discuss the patient’s medical
condition.
A doctor who is reviewing a patient’s record leaves the folder in the doctor’s
lounge to review later.
A doctor emails a physician colleague to consult about a patient’s condition. He
explains the condition but omits any identifying information regarding the patient.

If you selected #1 and #3, you are correct. In both these cases the patient’s
privacy was protected.

CONFIDENTIAL INFORMATION

What is confidential information?

When patient give information to their providers, they expect that only people
involved in their healthcare will see it. Confidential information includes patient
identity, address, age, Social Security number, and any other personal
information that patients are asked to provide. In addition, confidential
information includes the reason a person is sick or in the hospital, the treatments
and medications he or she may receive, and other observations about his or her
condition or past health conditions.

How is patient information used?

The hospital collects this information so that it can take care of patients and
perform other related functions. However, the facility and its workforce can use it
only in limited ways.

Obviously, doctors, nurses, therapists, dietitians, and other caregivers use
information about patients to determine what services they should receive. In
addition, the billing department uses confidential information to bill patients or
their insurance companies for the services they receive. And, other physicians
and quality control directors review confidential information to make sure patients
are getting good care.

Other uses are, generally speaking, not allowed. It is helpful to ask yourself
before looking at any patient information:
Do I need this in order to do my job and provide good patient care?
What is the least amount of information I need to do my job?

This requirement to use or share only the “minimum necessary” is covered in the
HIPAA privacy rule, section 164.502(b).

Who is authorized to see information?

All members of the workforce at a hospital contribute to the quality of care. But
that doesn’t mean everyone needs to see health information about patients.
Many employees have no access to patient information, whether in the computer
or on paper. That’s because they don’t need to know the information. That’s an
important phrase to remember: Need to know.

If you do not need to know confidential patient information to do your job, you will
not be given access to it. That means that you should not look at medical
records, either in the computer or on paper.

But there still will be occasions when you will have access to confidential
information. For example, if a patient is placed in an isolation room, you may
learn of why he or she is there, or you may suspect you know why. This is
confidential information about a patient, and you should not share it with anyone
else.

Another example of confidential information is the information about a patient’s
condition that you see written on whiteboards around the hospital. The
information contained on these boards is used for giving care to patients. In
general, it is recorded in places where the public will not see it. But you may
work in areas where this information is visible. This information is confidential.
That means you should not use it or share it with anyone, including coworkers,
other patients, patient visitors, or anyone else who may ask you about it.

In the course of doing your job, you may also find that patients speak to you
about their condition. Although there is nothing wrong with this, you must
remember that they trust you to keep that information confidential, and you must
not pass it on.

Case Scenario #3:

The newspaper has reported that someone famous has come to the hospital,
and you’re curious to know if this is true.

Q: Should you ask around or look for records about this person?

A: Obviously the answer is no. You are not allowed to satisfy your curiosity. If
you do look at patient records to satisfy curiosity, or for any non-business reason,
it is cause for dismissal and possible legal consequences. Remember that this
rule applies not just to people without access to medical records, but to anyone.

If doctors or nurses look at confidential information about patients for non-
treatment purposes, they can be fired or lose their privileges to work at the
hospital. If doctors or nurses share information about patients outside the
hospital with people who do not have a right to know that information, they can
be fired or lose their privileges to work at the hospital. Further, there may be
legal consequences and their licenses may be in jeopardy.
It is important to realize that protecting confidential information is a responsibility
that the entire workforce shares, including volunteers, regardless of whether they
directly care for patients.

Case Scenario # 4:

A friend is concerned because his girlfriend is in the hospital. He asks you to find
out anything you can.

Q: Should you try to find information for your friend?

A: Again, of course, the answer is no. In fact, you should not even acknowledge
that the girlfriend is in the hospital. You should direct your friend to the front
desk, where he can learn the patient’s location and general condition, if the
patient has agreed to have her information in the directory.

Remember that you are not to seek out confidential patient information other than
when required by your job. When it is made available to you, you are not to
repeat it to anyone. Protecting patient confidentiality is NOT just a hospital
priority, it is the LAW.

Remember, if you decide to violate these policies, you can be fired and
prosecuted. Violating patient confidentiality is a crime. More information about
how the hospital will respond to HIPAA violations is contained in Decatur Health
System’s HIPAA policy.



Test your Knowledge about HIPAA:
1. A patient’s confidential information includes his or her:
a. Social Security number
b. Address
c. Age
d. Name
e. All of the above

2. Which of the following phrases should you keep in mind when determining
whether you should have access to patient information?
a. Disregard all patient information
b. Any information out in the open is public record
c. Need to know
d. All of the above

Did you choose “All of the above” for each of the questions? If so, you are on
your way to understanding HIPAA privacy laws.
AUTHORIZATION

In order to use or share health information for certain business-related purposes,
such as releasing information to financial institutions that offer loans or selling
mailing lists to marketing companies, organizations need to receive
authorizations from patients. With an authorization—which must be in writing—
the patient voluntarily agrees to let your organization use the information only for
a particular request or need. This is covered under HIPAA section 164.508.
Providers may not refuse to treat patients who won’t sign authorization forms.

Authorization is also required to disclose psychotherapy notes, but it is not
needed to disclose information about an organ donor, about a deceased patient,
or for fundraising as long as the information is limited to individual demographics
and dates of service and your organization or fund-raising arm is performing the
fundraising.

Patients have the right to revoke their authorization at any time. They may also
ask providers to restrict how their medical information is used to carry out
treatment, payment, and healthcare operations, but providers are not required to
agree to the restrictions.


HELPING PATIENTS UNDERSTAND THEIR RIGHTS

It is important that patients understand how they can protect their own health
information and how providers protect their information. That’s why the HIPAA
rule also requires healthcare providers to post notices telling patients how their
information will usually be used.

This notice of privacy practices tells patients about the provider’s privacy policies
and practices and ways the provider will use their information. It also tells
patients about their rights, including the right to access their own records and
request amendments to them. HIPAA requires providers to make “good faith
efforts” to obtain patients’ written acknowledgement that they received a copy of
the notice of privacy practices.

These information notices are posted in places where patients can see them. If
patients have questions about how the organization uses information, you can
direct them to these posted notices, or to the HIPAA privacy officer for answers.

Test Your Understanding:

1. The notice of privacy practices explains the ways the organization will use
patient information and tells patient about their rights regarding the information.
True or False?
2. A patient can be denied treatment if he or she hasn’t signed an authorization
form. True or False?

Did you give the correct answers of True on Question 1 and False on Question
2?

TYPICAL WAYS TO PROTECT CONFIDENTIALITY

Ways to protect patient confidentiality: Using records and other
information

Decatur Health Systems uses many tools to protect confidentiality. Records are
kept locked, and only people with a need to see information about patients have
access to them.
Employees who use computerized patient records must not leave their
computers logged in to the patient information systems while they are not at their
workstations. Computer screens containing patient information should be turned
away from the view of the public or people passing by.
Posted or written patient information maintained in work areas such as nurses’
stations is kept covered from the public.
Discussions about patient care are kept private to reduce the likelihood that
those who do not need to know will overhear.
Electronic records are kept secure, and the facility monitors who gains access to
records to ensure that they are being used appropriately.
Paper records must always be shredded. They must never be left in the
trashcans to be disposed of with regular garbage.

All of these are basic ways that Decatur Health Systems protects confidentiality.
But truly protecting confidentiality depends upon you. You must not share
information that you overhear or see in the course of your work. Doing so is a
violation of the law.

Case scenario #5:

You are walking by a trashcan and notice that a pile of photocopied records has
been laid on top of the trash.

Q: How should you handle this? Should you dispose of the records in the
shredder?

A. The best response is to gather the records and take them to your supervisor.
He or she will want to report this to the facility’s privacy officer so that the facility
can try to find out why the records were disposed of improperly.

Case Scenario #6:
While you are entering a room containing records during off-hours, you find that
the door is unlocked.

Q: Should you lock the door? How should you respond?

A: The best response is, again, to contact your supervisor or the security
department and notify them of the unlocked door. They will want to follow up
with the privacy officer to find out why the door was left unlocked.

Case scenario #7:

You are approached by an individual who tells you that he is here to work on the
computers and wants you to unlock a door for him or point the way to a
workstation.

Q: How do you respond to this request?

A: The best response is to ask this person who his or her contact is at the
facility. Often, this is the information services manager. That individual can take
the repairperson to the appropriate work area. If the repairperson cannot tell you
who his point of contact is, contact your supervisor to assist the repairperson in
finding the contact.

Even if you do not have access to records yourself as part of your job, by being
on the lookout for potential violations of privacy, you help the facility keep its
commitment to patient confidentiality. You should feel comfortable going to your
supervisor or the privacy officer with any questions about how to respond in
situations in which privacy or confidentiality seem to be at risk.

ELECTRONIC CONFIDENTIALITY PROTECTIONS

Methods for protecting electronic information

Because so much information can be obtained so quickly in electronic format,
special attention is paid to computerized patient health information.

Using e-mail in the job

Decatur Health Systems has developed policies about the use of e-mail. Be sure
to familiarize yourself with them if you use e-mail in your job. These policies will
protect both confidentiality of information and the computers from viruses that
can harm it.

Remember that work e-mail accounts are not meant for personal use. Sharing or
opening attached files from an unknown source can open the door to viruses and
hackers. It is also important to remember that you can never be sure who will
have access to your e-mail on the receiving end. Never send confidential
information about a patient in an e-mail over a public network unless it is
encrypted. When you send e-mails, always double-check the address line just
before sending the message. Be sure that your e-mail doesn’t go to the wrong
person or list by mistake!

Passwords

Passwords and other security features that restrict access to the computer
system protect patient information. If you have password access to Decatur
Health System’s computer system, never share passwords or log in to the health
information system using borrowed credentials. Letting someone else use your
password, or logging on and letting him or her use the system in your session,
may seem like a timesaver. But it’s essential that the organization be able to tell
who gains access to what records. Don’t write your password down, post it, or
keep it where other can find it. These are all ways to put information at risk.

More steps for protecting electronic information

Make sure that computer screens are pointed away from the public and that
computers are not connected to the patient information system when they are not
in use. If you notice screens and information that appear easy for passersby to
see or read, let the user or someone in the department know about the problem
so that it can be corrected right away.

Because of the need to adequately protect patient information, you must never
remove computer equipment, disks, or software from the facility even if you think
they are no longer used, unless you fist have permission from your supervisor.
Special precautions must be taken to make sure that all patient information is
removed from computer equipment before it is discarded.

Case scenario # 8

You enter an unattended work area and notice a password for the computer
system is posted on the wall.

Q: What should you do?

A: Notify your supervisor that a password appears to be publicly available and
that you are concerned this might allow unauthorized access to the computerized
health records of patients.

Case scenario # 9

You find an old computer in the back of a room that is used for trash. You’re
certain that this machine is not being used any longer.
Q: Can you take this computer to use in performance of your job?

A: The best thing to do is consult your supervisor. Any unauthorized removal of
facility property is considered theft, so under no circumstances are you allowed
to take the computer out of the facility without approval. But even if you intend to
use the computer to do your job, you should first ask your supervisor to ensure
that it never contained patient records or, if it did, that they have been adequately
removed.

Case scenario # 10:

The hospital has, for many years, sent patients follow-up mailing after they leave
the hospital to maker the hospital’s services. The company that does the
mailings calls and tells you they have lost the computer disk containing the
names and addresses for letters to be mailed out. They want you to e-mail them
the latest list of names and addresses.

Q: You know that the hospital notifies patients that they will be receiving
this mailing, so can you send the requested information?

A: Most likely, the answer here is no. The best idea is to send the information
offline via diskette. Check with your supervisor or the privacy and security officer
about whether and how to send it. The facility might require a contracted carrier
send such information.

HELPFUL HINTS TO USE WHEN WORKING WITH COMPUTERS

Review your organization’s policies on using computers
Do not use work e-mail for personal messages
Never share or open attached files from an unknown source.
Never send confidential patient information in an e-mail unless it is encrypted
Always double-check the address line of an e-mail before you send it.
If you use a password to access the organization’s computer system, never
share your password or log in to the system with someone else’s password
Always keep computer screens pointed away from the public
Never remove computer equipment, disks, or software from the facility unless
you have permission

EXCEPTIONS TO THE RULES

There are some exceptions to confidentiality. You must be sure you know your
organization’s policies before releasing information and check that the particular
instance is approved. There are some cases in which patients do not have the
right to keep their information private.
In these situations, Decatur Health Systems has a responsibility to release
information, regardless of whether the patient agrees.

SEVEN REASONS FOR RELEASING CONFIDENTIAL INFORMATION

      Providers are required to report certain communicable disease to state
       health agencies. The facility must report when patients have these
       diseases, even if the patient doesn’t want the information reported.
      The Food and Drug Administration (FDA) requires providers to report
       certain information about medical devices that break or malfunction.
      Some states require that, when physicians or other people who provide
       patient care suspect child abuse or domestic violence, they must report it
       to the police.
      Police have the right to request certain information about patients to
       determine whether they are suspects in a criminal investigation
      The courts have the right to order providers to release patient information.
      Providers must report cases of suspicious deaths or certain suspected
       crime victims, such a people with gunshot wounds.
      The hospital or provider reports information to coroners and funeral
       directors in cases where patients die.

UNDERSTANDING YOUR ROLE

In most cases, patients are informed when their health information is being
reported to police or others outside the facility, but these are cases in which they
do not have the right to control their information.

In all of these cases, the facility complies with the law and makes reports when
necessary. Unless reporting this information is part of your job, you should not
report this information yourself.

If you are interested in more information about what your state requires, you may
find it useful to contact your facility’s privacy or security officer. That person can,
if needed, check with legal counsel or the attorney general.

SUMMARY

Summary of issues

As an employee of Decatur Health Systems, one of your jobs is to help maintain
privacy for patients as the receive care and help protect the confidentiality of
information that patients give to their providers.

There will be times when you will hear or see patient information. You are
expected to not seek out information about patients unless it is job-related. But
when you do see or hear information in the course of doing your job, remember
that the information is confidential and you are not allowed to repeat it or share it
with others. This applies even when you no longer work at this facility.

Reporting violations

The organization expects all employees to adhere to the privacy and
confidentiality policies, but it recognizes there may be times when the policy is
being abused.

Employees are encouraged to report violations or suspected violations to the
facility’s privacy officer. You may report abuses anonymously, if you wish, by
following the procedures in the privacy policy. However, do not fear any
retaliation if you report a privacy violation.

Decatur Health Systems does not punish employees for reporting violations. In
fact, it is considered part of your job to report instances where you suspect the
privacy or confidentiality policies are being broken.

Review Your Knowledge About HIPAA:

Quickly jot down numbers 1 through 15, and then give your answers to the
following questions on this Practice Test. Then check your responses with the
answers found at the end. This is NOT the Employee Assessment test on
HIPAA. It is a PRACTICE TEST.

1. The criminal penalties for improperly disclosing patient health information can
be as high as fines of $250,000 and prison sentences of up to 10 years.

True or False?

2. Confidentiality and privacy are important concepts in healthcare because:

a. They help protect hospitals from lawsuits
b. They allow patients to feel comfortable sharing information with their doctors.
c. They avoid the confusion of having people other than a physician distributing
information about a patient
d. Both a and b


3. Which of the following are common ways that employees protect patient
privacy?

a.   Closing patient doors
b.   Knocking before entering a patient room
c.   Using curtains to shield patients during treatment
d.   All of the above
4. You are working in the emergency department and see that a neighbor has
just arrived for treatment after a car crash. You should:

a. Contact the neighbor’s spouse to alert him or her about the accident
b. Say nothing and pretend you didn’t recognize your neighbor
c. Tell an emergency department nurse that you know how to reach the patient’s
spouse and offer the information if it is needed

5. Confidentiality protections cover not just patients’ health-related information,
such as the reason they are being treated, but also information such a address,
age, Social Security number, and phone number.

True or False?

6. You are approached by an individual who tells you that he is here to work on
the computers and wants you to unlock a door for him or point the way to a
workstation. How do you respond to this request?

a. Provide him with the information or access he needs
b. Ask him who at the hospital has hired him and refer him to that person for
assistance
c. Call the police

7. Any employee or physician who violates the hospital privacy policy is subject
to punishments up to and including firing or termination of work privileges.

True or False?

8. Which of the examples below is NOT a common work practice that protects
the confidentiality of patient information:

a. Keeping computers logged out of the patient information system when not in
use
b. Keeping records locked when not in use
c. Limiting the number of visitors who can see a patient
d. Limiting the people who can look at electronic patient records

9. Privacy laws have provisions that allow physicians to report suspected cases
of child abuse to the police, when they are required to do so by other laws.

True or False?
10. Under what circumstances are you free to repeat to others private health
information that you hear on the job?

a.   After you no longer work at the hospital
b.   After a patient dies
c.   Only if you believe the patient won’t mind
d.   When authorized for business purposes

11. If you suspect someone is violating the facility’s privacy policy, you should:

a. Say nothing. It’s none of your business
b. Watch the individual involved until you have gathered solid evidence against
him or her
c. Report your suspicions to the privacy officer or your supervisor, as outlined in
the facility privacy policy


12. Which of the following are common features designed to protect
confidentiality of health information contained in patient medical records?

a. Locks on medical records rooms
b. Passwords to access computerized records
c. Rules that prohibit employees from looking at records unless they have a
need to know
d. All of the above

13. Computer equipment that has been used to store patient health information
must undergo special processing to remove all traces of the information before it
can be discarded.

True or False?

14. Providers have a special concern now for protecting patient privacy because:

a. Patients are suing more often when their information is released without their
knowledge
b. A HIPPA law makes it a criminal offense not to protect patient health
information
c. Healthcare workers have gotten sloppier than they were in the past about
protecting privacy.
d. Both a and b

15. Only employees who need access to patient records have to worry about
protecting patient privacy and confidentiality.

True or False
Check the Answers on your Practice Test:

1. True
2. d
3. d
4. c
5. True
6. b
7. True
8. c
9. True
10. d
11. c
12. d
13. True
14. d
15. False


The confidentiality of patient information at Decatur Health Systems should be
safeguarded at all times. Patients and residents who utilize our services depend
on YOU to do your part.



Go Home                          Take the HIPAA Test
                 ***************************************************

INCIDENT COMMAND SYSTEM (ICS)                                                   Go Home
       Hospital Incident Command System (HICS)
Activation of the Incident Command System

Several diverse instances can trigger the activation of the Incident Command System. Some
triggering incidents could be:

   A traffic accident with multiple casualties
   An explosion with several victims
   An interruption of utilities
   A tornado striking the community
   A patient surge due to a pandemic
   A bioterrorist attack
   A hazardous materials release
   A fire emergency
   Any other incident that interrupts and stresses the usual operation of our facility

Six Step Planning

When an incident occurs that triggers the activation of the Incident Command System,
planning how to address the situation should follow these six steps:

1. SIZE UP THE SITUATION
   Assess the situation. What information do you know for certain?

2. IDENTIFY CONTINGENCIES
    What bad can happen?

3. DETERMINE OBJECTIVES
   What do you want to do initially?

4. IDENTIFY NEEDED RESOURCES
    What means do you have available that will be needed to assist you to accomplish your
objectives?

5. BUILD A PLAN AND A STRUCTURE
   Your plan and structure should identify responsibilities and tasks that are coordinated
through a chain of command.

6. TAKE ACTION
   Establish command and mobilize resources to address your objectives.

Continue to monitor for changes in the situation. Be prepared to repeat these six steps until
the situation is resolved.
ICS Structure
In the event of a disaster, the Chief Executive Officer, Chief Nursing Officer, Chief of Medical
Staff or the current Charge Nurse on Duty will announce the disaster and assume the duties
and responsibilities of the Incident Commander. To ensure an orderly organization, reports
are to be made following a strict chain of command system. Please refer to page 6 in the
red Emergency Operations Plan (EOP) notebook located in your department to see a
clear illustration of the Hospital Incident Command System (HICS) structure.

IMPORTANT:
Each of the different areas in the plan could be filled with any hospital employee who is
currently present and qualified to fill that position.

An incident may be so large as to require that all or almost all of the positions be filled. An
incident could also be smaller in scope, which would require fewer of the positions to be
filled. When the Incident Command System is activated, employees at Decatur Health
Systems will be called upon to be flexible to fill those positions that are needed in that
particular emergency situation.



                            COMMAND SECTION

                             INCIDENT COMMANDER

The Incident Commander:
    Organizes and directs the Hospital Command Center (HCC
    Gives overall strategic direction for hospital incident management and support activities,
including emergency response and recovery
    Authorizes total facility evacuation if warranted.

Eight Section Chiefs are to report directly to the Incident Commander. Those Section
Chiefs are:

   Safety Officer
   Public Information Officer
   Liaison Officer
   Medical/Technical Specialists
   Operations Section Chief
   Planning Section Chief
   Logistics Section Chief
   Finance/Administration Section Chief

It is of utmost importance to note that all other Section Managers, Branch Directors and Unit
Leaders are to report directly to their own Section Chief. This system enables important
information to be passed on quickly and efficiently and prevents confusion at all levels. When
an incident happens, information will be passed along on a need to know basis. All
employees who are called upon to work when the Incident Command System is activated will
be assigned a specific job and will report according to the chain of command established
under the ICS Plan made at that time. The chain of command under ICS may be different
than what an employee observes on a normal basis.

SAFETY/SECURITY OFFICER
The Safety/Security Officer:
  Ensures safety of staff, patients, and visitors, monitors and corrects hazardous condition
  Has authority to halt any operation that poses immediate threat to life and health
  Is responsible to report directly to the Incident Commander.

PUBLIC INFORMATION OFFICER
The Public Information Officer:
    Serves as the conduit for information to internal and external stakeholders, including staff,
visitors and families, and the news media, as approved by the Incident Commander
    Is responsible to report directly to the Incident Commander.

LIAISON
The Liaison Officer:
   Functions as the incident contact person in the Hospital Command Center for
representatives from other agencies
   Is responsible to report directly to the Incident Commander.

MEDICAL/TECHNICAL SPECIALISTS
The Medical/Technical Specialists or Medical Staff:
    Advise the Incident Commander or Operations Section Chief, as assigned, on issues
related to the Medical Staff
    Are responsible to report directly to the Incident Commander.




                        OPERATIONS SECTION CHIEF
The Operations Section Chief:
   Develops and implements strategy and tactics to carry out the objectives established by
the Incident Commander
   Organizes, assigns, and supervises Staging, Medical Care, Infrastructure, Security,
Hazardous Materials, and Business Continuity Branch resources
   Is responsible to report directly to the Incident Commander.

STAGING MANAGER
The Staging Manager:
   Organizes and manages the deployment of supplementary resources, including
personnel, vehicles, equipment, supplies, and medications
   Is responsible to report directly to the Operations Section Chief.

   *Personnel - Organizes and manages the deployment of supplementary personnel
resources.

   *Vehicles - Organizes and manages the deployment of supplementary vehicle resources.

  *Equipment/Supplies - Organizes and manages the deployment of supplementary
equipment and supplies.
  *Medication - Organizes and manages the deployment of supplementary medications
and supplies.



MEDICAL CARE BRANCH DIRECTOR
The Medical Care Branch Director:
   Organizes and manages the delivery of emergency, inpatient, outpatient, and casualty
care, and clinical support services
   Is responsible to report directly to the Operations Section Chief.

   *In-Patient Unit Leader - Assures treatment of inpatients, manages the inpatient care
area(s), and provides for a controlled patient discharge.

  *Out-patient Unit Leader - Prepares outpatient service areas to meet the needs of in-
house and newly admitted patients.

   *Casualty Care Unit Leader - Assures delivery of emergency care to arriving patients.

   *Mental Health Unit Leader - Addresses issues related to mental health emergency
response, manages the mental health care area, and coordinates mental health response
activities.

   *Clinical Support Services Unit Leader - Organizes and manages clinical support
services. Assists in providing the optimal functioning of these services. Monitors the use and
conservation of these resources.

   *Patient Registration Unit Leader - Coordinates inpatient and outpatient registration.

INFRASTRUCTURE BRANCH DIRECTOR
The Infrastructure Branch Director:
    Organizes and manages the services required to sustain and repair the hospital’s
infrastructure operations, including: power/lighting, water/sewer, HVAC, buildings and
grounds, medical gases, medical devices, structural integrity, environmental services, and
food services
    Is responsible to report directly to the Operations Section Chief.

  *Power/Lighting Unit - Maintains power and lighting to the hospital and campus facilities.
Ensures adequate generator fuel.

   *Water/Sewer Unit - Evaluates and monitors the patency of existing water, sewage, and
sanitation systems. Enacts pre-established alternate methods of waste disposal if necessary.

   *HVAC Unit - Maintains heating and air conditioning to the facility and adjacent facilities.

   *Building/grounds Damage Unit - Organizes and manages the services required to
sustain and repair the hospital’s buildings and grounds.

   *Medical Gases Unit - Organizes and distributes medical gases to requesting clinical
care areas.

   *Medical Devices Unit - Organizes and distributes medical devices to requesting clinical
care areas.
   *Environmental Services Unit - Ensures proper cleaning and disinfecting of hospital
environment.

    *Food Services Unit - Organizes and maintains food preparation and delivery services
for patients, families and visitors.

HAZMAT BRANCH DIRECTOR
The HazMat Branch Director:
   Organizes and directs hazardous material incident response activities: detection and
monitoring; spill response; victim, technical, and emergency decontamination; and facility
and equipment decontamination
   Is responsible to report directly to the Operations Section Chief.

   *Detection and Monitoring Unit - Coordinates detection and monitoring activities related
to hazardous material incident response.

   *Spill Response Unit - Coordinates on-site activities related to implementation of
hospital's internal hazardous material spill response plan.

   *Victim Decontamination Unit - Coordinates the on-site patient decontamination
activities related to hazardous material incident response.

   *Facility/Equipment Decontamination Unit - Coordinates on-site facility and equipment
decontamination activities related to hazardous material incident response.


SECURITY BRANCH DIRECTOR
The Security Branch Director:
   Coordinates all of the activities related to personnel and facility security such as access
control, crowd and traffic control, and law enforcement interface
   Is responsible to report directly to the Operations Section Chief.

   *Access Control Unit - Ensures the security of the facility and personnel by monitoring
individuals entering and exiting the building.

   *Crowd Control Unit - Maintains scene safety and ensure crowd control.

   *Traffic Control Unit - Organizes and enforces vehicular traffic security for facility.

  *Search Unit - Coordinates the search and rescue of missing staff, patients, and family
members.

   *Law Enforcement Interface Unit - Coordinates security of facility with outside law
enforcement agencies.


BUSINESS CONTINUITY DIRECTOR
The Business Continuity Director:
   Ensures business functions are maintained, restored or augmented to meet designated
Recovery Time Objectives (RTO) and provides limited interruptions to continuity of essential
business operations
   Is responsible to report directly to the Operations Section Chief.
    *Information Technology Unit - Ensures IT business functions are maintained, restored
or augmented to meet designated Recovery Time Objectives (RTOs) and provides limited
interruptions to continuity of essential business operations.

  *Service Continuity Unit - Ensures business/clinical/ancillary service functions are
maintained, restored or augmented to meet designated Recovery Time Objectives (RTO)
and provides limited interruptions to continuity of essential business operations.

    *Records Preservation Unit - Ensures vital business/medical records are maintained
and preserved to meet designated Recovery Time Objectives (RTO) and provides limited
interruptions to continuity of essential business operations.

    *Business Function Relocation Unit - Ensures business functions are moved to
alternative work sites to maintain designated Recovery Time Objectives (RTO) and provides
limited interruptions to continuity of essential business operations.




                            PLANNING SECTION

                           PLANNING SECTION CHIEF
The Planning Section Chief:
   Oversees all incident-related data gathering and analysis regarding incident operations
and assigned resources, develop alternatives for tactical operations, conduct planning
meetings, and prepares the Incident Action Plan (IAP) for each operational period
   Is responsible to report directly to the Incident Commander

RESOURCE UNIT LEADER
The Resource Unit Leader:
   Maintains information on the status, location, and availability of personnel, teams,
facilities, supplies, and major equipment to ensure availability of use during the incident
   Maintains a master list of all resources assigned to incident operations
   Is responsible to report directly to the Planning Section Chief

   *Personnel Tracking - Maintains information on the status, location, and availability of
on-duty staff and volunteer personnel

   *Materiel Tracking – Maintains information on the status, location, and availability of
equipment and supplies within the hospital inventory and additional materiel received from
outside agencies in support of the incident

SITUATION UNIT LEADER
The Situation Unit Leader:
   Collects, processes, and organizes ongoing situation information; prepares situation
summaries; and develops projections and forecasts of future events related to the incident
   Prepares maps and gathers and disseminates information and intelligence for use in the
Incident Action Plan (IAP)
   Is responsible to report directly to the Planning Section Chief
   *Patient Tracking - Monitors and documents the location of patients at all times within
the hospital's patient care system, and tracks the destination of all patients departing the
facility

   *Bed Tracking - Maintains information on the status, location, and availability of all
patient beds, including disaster cots and stretchers



DOCUMENTATION UNIT LEADER
The Documentation Unit Leader:
    Maintains accurate and complete incident files, including a record of the hospital’s /
HCC’s response and recovery actions and decisions; provides duplication services to
incident personnel; and files, maintains, and stores incident files for legal, analytical, and
historical purposes
    Is responsible to report directly to the Planning Section Chief

DEMOBILIZATION UNIT LEADER
The Demobilization Unit Leader:
    Develops and coordinates an Incident Demobilization Plan that includes specific
instructions for all staff and resources that will require demobilization
    Is responsible to report directly to the Planning Section Chief



                            LOGISTICS SECTION
                           LOGISTICS SECTION CHIEF

The Logistics Section Chief:
   Organizes and directs those operations associated with maintenance of the physical
environment and with the provision of human resources, materiel, and services to support
the incident activities
   Participates in Incident Action Planning
   Is responsible to report directly to the Incident Commander

SERVICE BRANCH DIRECTOR
The Service Branch Director:
   Organizes and manages the services required to maintain the hospital’s communication
system, food and water supply for staff, and information technology and systems
   Is responsible to report directly to the Logistics Section Chief.

  *Communications Unit - Organizes and coordinates internal and external
communications connectivity

   *IT/IS Unit - Provides computer hardware, software and infrastructure support to staff

   *Staff Food & Water Unit - Organizes food and water stores and prepares for rationing
during periods of anticipated or actual shortage

SUPPORT BRANCH DIRECTOR
The Support Branch Director:
   Organizes and manages the services required to maintain the hospital’s supplies,
facilities, transportation, and labor pool
   Ensures the provision of logistical, psychological, and medical support of hospital staff
and their dependents
   Is responsible to report directly to the Logistics Section Chief.

    *Employee Health & Well-Being Unit - Ensures the availability of medical care for
injured or ill staff. Ensures the availability of behavioral and psychological support services to
meet staff needs during and following an incident. Coordinates mass
prophylaxis/vaccination/immunization of staff, if required. Coordinates medical surveillance
program for employees

   *Family Care Unit - Ensures the availability of medical, logistic and mental health and
day care for the families of staff members. Coordinates mass
prophylaxis/vaccination/immunization of family members if required.

   *Supply Unit - Acquires, inventories, maintains, and provides medical and non-medical
care equipment, supplies, and pharmaceuticals.

   *Facilities Unit - Organizes, manages and supports building systems, equipment and
supplies. Ensures proper cleaning and disinfecting of hospital environment.

   *Transportation Unit - Organizes and coordinates the transportation of all ambulatory
and non-ambulatory patients. Arranges for the transportation of human and material
resources within or outside the facility.

    *Labor Pool & Credentialing Unit - Collects and inventories available staff and
volunteers at a central point (Labor Pool) for assignment by the Staging Officer. Maintains
adequate numbers of both medical and non-medical personnel. Assists in the maintenance
of staff morale.




                              FINANCE SECTION
             FINANCE/ADMINISTRATION SECTION CHIEF

The Finance/Administration Section Chief:
  Monitors the utilization of financial assets and the accounting for financial expenditures
  Supervises the documentation of expenditures and cost reimbursement activities
  Is responsible to report directly to the Incident Commander.

TIME UNIT LEADER
The Time Unit Leader:
   Is responsible for the documentation of personnel time records
   Monitors and reports on regular and overtime hours worked/volunteered
   Is responsible to report directly to the Finance/Administration Section Chief.
PROCUREMENT UNIT LEADER
The Procurement Unit Leader:
   Is responsible for administering accounts receivable and payable to contract and non-
contract vendors
   Is responsible to report directly to the Finance/Administration Section Chief.

COMPENSATION/CLAIMS UNIT LEADER
The Compensation/Claims Unit Leader:
   Is responsible for receiving, investigating and documenting all claims reported to the
hospital during the emergency incident, which are alleged to be the result of an accident or
action on hospital property
   Is responsible to report directly to the Finance/Administration Section Chief.

COST UNIT LEADER
The Cost Unit Leader:
  Is responsible for providing cost analysis data for the declared emergency incident and
maintenance of accurate records of incident cost
  Is responsible to report directly to the Finance/Administration Section Chief


                       Activation of Surge EOP Phase I
The First 30 Minutes

The activation of the Surge Emergency Operations Plan (EOP) can happen at any time of
night or day. It is important to realize that YOU may be the person who will be in charge.
Since incidents happen quickly it is also important to have a clear outline set in your mind of
what should be done without a moment's hesitation.

When the call comes in from an ambulance crew that a multiple casualty accident has
occurred and transport will happen in the next few minutes, the following outline is an
essential and reasonable plan of action, even before the ambulance arrives.

Assume the role of Incident Commander/Operations Section Chief.
This role is usually assumed by the Chief Executive Officer, Chief Nursing Officer, Chief of
Medical Staff or the current Charge Nurse on Duty who will announce the disaster and then
assign positions that are needed to address the incident as efficiently as possible. The
Incident Commander will immediately:
   1. Assign a Radio/Phone Monitor This person monitors/records radio traffic and
answers and records radio traffic and answers and records phone calls. If enough personnel
are present, a possible runner or scribe could also be assigned to assist the monitor. A
communications board may be utilized to track information on multiple casualties. The
communication board will be placed near the hospital nurses station.

   2. Assign an Inpatient Unit Leader This person is responsible for inpatient care until he
or she is relieved from this duty.

   3. Assign a Casualty Unit Leader This person works as the triage nurse and determines
which incoming patients are the most seriously injured, assigning treatment rooms
accordingly. The triage nurse assigns one nurse, one scribe and one runner to go with each
patient to their assigned treatment room. The triage nurse sends requests for additional
staffing needs to the Labor Pool Unit Leader.
   4. Assign Labor Pool Unit Leader The Labor Pool Unit Leader calls needed staff and
documents who has been called.

      ~SMT (Senior Management Team)
      ~Physicians
      ~Lab
      ~X-Ray
      ~Maintenance
      ~Replacements for Positions
      ~Patient Registration replacement
      ~Additional staff as requested

   5. Assign Patient Registration Unit Leader The Patient Registration Unit Leader
assembles Triage Clipboards and registers patients.

   6. Assign Supply Unit Leader The Supply Unit Leader gets supplies as needed.

Assigned positions are kept as assigned until relieved. When relieved, persons report to the
labor pool for additional assignment. The labor pool will be located in the front lobby.


Go Home                Take the Hospital Incident Command Test
***********************************************************

               Infection Control                               Go Home
                           Employee Health Requirements


Purpose Of The Employee Health Policy:
To outline the requirements of the organization’s Employee Health program for both the
facility and for each facility employee.

Policy On Employee Health Issues:
As an extension of the organization’s Risk Management and Human Resources obligations,
the Employee Health function is to specify and adhere to clear standards. This expectation
has requirements for both employee and organization alike. The Employee Health Nurse will
be held accountable to the Administrator through the Performance Improvement Committee
for attesting that all employee health requirements are met by the organization. Department
Heads, Staff Members, and Administrative Staff are equally accountable to the Employee
Health Nurse for ensuring that employee’s fulfill the requirements of the program. These
expectations testify that the following requirements of the employee health program must be
met at all times.

Procedure/Intervention(s):
The following requirements and standards must be fulfilled as a routine matter:

1. Conditional Period Drug Screen. All prospective employees must take and pass a drug
test at some time during their conditional period, as outlined in the Human Resource Policy
and Procedure Manual.
2. Post-offer Medical Examinations. Upon employment, all facility personnel shall have a
medical examination, which shall consist of examinations appropriate to the duties of the
employee, including a chest x-ray or tuberculin skin test.
3. New Hire Health Screening. All new employees will complete an Employee Health
Questionnaire at the time of hiring.
4. Annual TB Screening. Subsequent TB screening will be done annually or more often if
indicated.
5. Sick Leave Documentation. A return to work permit from a physician must be obtained
by the employee who has missed scheduled hours 3 or more consecutively scheduled shifts
before returning to work.
6.Required Work Restrictions. Any employee work restrictions deemed necessary by a
physician must be written and signed by the physician, given to the employee’s supervisor,
then forwarded to the Employee Health Nurse who will place the documentation in the
employee’s health file. The employee is accountable for following the work restrictions
placed by the physicians.
       Employees who develop an illness or physical condition, which requires medical
treatment or restrictions and precautions as to their health will be required to submit a
physician’s statement. This statement must give approval that continued full-time
employment in their present position would not jeopardize their health or the safety of others,
in the event they continue to work. A similar statement is required upon return from a
disability leave. The physician must indicate whether this is a temporary or permanent
restriction. If it is temporary a review by this physician must by done every 30 days.
7. Hepatitis Vaccinations. Hepatitis B vaccine is available at no cost for all employees who
may be exposed to blood or bodily fluids.
8. Exposure Reports. Exposure reports will be completed for all employees reporting
exposures to blood and body fluids.
9. Illness Reports. Illness reports are to completed for all employees calling in ill or who
become ill at work.
10. Injury Reports. Injury reports are to be completed for all employee injuries within 10
days.
11. Follow-up Medical Reviews. Subsequent medical examinations or health assessments
shall be done annually.




                   EMPLOYEE ILLNESS REQUIREMENT

Purpose of Employee Illness Requirement:
To outline the mutual responsibilities of the employee and organization in the event an
employee illness disrupts the individual’s capacity to meet scheduled work requirements.

Employee Illness Policy:
The organization acknowledges that a person will, from time to time, experience an illness
that will prevent the fulfillment of routine work schedules and duties. At such times, it is
essential for the facility to provide an effective method of reporting and follow-up of those
employees who are absent from work because of illness. Also, it is necessary to prevent the
spread of infection to patients, residents, and other employees within the facility. Further,
since illnesses and sick leave usage has the potential to be disruptive to the organization’s
mission, it is also necessary to provide a format for tracking trends or patterns of employee
illness. Through the implementation of this policy, the facility intends to balance each staff
member’s need for relief during bona fide illnesses with the organization’s need to have a
reliable work force on a consistent basis.

Procedure/Intervention(s):
     A. Notification. The employee is to notify his/her immediate supervisor in person or by
phone as soon as he/she determines that he/she will be unable to work the scheduled shift.
If the immediate supervisor is not available the employee should notify the person in charge.
Each department will have a chain of command to follow in case of the absence of the
immediate supervisor.
     B. Illness Clarification. The supervisor or designee receiving the notification will ask for
specific symptoms if not given by the employee. Employees are requested not to call in with
or report “FLU” or “DOESN’T FEEL WELL” without describing their symptoms.
     C. Illness Documentation. The supervisor or designee will initiate the EMPLOYEE
ILLNESS REPORT when the employee calls in. The report will then be submitted to the
supervisor who will complete it and place it in the Employee Health Nurse’s mailbox in the
front office. An illness form should include each date the employee is ill.
        Injury Alternative. If the illness is work related, refer to the Accident Report Process
in the EMPLOYEE INJURY POLICY. The Accident Report is to be completed by the
employee and the supervisor and given to the Human Resource Manager. A copy of this
report is given to the Employee Health Nurse for placement in the employee health file. The
employee illness report is also kept in the employee health file.
     D. Return to Work Documentation. If the illness causes the employee to miss
scheduled work hours during 3 or more consecutively scheduled days, a release to return to
work must be obtained from the physician prior to returning to work. This release will be
shown to the employee’s supervisor and will be kept in the employee’s health file. Any work
restrictions ordered by the physician must also be written, shown to the supervisor and then
placed in the employee’s health file.
   E. Surgery or Hospitalization. Surgery or hospitalization required for the employee will
be considered the same as an illness. If possible, arrangements should be made with the
employee’s supervisor to plan for scheduling changes necessary to cover the employee’s
absence.

                          STANDARD PRECAUTIONS
Standard precautions apply to blood, all body fluids, secretions, excretions (regardless of
whether or not they contain visible blood), non-intact skin, and mucous membranes.

Standard precautions should be used for the care of all hospitalized patients. Such
precautions prevent the occurrence of nosocomial infections, which are those
infections that occur in patients during or after hospitalization that weren't present at
the time of their admission.


    Handwashing
Wash hands after touching blood, body fluids, secretions, excretions, and contaminated
items, whether or not gloves are worn. Wash hands or use anti-microbial agent immediately
after gloves are removed and between patient contacts.

   Gloves
Wear gloves when touching blood, body fluids, secretions, excretions, and contaminated
items. Put on clean gloves just before touching mucous membrane and non-intact skin.
Remove gloves promptly after use, before touching non-contaminated items and
environment surfaces, and before going to another patient. Wash hands immediately to
avoid transfer of microorganisms to other patients or environments.

   Mask, eye protection, face shield
Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes,
nose, and mouth during procedures and patient-care activities that are likely to generate
splashes or sprays of blood, body fluids, secretions, and excretions.

   Gown
Wear a clean gown to protect skin and prevent soiling of clothing during procedures and
patient-are activities that are likely to generate splashed or sprays of blood, body fluids,
secretions, or excretions or to cause soiling of clothing. Remove a soiled gown as promptly
as possible and wash hands to avoid transfer of microorganisms to other patients or
environments.

    Patient-care equipment
Handle used patient-care equipment soiled with blood, body fluids, secretions, or excretions
in a manner that prevents skin and mucous membrane exposure, contamination of clothing,
and transfer of microorganisms to other patients and environments. Reusable equipment
must be processed appropriately before it is used for the care of another patient. Single-use
items must be appropriately discarded.
   Linen
Handle, transport, and process used linen soiled with blood, body fluids, secretions and
excretions in a manner that prevents skin and mucous membrane exposure and
contamination of clothing.

    Needle disposal
Take care to prevent injuries when using needles, scalpels and other sharp instruments or
devices; when handling sharp instruments after procedures; when cleaning used
instruments; and when disposing of used needles. Never recap used needles or manipulate
then with any other technique that involves directing the point of a needle toward any part of
the body. A one-handed scoop technique or a mechanical device for holding the needle
sheath may be used. Do not remove used needles from disposable syringes by hand, and do
not bend, break, or manipulate used needles by hand. Place used disposable syringes and
needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers,
located as close as practical to resistant container for transport to the reprocessing area.

   Resuscitation equipment
Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-
to-mouth resuscitation in areas where the need for resuscitation is predictable.

   Patient placement
Place a patient who contaminates the environment or who does not assist in maintaining
appropriate environment control in a private room. If a private room is not available, consult
with the infection control nurse regarding patient placement or other alternatives.

                         EXPOSURE CONTROL PLAN

Exposure Control Policy:
Decatur Health Systems is committed to providing a safe and healthful work environment for
our entire staff. In pursuit of this endeavor, the following exposure control plan (ECP) is
provided to eliminate or minimize occupational exposure to blood-borne pathogens in
accordance with OSHA standard 29CFR 1910.1030, “Occupational Exposure to Blood-borne
Pathogens.”

Exposure Control Procedure/Intervention(s):
The Exposure Control Plan is a key document to assist DHS in implementing and ensuring
compliance with the standard, thereby protecting our employees. The Exposure Control Plan
will include:
    Determination of employee exposure
    Implement of various methods of exposure control, including:
         ~Standard Precautions
         ~Engineering and work practice controls
         ~Personal Protective Equipment
         ~Housekeeping
    Hepatitis B vaccination program
    Post exposure evaluation and follow-up
    Communications of hazards to employees and training
    Record keeping
    Procedures for evaluating circumstances surrounding an exposure incident
STATEMENT OF PURPOSE
The Occupational Safety and Health Administration (“OSHA”) has made a determination that
personnel face a significant health risk as a result of occupational transmission of blood-
borne pathogens in a healthcare setting. In the 1999 compliance directive titled Enforcement
Procedures for Occupational Exposure of Blood-borne Pathogens, OSHA defines blood-
borne pathogens by stating, “While HBV (Hepatitis B virus), and HIV (Human
Immunodeficiency virus) are specifically identified in the standard, the term includes any
pathogenic microorganism that is present in human blood or other potentially infectious
material and can infect and cause disease in persons who are exposed to blood containing
the pathogen. Pathogenic microorganisms can also cause diseases such as Hepatitis C,
malaria, etc. Although a variety of pathogens may be blood-borne, the pathogens of greatest
concern continue to be HIV, HBV, and Hepatitis C Virus.

The main risk to workers is through percutaneous injuries involving a needle or device used
during the care of an infected individual. The risk of transmission is likely higher with hollow-
bore needles. Several additional factors appear to affect the risk of transmission following an
occupational exposure. The risk is increased when one of the following conditions is met:

   The device involved is physically contaminated with the patient’s blood
   The exposure occurs during a procedure that involves a needle placed directly in a vein
or artery
   The exposure results in a deep injury

Exposures can also be a risk when blood enters the body via open wounds, cuts and by
splashing in the face, eyes and mouth, though this is a much lower risk.

Because the infectious status of patients is often unknown, health care workers are to
observe precautions when dealing with all patient body fluids, at all times. Most important is
the avoidance of blood contaminated penetrating injuries from sharp needles and blades,
etc. The use of Standard Precautions is therefore to be practiced in all circumstances.

       EXPOSURE CONTROL PROGRAM ADMINISTRATION

CEO
The facility CEO is responsible and accountable for the facility's overall infection control
program including exposure control of blood-borne pathogens. The CEO is responsible for
assuring that exposure control activities are carried out as identified in the facility-wide plan
and in the final rule and regulations. Important information specific to blood-borne pathogens
exposure incidents shall be reported to the appropriate committee (safety and/or infection
control, and quality assurance) on a quarterly and as needed basis. The CEO is responsible
for assuring the protection of the confidentiality rights of the employees.

Infection Control Nurse
The Infection Control Nurse or designee is responsible for overall implementation of the
Exposure Control Plan; for working collaboratively with the CEO, employees and the medical
staff regarding infection control issues; for the development and implementation of policies
and procedures specific to the blood-borne pathogen standards; and for providing direction
relative to the implementation of the applicable policies and procedures. The Infection
Control Nurse will serve as a resource regarding all matters pertaining to Infection Control
and blood-borne pathogens. The IC Nurse will act as the facility liaison in instances of OSHA
inspections and will be accountable to assist in facility-wide monitoring and evaluation
activities to assure the facility is in compliance with the identified standard and to assure that
an up-to-date Exposure Control plan is in existence.

Performance Improvement Committee
The Performance Improvement Committee is responsible for assisting the Infection Control
Nurse, as necessary, in carrying out his/her functions as identified in this Exposure Control
Plan and to provide support and feedback as requested on all matters related to blood-borne
pathogens and the identified standards.

Department managers and supervisors
Department managers and supervisors are responsible for exposure control in their
respective areas. They work directly with the Infection Control Nurse, the Performance
Improvement Committee and our employees to ensure that proper exposure control
procedures are followed.

Education/training coordinator
Our Education Coordinator will be responsible in coordination with the Infection Control
Nurse for providing information and training to all employees who have the potential for
exposure to blood-borne pathogens.

Employees
The employees of DHS must take the responsibility to participate in, comply with and support
the principles, policies, procedures and work practices outlined in this Exposure Control
Plan. Employees have the right to access information and training programs, personal
protective equipment and engineering controls in the work place in order for them to
decrease the risk of exposure to blood-borne pathogens. Each employee has the right to
access and review the Exposure Control Plan. A copy of the plan is available in each
department manual.


                      ANNUAL REVIEW AND REVISION

There is a formal review of the facility’s Exposure Control Plan on an annual basis
coordinated by the Performance Improvement Committee in collaboration with the Infection
Control Nurse, Employee Health Nurse and others designated as being appropriate. The
assessment will encompass the scope of the plan, education, training, organization and
effectiveness of the program and will aid in identifying opportunities for improvement. In
addition to the formal review, the exposure control plan will be revised as necessary when
new or modified tasks, technologies or procedures are initiated and have the potential to
increase or affect the risk of occupational exposure. The review and update of the plan shall
also reflect changes in technology that eliminate or reduce exposure to blood-borne
pathogens and document annually consideration and implementation of appropriate
commercially available and effective safer medical devices designed to eliminate or minimize
occupational exposure.

  EVALUATION OF SAFETY-ENGINEERED SHARPS DEVICES

The facility will solicit input from front line non-managerial employees responsible for direct
patient care in identification, evaluation and selection of the most effective safety-engineered
sharps devices when these devices are commercially available and do not interfere with
patient safety or the success of a medical procedure.     In-service training will be
provided to the employees on the use of the new safety-engineered device prior to use.

SHARPS INJURY LOG
Decatur County Hospital will establish and maintain a sharps injury log for the recording of
percutaneous injuries from contaminated sharps. Employees will be required to complete an
‘Occurrence Report’ after an exposure incident. The information obtained from this report
shall be recorded in the ‘Occurrence Report’ database and shall be maintained in such a
manner as to protect the confidentiality of the injured employee.

   The ‘Occurrence Report’ shall contain:
   1. The type and brand of device involved in the incident
   2. The department or work area where the exposure incident occurred
   3. An explanation of how the incident occurred

EMPLOYEE EXPOSURE DETERMINATION
    Category I: Jobs with tasks that routinely involve exposure or potential exposure to
blood, body fluids or tissues.
    Category II: Jobs with tasks that do not routinely involve exposure to blood, body fluids
or tissues, but exposure or potential exposure may be required as a condition of
employment.
    Category III: Jobs with tasks that do not routinely involve exposure to blood, body fluids
or tissues (persons in this category are not called upon to perform or assist in emergency
medical aid or to be potentially exposed in any other way as a condition of employment).

Departments listed according to exposure category are as follows:

DEPARTMENT
Activities: Category III
Administration: Category III
Business Office: Category III
Dietary: Category III
Health Information: Category III
Home Health: Category I
Housekeeping: Category II
Laboratory: Category I
Laundry: Category II
Materials Management: Category III
Nursing Services: Category I
Plant Operations: Category II
Physical Therapy: Category II
Radiology: Category I
Respiratory Therapy: Category I
Surgical Services: Category I
Social Services: Category III
Volunteers: Category III

Specific role summaries within a department may differ in category classification depending
on duties performed; category classification is identified on each role summary. Part-time,
temporary, contract and per diem employees are covered by this standard and job
classifications will be the same for these employees according to the aforementioned
categories.
PHYSICIAN EXPOSURE
The employee provisions of this plan covers physicians who are employees of the facility,
however the facility is not responsible for enforcing the requirements covering employee
protection for physicians who are independent practitioners. OSHA views these physicians
as outside the employer-employee relationship. Therefore, while the facility does not have a
duty to force an independent practitioner to follow the standard for him or herself, it does
have a duty to force a physician to change practice patterns if his or her practice creates an
unsafe environment.



AGENCY STAFF EXPOSURE
Agency nurses (pool nurses): Agency staff has an unusual standing under the Blood-borne
Pathogen Standard. The employing agency (recruitment agency or place of employment of
staff pool) has a duty to perform initial and annual training of its employees in blood-borne
protection. The facility has the duty to provide pool or agency staff with the same safety
devices and workplace controls that it would to its regular employees. In these situations,
regular employees must be aware of the practice patterns of agency personnel and notify
their supervisors of practices that do not satisfy the standard.

          METHODS OF IMPLEMENTATION AND CONTROL


STANDARD PRECAUTIONS
Standard Precautions are observed to prevent contact with blood or other potentially
infectious materials. Under circumstances in which differentiation between body fluid types is
difficult or impossible, all body fluids shall be considered potentially infectious materials.

EXPOSURE CONTROL PLAN
Employees covered by the blood-borne pathogens standard receive an explanation of this
Exposure Control Plan during their initial training session. It will also be reviewed in their
annual refresher training. All employees have an opportunity to review this plan at any time
during their work shifts. If requested, the facility will provide an employee with a copy of the
ECP free of charge and within 15 days of the request.

Engineering Controls, Work Practice Controls and Safety Products and Devices for
Preventing Sharp Injuries include, but are not limited to the following and are chosen based
on procedures and immediate risks:
   Hand washing facilities (or antiseptic hand cleaners and towels or towelettes), which are
readily accessible to all employees who have the potential for exposure.
   Self-sheathing needles
   Containers for contaminated reusable sharps are puncture-resistant, color-coded or
labels with biohazard warning label and leak-proof on the sides and bottom
   Specimen containers are leak proof, color-coded or labeled with biohazard warning label
and puncture-resistant, when necessary
   Employees wash their hands immediately, or as soon as feasible, after removal of gloves
or other personal protective equipment.
   Following any contact of body areas with blood or any other infectious materials,
employees wash their hands and any other exposed skin with soap and water as soon as
possible. They also flush exposed mucous membranes with water.
    Contaminated needles and other contaminated sharps are not bent, recapped or
removed unless It can be demonstrated that there is no feasible alternative, The action is
required by specific medical procedure accomplished through the use of a medical device or
a one-handed technique.
    Contaminated reusable sharps are placed in appropriate containers immediately, or as
soon as possible, after use.
    Food and drink is not kept in refrigerators, freezers, on counter tops or on other storage
areas where blood or other potentially infectious materials are present.
    Mouth pipetting/suctioning of blood or other infectious materials is prohibited
    All procedures involving blood or other infectious materials minimize splashing, spraying
or other actions generating droplets of these materials.
    Specimens of blood or other materials are placed in designated leak-proof containers and
appropriately labeled for handling and storage.
    If outside contamination of a primary specimen container occurs, that container is placed
within a second leak-proof container, appropriately labeled, for handling and storage.
    Equipment that becomes contaminated is examined prior to servicing or shipping, and
decontaminated as necessary and if feasible. An appropriate biohazard-warning label is
attached to any contaminated equipment, identifying the contaminated portions. Information
regarding the remaining contamination is conveyed to all affected employees, the equipment
manufacturer and the equipment service representative prior to handling, servicing, or
shipping.
    When a new employee comes to our facility, or an employee changes jobs within the
facility, the following process takes place to ensure that they are trained in the appropriate
work practice controls:
    ~~1. The employee's job classification and the tasks and procedures that they perform
are checked against the job classifications that we have identified in our Exposure Control
Plan as those with occupational exposure potential.
    ~~2. If the employee is transferring from one job to another within our facility, the job
classifications and tasks pertaining to their previous position are also checked against these
lists.
    ~~3. The Infection Control Nurse and/or the facility educator regarding any work practice
controls that the employee is not experienced with then train the employee.



The facility identifies the need for changes in engineering controls and work practices
through:
   · The review of OSHA records
   · Employee interviews
   · Committee reviews
   · Medical Staff interviews



The facility evaluates any new procedure or new products utilizing safety feature evaluation
forms. The facility includes its employees in the selection of these safety devices. Evaluators
are provided with test samples to use and examine. Proper use of each device is
demonstrated prior to evaluation. Each evaluator is allowed adequate time to thoroughly
examine the design for use. Each evaluator will be encouraged to comment on the forms and
prioritize the questions at the end of the evaluation. This will provide a useful decision
making tool and will help alert the Performance Improvement Committee and Infection
Control Nurse to specific areas of concern.
The Patient Care Committee with representatives from:

· Infection Control/Employee Health
· Risk/Quality Management
· Nursing
· Medical Staff
· Laboratory
· Surgery/Anesthesia
· Safety
· Materials Management
· Front line workers and departments using devices

This group will annually gather information on current use and availability of safety devices
used in the facility. This team will select targeted devices for evaluation and meet with
vendors to identify and choose safety devices to test. These safety devices will be pilot
tested for impact on patients and health care workers. Then a safety device will be selected
to replace the targeted device. Education and training will be provided for all staff members
using the new safety device. The existing device will be replaced with the new safety device
following training. Data will be collected at periodic intervals following use of the new safety
device to evaluate its impact on worker injury and patient safety.




                               EXPOSURE CONTROL

Personal Protective Equipment
Personal Protective Equipment (PPE) is the "last line of defense" against blood borne
pathogens. Because of this, our facility provides (at no cost to our employees) the personal
protective equipment that they need to protect them against such exposure. This equipment
includes, but is not limited to:

*Gloves (latex or vinyl, powdered or powder free)
*Face shields/masks
*Goggles
*Resuscitation bags
*Hoods
*Gowns
*Safety Glasses
*Mouthpieces
*CPR Masks
*Shoe Covers

Hypoallergenic gloves, glove liners, and similar alternatives are readily available to
employees who are allergic to the gloves the facility normally uses.

All employees using PPE must observe the following precautions:
    Any garment penetrated by blood or other infectious materials is removed, immediately or
as soon as feasible, in such a way as to avoid contact with the outer surface.
    Wash hands immediately or as soon as feasible after the removal of gloves or other PPE.
    All personal protective equipment is removed prior to leaving the work area.
     Gloves are worn whenever employees anticipate hand contact with potentially infectious
materials, when performing vascular access procedures and when handling or touching
contaminated items or surfaces. Replace gloves as soon as practical after contamination or
if they are torn, punctured or if their ability to function as a barrier is compromised. Hands
must be washed or hand antiseptic sanitizer MUST be used after removing a
contaminated pair of gloves and before putting on a clean pair of gloves.
     Never wash or decontaminate disposable gloves for reuse.
     Masks and eye protection are used whenever splashes or sprays may generate droplets
of infectious materials that may pose a hazard to eye, nose, or mouth.
     Protective clothing (such as gowns and aprons) is worn whenever potential exposure to
the body is anticipated.

In the event of an employee transfer within departments or in instances where the job
classification of the employee changes, an assessment will be performed by the supervisor
to determine if the employee has received appropriate education and training to the work
practice controls that relate to the specific job duties. Additional education will be provided if
necessary.

The facility is responsible for cleaning, laundering and disposal of contaminated personal
protective equipment. Mechanisms are in place to assure PPE is appropriate, in good
condition and is available in all sizes. Inspection of PPE and availability is done on a routine
basis by the department supervisor. Equipment designed for single use will be disposed of
appropriately.

                                    HOUSEKEEPING

The facility shall ensure that the work site is maintained in a clean and sanitary condition.
The conditions are to meet the standards of Infection Control, OSHA Blood-borne Standards
and others as required by regulatory bodies.


Schedule for Cleaning and Decontamination
The Head of Housekeeping or his/her designee shall determine and implement an
appropriate written schedule for cleaning and method of decontamination based upon the
location within the facility, type of surface to be cleaned, type of soil present, and tasks or
procedures being performed in the area.

Method of Cleaning and Decontamination
All equipment and environmental and working surfaces shall be cleaned and decontaminated
after contact with blood or other potentially infectious materials. Contaminated work surfaces
shall be decontaminated with the facility approved disinfectant after completion of
procedures; immediately or as soon as feasible when surfaces are overtly contaminated or
after a spill of blood or other potentially infectious material; and at the end of the work shift if
the surface may have become contaminated since last cleaning.

IV pumps will be cleaned by housekeeping and decontaminated with the facility-approved
disinfectant.

All bins, pails, cans and similar receptacles intended for reuse which have a reasonable
likelihood of becoming contaminated with blood or other potentially infectious materials shall
be inspected and decontaminated on a regularly scheduled basis (weekly) and cleaned and
decontaminated immediately or as soon as feasible upon visible contamination.

Broken glassware shall not be picked up directly with the hands. It shall be cleaned up using
mechanical means, such as a brush and dustpan, tongs or forceps.

REGULATED WASTE
DHS maintains safe and sanitary procedures for the collection, storage, handling and
disposal of contaminated waste and trash generated within the facility. All regulated waste is
placed in red bags and deposited in the designated locked holding bin located at the rear
entrance to the hospital. All containers are color coded (red) or have a universal biohazard
label attached in accordance to regulation. Regulated wastes are transported to Decatur
County landfill for disposal.

                     BIOHAZARD LABELS AND SIGNS

A comprehensive biohazard-labeling program is in effect in the facility. In instances where
deemed appropriate, the use of color-coded containers is utilized.

The following are labeled accordingly within the facility:
  Regulated waste containers
  Refrigerators/freezers containing blood or potentially infectious materials
  Sharps disposal containers
  Containers used to store, transport or ship blood or other infectious materials
  Contaminated equipment

Red bags are utilized for containment of medical/hazardous waste within the facility. Red
bags or containers may be substituted for labels.
Containers of blood, blood components or blood products that are labeled as to their
contents and have been released for transfusion or other clinical use are exempted from
labeling requirements.

Individual containers of blood or other potentially infectious materials that are placed in a
labeled container during storage, transport, shipment or disposal are exempted from labeling
requirements.




              EXPOSURE CONTROL - Disposal of Sharps

Discarding And Containment of Contaminated Sharps
Contaminated sharps (needles, blades, scalpels, broken glass, disposable scissors,
disposable instruments) shall be discarded immediately or as soon as feasible in containers
that are:
   1. Able to be closed
   2. Rigid
   3. Puncture resistant
   4. Leak-proof
   5. Labeled with red biohazard label
Needles or sharps are not to be bent, broken or otherwise manipulated by hand prior
to disposal.

PLACEMENT OF SHARPS CONTAINERS
The sharps containers are placed in areas easily accessible to personnel and located as
close as feasible to the immediate area where sharps are used or can be reasonably
anticipated to be found (e.g., patient rooms, med rooms, ER, OR, OB, Recovery Room,
Ambulatory Care).

The containers shall be placed on walls in locked holders in an upright position. The
containers are placed at a height that is accessible for all staff members. They are replaced
when ¾ full and not allowed to over-fill. They shall be closed immediately prior to removal or
replaced to prevent spillage or protrusion of contents during handling, storage or transport.

DISPOSAL OF SHARPS CONTAINERS

The containers shall not be opened, emptied or cleaned manually or in any other manner
that would expose employees to the risk of percutaneous injury. The containers are placed in
appropriate regulated waste receptacles for disposal.

                                        LAUNDRY

METHOD OF HANDLING SOILED LINENS/LAUNDRY
Contaminated linen shall be handled as little as possible. Contaminated laundry shall be
bagged or containerized at the location where it was used and shall not be sorted or rinsed in
the location of use.

USE OF STANDARD PRECAUTIONS
The facility uses Standard Precautions in the handling of all soiled laundry. The facility shall
ensure that employees who have contact with contaminated laundry wear protective gloves
and other appropriate PPE.

                 HEPATITIS B VACCINATION PROGRAM

HEPATITUS B VACCINATION POLICIES
DHS has implemented a Hepatitis B Vaccination Program in accordance with requirements
identified in the OSHA Blood-borne Pathogens Standards.

The facility will provide training to employees regarding hepatitis B vaccine and vaccination
series, addressing the safety, benefits, efficacy, methods of administration, and availability,
upon employment. The facility will also make available post exposure evaluation and follow-
up treatment to all employees who have had an exposure incident.

The facility ensures that all medical evaluations and procedures including the hepatitis
vaccine and vaccination series and post exposure evaluation and follow-up, including
prophylaxis, are:

   Made available at no cost to the employee
   Made available to the employee at a reasonable time and place
   Performed by or under the supervision of a licensed physician or by or under the
supervision of another licensed healthcare professional (Registered Nurse)

HEPATITIS B VACCINATION
The hepatitis B vaccination series is available at no cost after training and within 10 days of
initial assignment to employees identified in the exposure determination section of this plan.
The facility shall not make participation in a prescreening program a prerequisite for
receiving the hepatitis B vaccination.

Vaccination is encouraged unless:
  Documentation exists that the employee has previously received the series
  Antibody testing reveals the employee is immune, or
  Medical evaluation shows the vaccination is contraindicated

If an employee chooses to decline vaccination, the employee must sign a declination form.
Employees who decline may request and obtain the vaccination at a later date at no cost.
Documentation of refusal of the vaccination is kept in the employee’s health file.

If a routine booster dose(s) of hepatitis B vaccine is recommended by antibody testing, such
booster dose(s) shall be made available at no cost to the employee.


EXPOSURE CONTROL - POST-EXPOSURE EVALUATION AND
                   FOLLOW-UP

POST EXPOSURE EVALUATION AND FOLLOW-UP

Following the initial first aid (cleaning the wound, flushing eyes or other mucous membrane,
etc.) of an exposure incident, an exposure incident protocol will be instigated.

Following a report of an exposure incident, the facility shall make immediately available to
the exposed employee a confidential medical evaluation and follow-up by a qualified
healthcare professional (Physician) including at least the following elements:

    Documentation of the routes of exposure and the circumstances under which the
exposure incident occurred.
    Identification of the source individual; (unless the facility can establish that identification is
infeasible or prohibited by law.)
    Obtain consent and make arrangements to have the source individual's blood tested to
determine HCV, HBV and HIV infectivity. If consent for testing is denied or cannot be
obtained, the facility shall establish and document that legally required consent cannot be
obtained. If consent is obtained, document that the source individual’s test results were
conveyed to the employee’s health care provider.
    If the source individual is known to be infected with HIV, HBV or HCV, new testing need
not be performed.
    The exposed employee is provided with the source individual’s test results and
information regarding applicable disclosure laws and regulations concerning the identity and
infectious status of the source individual. (e.g., laws protecting confidentiality)
    After obtaining consent, collect and test the blood of the exposed employee as soon as
feasible after the exposure incident, testing for HCV, HBV and HIV serological status.
Following an incident involving potentially infectious material, the employee is given a
Gamma Globulin injection. If the employee has not been given or started the Hepatitis B
vaccination series, this is started immediately
    If the exposed employee consents to baseline blood testing but does not consent to
testing for HIV, the employee's blood sample must be preserved and retained for a time
period of a least 90 days from the time of the blood drawing. If, within 90 days of the
exposure incident, the employee elects to have the baseline sample tested, such testing
shall be done as soon as feasible.
    Each employee who is occupational exposed to blood-borne pathogens is entitled to a
written opinion from a licensed healthcare professional within fifteen (15) days following
completion of the evaluation.

EVALUATING AN EXPOSURE INCIDENT

Review of Exposure Incident
The Infection Control Nurse and Performance Improvement Committee will review the
circumstances of all exposure incidents to determine:

   ·Engineering controls in use at the time
   ·Work practices followed
   ·Description of the device being used
   ·PPE or clothing that was used at the time of the incident
   ·Location of the incident
   ·Procedure being performed when the incident occurred
   ·Type of sharp or device involved in the incident
   ·Employee training

Necessary Revisions
If it is determined that revisions need to be made, the above individuals will ensure that
appropriate changes are made. Changes may include but are not limited to:
     ·Evaluation of safer devices
     ·Retraining of employee
     ·Evaluation of protective equipment
     ·Evaluation of work practices

     EXPOSURE CONTROL - INFORMATION AND TRAINING

EXPOSURE CONTROL TRAINING
DHS ensures that all employees with potential for occupational exposure to blood-borne
pathogens participate in a training program on the epidemiology, symptoms and
transmission of blood-borne pathogen diseases. Training shall be provided at the time of
initial assignment to tasks where occupational exposure may take place and at least annually
thereafter. The facility shall provide additional training when changes such as modification of
tasks or procedures or institution of new tasks or procedures affect the employee’s
occupational exposure risk. The additional training shall be limited to addressing the new
potential exposures created.

Material appropriate in content and vocabulary to the educational level, literacy and language
of employees shall be utilized.

The training program shall be provided at no cost to the employee and during normal
working hours and shall cover, at a minimum, the following elements:
  An accessible copy of the regulatory text of the OSHA Blood borne Standard and an
explanation of its content.
    A general explanation of the epidemiology and symptoms of blood-borne diseases
    An explanation of the modes of transmission of blood-borne pathogens
    An explanation of the appropriate methods for recognizing tasks and other activities that
may involve exposure to blood and other potentially infectious materials
    An explanation of the use and limitations of methods that will prevent or reduce exposure
including appropriate engineering controls, work practices and personal protective equipment
    Information on types, proper use, location, removal, handling, decontamination and
disposal of personal protective equipment
    An explanation of the basis for selection of personal protective equipment
    Information on the hepatitis B vaccine, including information on its efficacy, safety,
method of administration, the benefits of being vaccinated and that the vaccine and
vaccination will be offered free of charge
    Information on the appropriate actions to take and persons to contact in an emergency
involving blood or other potentially infectious materials
    An explanation of the procedure to follow if an exposure incident occurs, including the
method of reporting the incident and the medical follow-up that will be made available
    Information on the post-exposure evaluation and follow-up that the facility is required to
provide for the employee following an exposure incident
    An explanation of the signs and labels utilized in the facility
    An opportunity for interactive questions and answers with the person conducting the
training session

The person conducting the training session shall be knowledgeable in the subject matter
covered by the elements contained in the training program as it relates to the workplace.
Training materials for the facility regarding blood-borne pathogens and the standard are
available from the education coordinator.

             EXPOSURE CONTROL - MEDICAL RECORDS

ACCURATE MEDICAL RECORDS FOR EMPLOYEES
The facility shall establish and maintain an accurate medical record for each employee with
occupational exposure, in accordance with 29 CFR 1910.20, “Access to Employee Exposure
and Medical Records.” The record shall include:
   Name and social security number of the employee
   A copy of the employee's Hepatitis B vaccination status, including dates of the all
hepatitis B vaccinations and any medical records relative to the employee’s ability to receive
vaccination
   Copies of the results of the examinations, medical testing and follow-up procedures
   The employee’s copy of the healthcare professional’s written opinion

CONFIDENTIALITY OF RECORDS
The Infection Control Nurse is responsible for the maintenance of the required medical
records. These confidential records are kept in a locked file cabinet in the infection control
nurses’ office for at least the duration of employment plus 30 years. The contents of the
medical records are not to be disclosed or reported without the employee’s express written
consent to any person within or outside the facility except as may be required by law.

TRANSFER OF RECORDS
The employee may request transfer of the medical record with written consent of the
employee or his/her designee. The facility shall comply with the request of transfer of
medical records.

NOTIFICATION OF CESSATION OF SERVICE
If the facility ceases to do business and there is no successor employer to receive and retain
the medical records for the prescribed period, the facility shall notify the employee, at least
three months prior to their disposal and transmit said records to that employee.




                       EXPOSURE CONTROL - Glossary

Definitions of Terms
    Standard Precautions: The routine and consistent use of appropriate barrier protection to
prevent skin and mucous membrane transmission of microorganisms resulting from contact
with blood and body fluids, and as part of the practice of general hygiene. All human blood
and body fluids are treated as if known to be infectious for HIV, HBV and other blood-borne
pathogens.
    Blood-borne Pathogens: Pathogenic microorganisms that are present in human blood
and body fluids and can cause disease in humans. These pathogens include, but are not
limited to, Hepatitis B Virus (HBV), Human Immunodeficiency Virus (HIV) and Hepatitis C
Virus (HCV).
    Blood: Human blood, human blood components and products made from human blood.
    Other Potentially Infectious Materials: amniotic fluid, body tissues, cerebrospinal fluid,
human organs, pericardial fluid, peritoneal fluid, pleural fluid, saliva (in dental procedures),
synovial fluid and vaginal secretions. Any body fluid that is visibly contaminated with blood
and all body fluids in situations where it is difficult or impossible to differentiate between body
fluids are considered to be infectious.
    Contaminated: The presence or the reasonable anticipated presence of blood or other
potentially infectious materials on an item or surface.
    Contaminated Laundry: Any laundry that has been saturated with blood or other
potentially infectious materials or that may contain sharps.
    Contaminated sharps: Any contaminated object that can penetrate the skin including, but
not limited to, needles, scalpels, broken glass, broken capillary tubes and exposed ends of
dental or orthopedic wires.
    Decontamination: The physical means to remove, inactivate or destroy blood-borne
pathogens on a surface or item to the point where they are no longer capable of transmitting
infectious particles and the surface or item is rendered safe for handling, use or disposal.
    Engineering controls: Controls or methods (e.g., sharps disposal containers) that isolate
or remove the blood-borne pathogens hazard from the workplace, safer medical devices,
such as sharps with engineered sharps injury protections and needleless systems.
    Exposure Incident: A specific eye, mouth, other mucous membrane, non-intact skin or
parenteral contact with blood or other potentially infectious materials that may result from the
performance of a staff member’s duties.
    Licensed Healthcare Professional: Person whose legally permitted scope of practice
allows her/her to independently perform the activities required to evaluate, treat and follow
up on any post exposure incident.
    HBV: Hepatitis B Virus
    HCV: Hepatitis C Virus
    HIV: Human Immunodeficiency Virus
    Needleless System: A device that does not use needles for: a) The collection of body
fluids or withdrawal of body fluids after initial venous or arterial access is established; b) The
administration of medication or fluids; or c) Any other procedure involving the potential for
occupational exposure to blood-borne pathogens due to percutaneous injuries from
contaminated sharps.
    Nosocomial Infection: An infection that occurs during or after hospitalization that wasn't
present at the time of admission.
    Occupational Exposure: Reasonable anticipated skin, eye, mucous membrane or
parenteral contact with blood or other potentially infectious materials that may result from the
performance of a staff member’s duties.
    Parenteral: Piercing of the mucous membranes or the skin barrier through such events as
needle sticks, human bites, cuts and abrasions.
    Personal Protective Equipment: Special clothing or equipment worn by personnel for the
protection against a hazard. Impervious (water or fluid is not able to penetrate) gowns,
goggles, masks, gloves are considered personal protective equipment. General work clothes
(e.g., uniforms, pants, shirts or blouses) are not intended to function as protection against a
hazard and are not considered to be personal protective equipment.
    Sharps With Engineered Sharps Injury Protection: A non needle sharp or a needle device
used for withdrawing body fluids, accessing a vein or artery, or administering medications or
other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an
exposure incident.
    Source Individual: Any individual, living or dead, whose blood or other potentially
infectious materials may be a source of occupational exposure to personnel.
    Regulated Waste: Liquid or semi-liquid blood or other potentially infectious materials;
contaminated items that would release blood or other potentially infected materials in a liquid
or semi-liquid state if compressed; items that are caked with dried blood or other potentially
infectious materials capable of releasing these materials during handling; contaminated
sharps; and pathological and microbiological wastes containing blood or other potentially
infectious waste materials.
    Sterilization: The use of a physical or chemical procedure to destroy all microbial life
including highly resistant bacterial endospores.
    Work Practice Controls: Controls or methods that reduce the risk of exposure by altering
the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-
handed technique). Not allowing eating or drinking in the work area where there is potential
for exposure to blood-borne pathogens.


Go Home                 Take the Infection Control Test
Bloodborne Pathogens                                               Go Home

Blood-borne diseases have historically been a serious concern in the United States.
Two diseases cause most of the problems.

Hepatitis B has been around the longest. It
    Is the most prevalent form of hepatitis.
    Infects over 70,000 people annually.
    Has over one million “carriers” in the United States.

Over three million people carry the Hepatitis C (HCV) virus, the newest form of hepatitis.
But “Human Immunodeficiency Virus (HIV) is the most publicized bloodborne disease. It
is estimated that HIV, which can lead to AIDS, currently infects over one million people.

In 1991 OSHA passed a “bloodborne pathogens” regulation, which calls for employers to
do a number of things aimed at preventing their employees from becoming infected with
these types of diseases.

These requirements include establishing ”safe work practices”, setting up engineering
controls, and posting warning labels and signs. A copy of your employer’s “exposure
control plan”, detailing these practices is available for you to review.

TERMS AND DEFINITIONS ARE IMPORTANT

In order to understand how blood-borne diseases are transmitted, and how to protect
yourself from them, it is necessary to know some of the terms that are used when these
diseases are discussed.

“Blood” is used to mean human blood, its components, or products made from human
blood.

“Bloodborne pathogens” refers to micro-organisms present in blood which can cause
a disease such as HIV, HBV or HCV.

“Other potentially infectious materials” includes:
    Human body substances
    Contaminated body materials
    Unfixed human tissue and organs
    HIV and HBV cultures
    Infected experimental animals

“Contaminated” means having infectious materials on an item or surface.

A “source individual” is someone who may be infected, and could be a source of
exposure.
“Standard precautions” means approaching all human blood and other body fluids as
if they contain blood-borne pathogens.

HIV Is One Major Bloodborne Disease
Human Immunodeficiency Virus (HIV) is the most “deadly” bloodborne disease in the
United States. One of the reasons that it is spreading so rapidly is that there is no
vaccine for HIV…and no known cure.

There is a great deal of research going on to develop both a vaccine and a treatment
therapy for HIV, but to date no vaccine has been found.

Symptoms of HIV infection include:
    Weakness
    Fever
    Sore throat
    Nausea
    Headaches
    Diarrhea
    Other “flu-like” symptoms

Many times, people who become infected with HIV exhibit these symptoms fairly quickly.
But it is also possible for HIV victims to show no apparent symptoms for years after their
infection.

Most people with HIV eventually develop AIDS. Once this happens, their immune systems
begins to break down. As a result, diseases such as pneumonia and tuberculosis (that they
could normally fight off easily with antibiotics and other modern medicines) become fatal.

Hepatitis Is The Other Major Bloodborne Disease
The symptoms for Hepatitis B and C are similar to those for HIV, in that many of them are
“flu-like” in nature.

Hepatitis symptoms include:
     Fatigue
     Stomach pain
     Loss of appetite
     Nausea
     Jaundice
Jaundice is probably the most recognizable symptom, turning the skin, eyes, urine and even
fingernails a dark yellow color.

Hepatitis attacks the liver, and one of its first effects is to inflame it significantly. Later,
hepatitis can often cause cirrhosis of the liver, or even liver cancer.

While there is no vaccine for Hepatitis C, there is a vaccine that can prevent Hepatitis B
infection. If you could be exposed to Hepatitis B, you need to participate in your employer’s
vaccination program.
You should also report any “exposure incident” immediately after it occurs. If you haven’t
had a recent hepatitis vaccination, you may still be able to be treated after you exposure///but
it is important to begin as soon as possible.

Facilities Must Have An Exposure Control Plan

Most exposure to bloodborne diseases occurs parenterally (through breaks in the skin or
mucus membrane). Parenteral exposures include needle sticks, human bites, and most
frequently, infectious material getting into cuts or abrasions.

To help prevent parenteral and other exposures, facilities must have an “exposure control
plan”, addressing:
     How the facility will comply with the regulation
     Determining employees’ potential exposure

The plan must also describe who employees’ exposure will be limited by using:
    “Standard precautions”
    Engineering controls
    Safe work practices
    Personal protective equipment (PPE)
    Good housekeeping practices

The exposure control plan, which must be reevaluated every year, must also cover:
    Implementing a Hepatitis B vaccination program
    Steps to be taken if an employee is exposed
    The use of biohazard warning labels and signs
    Setting up and conducting employee training
    Recordkeeping procedures

Remember, your facility’s plan is available for you to review. Talk to your supervisor if you
would like to look at it.

Infectious Materials Must Be Labeled

Labeling is also an important part of the regulation. Red biohazard warning labels must be
used to identify potentially infectious materials, as well as contaminated equipment. In some
cases, “red bags” or red-colored containers can be used as an alternative.

There are several exceptions to labeling requirements, including individual blood containers
(if they are inside a secondary container), labeled blood transfusion products… and
“obviously recognizable specimens” in facilities that practice standard precautions.

Warning labels are commonly found on:
    Refrigerators or freezers storing infectious material
    Storage and shipping containers
    Contaminated equipment
    Containers of regulated waste

In addition to biohazard warning labels, there are a number of other ways to recognize
situations involving potential exposure to bloodborne pathogens.
You can find out which jobs involve contact with blood or other body fluids by consulting the
list of job classifications in your facility’s exposure control plan.


There Are Several Ways To Reduce Exposure

There are three major ways to reduce exposure to bloodborne pathogens: engineering
controls, work practice controls and using PPE (Personal Protective Equipment).

Engineering controls refers to equipment such as ventilating laboratory hoods and self-
sheathing needles that can prevent you from encountering bloodborne pathogens.

Work practice controls are safer ways to perform tasks. Handwashing is an especially
important example. You should wash your hands immediately after removing gloves or other
PPE that may have become contaminated. You should also wash your hands after direct
contact with blood or other potentially infectious materials

OSHA also feels that good housekeeping practices are important, and requires facilities to:
   Perform periodic cleaning
   Draw up written cleaning schedules
   Decontaminate all surfaces after contact with any infectious materials
   Change equipment coverings if they are contaminated

Needles and Other “Sharps” Have Special Controls
Needles and other sharps have their own rules. They:
      Cannot be bent
      Should not be recapped
If they have to be recapped, a mechanical or one-handed technique must be used.

Contaminated sharps must be discarded into containers that are closable, puncture-resistant
and leak-proof.

Contaminated laundry should be handled as little as possible… always while wearing
personal protective equipment. Laundry should be bagged or containerized, and transported
in labeled or color-coded bags.

Equipment must be decontaminated if at all possible. Otherwise, biohazard labels should be
applied, and employees must be warned about possible contamination

The standard also governs the handling of other regulated waste. If your job involves waste
handling, make sure you know what the requirements are.

You should also develop good personal work habits where exposure to bloodborne
pathogens may occur. Do not eat, drink, smoke or apply cosmetics in these areas.



Personal Protective Equipment Is Especially Important
OSHA regards the use of personal protective equipment as extremely important. They
require that it be worn whenever there is a chance of exposure.
Gloves must be used whenever hand contact is anticipated. Disposable gloves must be
replaced as soon as they are contaminated. Hands must be washed or hand antiseptic
sanitizer must be used before a clean pair of gloves is put on. Other kinds of gloves that are
designed as reusable may be reused, once they are decontaminated.

Mouth and eye protection are especially important if you might be splashed or splattered with
infectious material. Goggles provide the best eye protection. “Pocket” or face masks should
be worn to protect the mouth.

Gowns, aprons and lab coats are commonly used to protect the bulk of the body. They
should be selected based on the type of exposure you are facing.

If you are involved in work where heavy contamination is anticipated, you should also wear:
      A surgical cap
      A hood
      Shoe covers or boots
A “full body suit” may even be called for.

If you face exposure situations, PPE will be available in your work area. Take off any PPE
before leaving the area, and deposit it into “collection” containers.



Vaccination Is Available For Hepatitis B

Vaccination is always the best way to guard against infection from any disease. While there
is no vaccine for HIV or Hepatitis C, there is a Hepatitis B vaccine, which has been
thoroughly tested. It is administered in a series of three injections.

Your facility’s HBV vaccination program:
    Is available at no extra charge
    Is for anyone who may be exposed to bloodborne pathogens

If you refuse to participate in the program you must sign an OSHA “Declination Form”.

OSHA feels it is very important that you are vaccinated against Hepatitis B if you face
potential exposure to bloodborne pathogens. If you have questions about the program, see
your supervisor.

If you are exposed to Hepatitis B and have not been vaccinated, an accelerated “post-
exposure vaccination” is available. This is also free of charge. While post-exposure
vaccination will not always prevent infection, it can frequently be helpful in combating
Hepatitis B.




Accidents Involving Infectious Materials Can Happen

If you are exposed to an infectious material, wash the area with soap and water immediately.
If the material has “spilled” onto other surfaces:
      Contain it using absorbent barriers
      Remove any remaining material with absorbent
      Disinfect the spill area
      Dispose of materials that are contaminated
      Discard or recycle contaminated PPE

Once you have dealt with the immediate problem, you will need to notify a number of people
about the incident. First, advise your immediate supervisor.

Next, your Environmental Services Department (if you have one), and your safety supervisor
should be informed. If you are in a facility that has an Infection Control Department, you
need to notify them as well.

After all the appropriate people have been notified, you will need to complete an “incident
report”. This provides your facility with information about the incident, and will help them
determine what, if anything, needs to be done medically.



Steps Will Be Taken If You Are Exposed

If you are involved in an exposure incident, a number of steps will be taken. First, your
employer will provide a written description of the incident. It will include the routes of
exposure and the identity of the source individual, if it is known. Your blood will also be
tested for HBV, HCV and HIV,

An appointment with a doctor will be arranged for you. They will be given information about
the work you were doing when you were exposed, the incident itself, and the results of the
source individual’s blood tests. They will also be given copies of your relevant medical
records.

Based on this information, they will discuss the results of your blood tests with you, as well
as recommend any appropriate treatment. Once the doctor has completed their evaluation,
they will notify your employer:
     That you have been informed of the results
     That they have talked over any medical issues with you
     Whether or not HBV vaccination is required
     If you have had the first part of the vaccination

All other information from your medical evaluation will remain confidential.


Remember…..
   Exposure to bloodborne pathogens can be greatly reduced by following proper
        workplace procedures.
       Biohazard warning labels should be used to identify most infectious materials
      Engineering controls, such as puncture-resistant sharps containers, should be used
       where appropriate.
      Personal protective equipment, especially gloves, should be used whenever there is
       the potential for exposure.
      Handwashing is a critical work practice control… and should be done immediately
       after exposure.
      Never eat, drink, smoke or apply cosmetics in an area where exposure may occur.
      It is essential to participate in your company’s Hepatitis B vaccination program.

Bloodborne pathogens are dangerous. But hazards can be greatly reduced by using
engineering controls…..employing safe work practices….. using PPE…. And participating in
your facility’s HBV vaccination program!

TYPES OF PRECAUTIONS:
      STANDARD PRECAUTIONS
      CONTACT PRECAUTIONS
      DROPLET PRECAUTIONS
      AIRBORNE PRECAUTIONS


STANDARD PRECAUTIONS:
THESE ARE THE SAFETY MEASURES THAT
SHOULD ALWAYS BE TAKEN WITH ALL
PATIENTS
1. HAND WASHING, THE MOST IMPORTANT STEP OF INFECTION CONTROL, prevents
nosocomial infections
2. DON GLOVES BEFORE CONTACT WITH ANYTHING WET, such as broken skin,
mucous membranes, blood, body fluids, soiled instruments, contaminated waste materials
3. WASH HANDS AGAIN UPON REMOVAL OF GLOVES AND BETWEEN PATIENTS
4. MASKS, GOWNS AND EYE PROTECTION SHOULD BE WORN IF THERE IS ANY
DANGER OF SPLASHING OF BODY FLUIDS


CONTACT PRECAUTIONS:
Before Entering Patient Room:
1. Wash Hands
2. DON Gown
3. Then Put On Gloves

Upon Entering Patient Room:
1. Use Disposable Equipment When Possible
2. If Disposables Are Not Available, Clean and Disinfect ALL Equipment Before Removing
From Room
Before Leaving the Patient's Room:
1. Remove Gloves and Dispose
2. Then Remove Gown
3. Place Soiled Gown in Designated Container
4. Wash Hands

Transporting A Patient:
1. Essential Transport Only
2. Patient Should Perform Hand Hygiene and Wear a Clean Gown
3. For Direct Contact with Patient, Nurse or Care Provider Should Wear a Gown and Gloves.
4. Notify Receiving Area

Contact Precautions Microorganisms:
1. Antibiotic Resistant Organisms, Such as:
    Methicillin Resistant Staphylococcus Aureu (MRSA)
    Vancomycin Resistant Enteracoccus (VRE)
    Penicillin Resistant Streptococcus Pneumoniae (PRSP)
    Multi-Drug Resistant Pseudomonas Aeruginosa (MDRP)
2. Scabies
3. Herpes Simplex Neonatal, Mucocutaneous, Disseminated or Primary, Severe
4. Diarrhea, Clostrididum difficile (C Diff)
5. Respiratory Syncytial Virus (RSV)
6. Bronchiolitis/Bronchitis Infants and Young Children
7. Diapered or Incontinent, with E. coli 0157:H7 (Enterohemorrhagic); EHEC; Rotovirus;
Salmonella; Shigella; or Hepatitis Type A
8. Diptheria, cutaneous
9. Enteroviral Infections, Infants and Young Children
10. Lice (Pediculosis)


DROPLET PRECAUTIONS:
Before Entering:
1. Wash Hands
2. DON Mask
3. DON Gown
4. Then Put on Gloves

Before Leaving Patient's Room:
1. Remove Gloves and Dispose
2. Then Remove Gown
3. Place Soiled Gown in Designated Container Before Leaving
4. Remove Mask
5. Wash Hands

Patient Transport:
1. Essential Transport Only
2. Patient Must Perform Hand Hygiene
3. Patient Must Wear a Surgical Mask
4. For Direct Contact With Patient, Nurse or Care Provider Should Wear a Mask, Gown and
Gloves.
5. Notify Receiving Area
Droplet Precaution Microorganisms:
1. Influenza (Flu)
2. Viral Respiratory Tract Infections (Adenovirus, Parainfluenza, Rhinovirus)
3. Streptococcus Group A Pharyngitis, Pneumonia, Scarlet Fever
4. Neisseria Meningitidis Invasive Infections
5. H. Influenzae Type B Invasive Infections
6. Pertussis
7. Rubella (German Measles)
8. Mumps
9. Diptheria, Pharyngeal
10. Parvovirus, B-19
11. Mycoplasma Pneumonia
12. Meningococcal Pneumonia
13. Meningococcemia (Meningococcal Sepsis)
14. Haemophilus Influenzae, Epiglottitis, Meningitis (Known or Suspected), Pharyngitis
(Infants and Small Children), Pneumonia (Infants and Small Children)


       AIRBORNE PRECAUTIONS:
        Before entering:
       1. Wash hands
       2. Don Mask*
       3. Don Gown
       4. Then Put on Gloves
       * If TB is Suspected/Confirmed, N95 Respirator Mask Must Be Worn

Negative Pressure Isolation Room
       KEEP DOOR CLOSED

       Before Leaving Patient's Room:
       1. Remove Gloves and Dispose
       2. Then Remove Gown, NOT N95 Mask
       3. Place Soiled Gown in Designated Container
       4. Wash Hands

       After Leaving Patient's Room:
       1. Shut Door
       2. Wash Hands
       3. Remove N95 Mask
       4. Wash Hands

       Transporting a patient:
       1. Patient Must Wear a Surgical or Procedure Mask and a Clean Gown
       2. Patient Must Wash Hands
       3. For Direct Contact with Patient, Nurse or Care Provider Should Wear a Gown and
       Gloves.
       4. Notify Receiving Area

       Airborne Precaution Microorganisms:
       1. Measles (Rubeola)
       2. Tuberculosis (TB) *(see explanatory note on next page)
       3. Chicken Pox (Varicella-Zoster virus)
       4. Herpes Zoster (Shingles), Disseminated
*A PERSON WHO HAS INACTIVE TUBERCULOSIS (TB) IS NOT CONTAGIOUS, AND
WILL NOT SPREAD THE TUBERCULOSIS INFECTION TO OTHERS.



NO EXCEPTIONS:
EVERY EMPLOYEE IS RESPONSIBLE FOR
INFECTION CONTROL AT DECATUR HEALTH
SYSTEMS.
Decatur Health Systems Policy on Management of Infectious Diseases in Patients

Decatur Health Systems Nurses and Other Health Professionals will use Contact
Precautions* for the Following Infectious Diseases:
1. Antibiotic Resistant Organisms, Such as:
    Methicillin Resistant Staphylococcus Aureus (MRSA)
    Vancomycin Resistant Enteracoccus (VRE)
    Penicillin Resistant Streptococcus Pneumoniae (PRSP)
    Multi-Drug Resistant Pseudomonas Aeruginosa (MDRP)
2. Scabies
3. Herpes Simplex Neonatal, Mucocutaneous, Disseminated or Primary, Severe
4. Diarrhea, Clostrididum difficile (C Diff)
5. Respiratory Syncytial Virus (RSV)
6. Bronchiolitis/Bronchitis Infants and Young Children
7. Diapered or Incontinent, with E. coli 0157:H7 (Enterohemorrhagic); EHEC; Rotovirus;
Salmonella; Shigella; or Hepatitis Type A
8. Diptheria, cutaneous
9. Enteroviral Infections, Infants and Young Children
10. Lice (Pediculosis)

Decatur Health Systems Nurses Other Health Professionals will use Droplet
Precautions* for the Following Infectious Diseases:
1. Influenza (Flu)
2. Viral Respiratory Tract Infections (Adenovirus, Parainfluenza, Rhinovirus)
3. Streptococcus Group A Pharyngitis, Pneumonia, Scarlet Fever
4. Neisseria Meningitidis Invasive Infections
5. H. Influenzae Type B Invasive Infections
6. Pertussis
7. Rubella (German Measles)
8. Mumps
9. Diptheria, Pharyngeal
10. Parvovirus, B-19
11. Mycoplasma Pneumonia
12. Meningococcal Pneumonia
13. Meningococcemia (Meningococcal Sepsis)
14. Haemophilus Influenzae, Epiglottitis, Meningitis (Known or Suspected), Pharyngitis
(Infants and Small Children), Pneumonia (Infants and Small Children)
Decatur Health Systems Nurses Other Health Professionals will use Airborne
Precautions* for the Following Infectious Diseases:
1. Measles (Rubeola)
2. Tuberculosis (TB)
3. Chicken Pox (Varicella-Zoster virus)
4. Herpes Zoster (Shingles), Disseminated

*When questions arise regarding whether isolation precautions should be used,
Decatur Health Systems Nurses and Other Health Professionals will use the
appropriate precautions especially if an Infectious Disease is suspected.

*When patient has a RULE OUT diagnosis for contagious disease on admission, place
them in appropriate isolation until definitive diagnosis is made.




Go Home

Take Infection Control 2 Blood born Pathogens Test
                   ************************************************

Lifting and                                                                       Go Home
Proper Body Mechanics
Proper posture and body mechanics can help to protect your body, especially your back,
from pain and injury. Back pain is usually the result of a number of contributory factors. Poor
posture and faulty body mechanics are generally involved.

GOOD POSTURE IS ACTIVE POSTURE

    1. Face the object you are lifting, bend your knees and lift with your legs and your arms
and your back. If the object is on the floor, kneel on one knee in the tripod position, so you
have better balance and stability.
Be sure to bend your knees when putting an object down as well as picking it up.
    2. Hold the object close to you, but don’t arch your back and don’t allow it to rest on your
stomach.
    3. Don’t try to lift objects above your waist; use a footstool if necessary.
    4. It is better to carry two packages of the same weight in each hand than it is to carry
one heavy package in one hand.
    5. Don’t try to lift objects beyond your capacity; ask for help.
    6. When lifting an object with someone else, count out loud so that you lift together.
    7. Lift objects slowly; never jerk or lift them suddenly.
    8. Beware of awkward or unbalanced loads. Even though they may not weigh much, they
can cause an uneven force on your back, resulting in a pulled muscle or twisted back.
    9. Don’t lean over obstacles to lift an object; walk around them to get close to the object
that you want to lift.
    10. Don’t lift or reach for objects over your shoulders; instead use a footstool to reach that
high shelf.
    11. Don’t bend and stretch repeatedly. If emptying a box, raise it to a higher level.
    12. When transferring objects from one place to another, don’t twist your back, but pivot
on your feet, keeping your back straight and your pelvis slightly tucked.
    13. Never bend and twist in the same movement. Separate the motions and pivot on your
feet when possible.
    14. When it is necessary to do an activity in the squatting position, try to sit on a footstool
or kneel in a tripod position.
    15. It is better to push rather than pull an object. When pushing, put one foot in front of
the other and lean towards the object. Take advantage of your body weight and use your
legs to push.
    16. If you need to pull an object, bend your hips and knees and lean slightly away from it.
    17. Maintain the three natural curves in your back throughout the entire transfer.

VACUUMING & MOPPING

   Stand in good spinal alignment with one foot in front of the other.
   Move the vacuum or mop back and forth in a small area in front of you.
   Don’t try to cover too much area at one time.
   To exert greater force, shift your weight back and forth between your feet.
   Remember to keep the back straight and pelvis slightly tucked. Let the arms and legs do
the work.
   When vacuuming under furniture, use the tripod position instead of bending and twisting.
CHAIR (OR BED) TO WHEELCHAIR TRANSFER

When transferring a resident:

   Ask the resident to assist you as much as possible.
   Adjust the bed to proper height.
   Lock the wheelchair brakes.
   Remove the leg rests from the wheelchair so as to lessen the risk of trauma to the
resident’s legs.
   Place a gait belt around the resident’s waist.
   Position your feet so that a pivot can be completed without twisting your legs.
   Position the patient’s legs to fulfill the same purpose.
   Have the resident slide to the front of the chair seat.
   Ask the resident to push up with his/her arms if possible.

Do not allow the patient to hold onto you around your neck.

   If the patient has a weaker leg, support that knee with your knee.
   Count to 3 aloud before beginning the transfer of sit to stand so the patient or an assisting
caregiver can work in unison with you.
   Always transfer towards the patient’s stronger side.


             WORKSTATION ERGONOMICS (COMPUTER)

CHAIR ADJUSTMENT

Sit Properly
    Sit with feet flat on the floor or supported by a footrest to help support the spine.
    Keep thighs parallel to the seat with knees bent at approximately a 90-degree angle.
    Allow adequate clearance behind knees to keep the chair from interfering with the
circulation to the legs.

Adjust the Chair Back
   Raise or lower the backrest so the contour of the chair provides maximum lumbar (lower
back) support.
   If possible, adjust the tilt of the backrest to support the body in an upright position.

Choosing Proper Arm Chairs
   If the chair has arms, they should allow you to get close to your work without getting in
the way.
   If you are typing, the arms of the chair should be at a height where they barely contact
your elbows when your arms are resting comfortably at your side.
   Chair arms should not force you to elevate your shoulders or wing your arms to the side.

Keyboard Adjustment
   Rest your arms comfortably at your sides. The ideal location of the home row of your
keyboard (the row with letters a, s, d…) should be at approximately elbow level.
   If the work surface is too high and cannot be adjusted, raise the chair to bring the elbows
to the home row level of the keyboard and support the feet with a footrest if necessary.
    If the work surface is adjustable, first adjust the chair. Once the chair is adjusted, then
adjust the work surface.

Monitor Adjustment
   Position the monitor so it is aligned in front or nearly in front of the keyboard to allow your
neck to remain straight when viewing the monitor.
   Raise or lower the computer monitor so that the top of the screen is at or just below eye
level.

Computer Input Devices
    Computer input devices such as a mouse or trackball should be located at the same level
and next to the keyboard to avoid reaching.
    If you must frequently look at reference materials as you type, use a document holder to
allow the head to remain in a more upright position. Position the document holder at the
same height and distance as your monitor.
    Wrists should remain straight when typing. Poor wrist habits can be corrected by using a
padded wrist rest that supports the wrists in a straight position. Height of the wrist rest should
not exceed the height of the space bar on the keyboard. Avoid wrist rests that are wider than
3 inches since this results in the need to reach further for the keyboard.




Go Home                 Take the Lifting and Body Mechanics Test
***************************************************

PHONE AND FAX USAGE                                                                Go Home



                                General Phone Usage

The telephone is an important method of communication at our facility. It is vital for all
employees to know how to use the phone to make calls, receive calls, transfer calls and
page over the intercom.

Telephone Courtesy

When using the phone, remember to speak with a pleasant and professional tone of voice.
Upon answering the phone, identify our facility by name, then identify yourself by name. Ask
the caller how you may help. If you do not know how to help, ask the caller if he/she can hold
for a short time so you can find someone who is able to help. Putting a call on Hold
maintains the privacy of any information that may be passing between health care givers
within hearing distance of the phone receiver.

Placing a Call on Hold

With the receiver lifted and caller on the line, push the red HOLD button to maintain the
connection with the caller. Then replace the handset until you find someone to help.
Responding to a phone call and finding someone else to help should be done in a timely
manner.

Retrieving a Call From Hold

To access the call on Hold, lift the hand set, then push the blinking green button once. If the
call has not been released from Hold within a minute of placing it on Hold, the connection will
be released automatically and the call will return to your phone with a beep.

Forwarding a Call to A Voicemail Box

If the caller is asking for a specific person that you know is not at the facility, inform them that
the person they are requesting is not available and ask if he or she would like to leave a
voice mail message. The voice mail message box of a specific extension may be accessed
quickly by pushing the Transfer button, dialing the extension number, followed by pushing
the 7 button.

Taking a Written Phone Message

Alternatively, the caller may wish you to take a written message. If so, take the name and
phone number of the caller along with a short message about what is being requested. After
the phone call is completed, make sure the written message is given to the charge nurse,
department head, or other person in charge.

Phone Requests for Specific Health Information

If the caller asks for specific patient or resident information, be aware that our facility is
governed by HIPAA privacy regulations. You may be legally prevented from giving the caller
their requested information. If you are unsure about whether you may divulge the requested
information, refer the call to your department manager, the CEO or the nurse in charge.


Phone Calls From the Media

Any calls from the media are to be referred to the department manager, the CEO or the
nurse in charge. Media includes magazine, newspaper, radio or television.


Making Outside Calls

Local Calls:

Calls to the outside are possible by dialing 9 before the phone number.
Local numbers are dialed with a 9 preceding the seven digit local number.

EXAMPLE: 9-475-0000

Long Distance Calls:

Long distance numbers are dialed with a 9 preceding the complete number, including the "1".

EXAMPLE: 9-1-785-308-0000

Paging On the Intercom System

If you need to page someone over the Intercom System, press the “Intercom” button,
followed by dialing the numbers 80. After the Intercom Active sounds (a beep heard over the
intercom) speak the name to whom you are addressing your message, then give a short
clear message. Repeat the name and the message a second time so that the message is
more likely to be heard.

If you answer the phone and need to page someone over the Intercom System to answer the
call, this procedure should be followed:
While you still have the caller on the line with the receiver off the hook, press the PkSet
button, then the Intercom button, then press 80. Speaking clearly into the receiver, announce
the name of the person the caller is trying to reach, then say “Answer Star Eight Zero”.
Repeat the same name and announcement. Return the receiver to the holder. If the paged
person does not answer, your phone will start beeping. Push the flashing green light. Inform
the caller that the person they are asking for is not responding. Then ask the caller if there is
someone else who could help them or if they would like to leave a voice mail message if that
person has an extension number. If the caller wishes to leave a voice mail message, forward
the caller to a specific voicemail box by pressing the Transfer button, then dialing the specific
Extension number, followed by pressing the 7 button. Alternatively a written message could
be taken or the caller could try to call back later.
If line 80 is blinking red showing it is in use and the phone display indicates that you are
using line 81, you would announce the name of the person whom you are trying to reach and
then say, “Answer Star Eight One”. If line 81 is also in use, the phone display would show
that you are using line 82. Your announcement will have to be made accordingly.



To Answer a Paged Call

Lift the phone receiver, press the Intercom button, then press the * button, followed by the
number buttons for the line that is holding the incoming call.

EXAMPLE: Intercom, * 8 0
(The numbers may also be *81 or *82, according to which line holds the call.)


Placing an Internal Call

Lift the receiver, press the Intercom button, and then dial the extension number of the
department or area you wish to call. If no one is in the department and you let the phone ring
a number of times, usually the system will allow you to leave a voicemail message.



Forwarding a Call

When you answer the phone and the call needs to be forwarded to a different department,
while the receiver is off the hook, press the Transfer button, then dial the extension number
of the party you are trying to reach. Wait until the phone begins ringing before replacing the
handset. That person’s phone will continue ringing and they can receive the call. If the phone
continues to ring in that office and is not answered, voice mail will answer, and the caller can
leave a message. This option of forwarding a call is used for internal calls.



Sending A FAX


A FAX machine is located in the front office. FAX machines are also located in the Medical
Records office and in the Diagnostic Imaging department. When a FAX is sent, the facility
face sheet containing the Confidentiality Notice should be used preceding the information to
be faxed. Place sheets to be faxed face down into the top send slot.

Faxes are sent in a similar way as phone calls are made.

Local FAXes:

Local FAX numbers are sent with a 9 preceding the seven digit local number.

EXAMPLE: Dial 9-475-0000; Then press the SEND button.
Long Distance FAXes:

Long distance FAX numbers are sent with a 9 preceding the complete long distance FAX
number, including the "1".

EXAMPLE: Dial 9-1-785-308-0000; Then press the SEND button.

Phone Directories

Directory sheets with departmental extension numbers are located close to the phones in
centralized areas such as the nurses stations, front office and kitchen. This directory
contains hospital room phone numbers, fax numbers and numbers to reach specific areas or
rooms located within the facility.

Phone number directory sheets with home phone numbers of employees are updated
periodically through the Public Relations Office. It is important if your home phone number
changes that you notify the Public Relations Clerk about that change. Phone number
directory sheets enable department heads and fellow employees to reach you about
scheduled events and changes in scheduling.

An emergency phone number database is maintained in our computer system. This
database can be accessed if an emergency arises, the Hospital Incident Command System
is activated, and additional help has to be called in.


                           Specialized Phone Features

Paging All Phones

To page all phones in the facility, lift the receiver and then dial 51. This will only announce
through all phones in the facility. It WILL NOT go over the intercom.

This is an option that is rarely, if ever, used. However, this could be a covert way of
summoning help from other areas of our facility should a threatening situation arise.

Voice Mail

Some staff members have been set up to receive voice mail. If receiving voice mail is part of
your job, you may check your voice mail by pressing the Message button. When the phone
rings, lift the receiver and put in your personal security code. When your personal voice
mailbox answers, wait for the verbal instructions to retrieve, review, forward or delete
messages. You will also be given the opportunity to change your set up options. Under your
set up options, follow the verbal instructions to change your standard greeting, to change
your alternate greeting or to switch from using one to the other to answer your voice mail.


A blinking red light at the top of the phone indicates that you have a waiting voice mail
message that has not yet been answered.
Do Not Disturb Feature

Some staff members have the option of setting up their office phone to show the main
console in the front office DND when they cannot take calls, are not available, or are absent
from their office. This set up allows important meetings to proceed without being disturbed
and also allows office personnel to take a message and tell callers that you are unavailable
to answer the phone. To select this option, press the Feature button, then dial 60, then press
the Feature button once again. Not all office phones will show that you are unavailable. Only
the main console will show this option.

To release the DND to show you are once again available to answer calls, press the Feature
button, then dial 69, then press the Feature button once more.


Go Home                        Take the Phone and FAX Usage Test
                *****************************************************

Resident/Patient Rights                                                          Go Home
Rights are Mandated by Law
Resident/Patient Rights are not just the ideal that we strive for, but they are also mandated
by federal and state regulations.

Respect and Dignity
Many of the rights deal with “respect & dignity” issues. For example, one of the rights is “to
be treated courteously, fairly, and with the fullest measure of dignity.” Another is “to be
treated with consideration and respect for your personal privacy.” One of the simplest things
that everyone can do to provide for these rights is to knock on doors and wait for a response
before entering a patient/resident room.

All Departments are Responsible
Always keep in mind that every department is responsible for seeing that these rights are put
into practice.

Facility Policies on Rights:
Residents/patients receive a copy of their rights on admission and additional copies are
available on request. It is the responsibility of all staff members to maintain these rights, so
everyone should be familiar with the contents. Copies of the rights are posted in the facility.
There are policies in place to see that the rights are provided for. Please address any
concerns about rights with a supervisor.


                                      Ombudsman
The following information is taken from the brochure “Ombudsman: Reaching Out for Quality
Care” provided by the Kansas Long-Term Care Ombudsman Program.

An Ombudsman is:
   An advocate for residents of long-term care facilities
   A person who is concerned with protecting the civil and human rights of elderly persons in
long-term care facilities
   A problem solver and mediator
   An objective investigator of complaints

Using the Ombudsman
Residents of long-term care facilities, their families and friends, and staff members and
administrators may use the ombudsman. The ombudsman should be called when abuse,
neglect or exploitation is suspected. In addition, the ombudsman can be called to answer
questions or concerns about Medicaid coverage or residents rights, and to seek information
about long-term care facilities.

Contacting the Ombudsman
The toll free number for the Ombudsman is posted at Cedar Living Center on the Residents
Rights Bulletin Board.
                         Patient/Resident Bill of Rights
DHS POLICY ON RESIDENT AND PATIENT RIGHTS:
The Facility will protect and promote the rights of each patient and resident.

DHS PROCEDURE ON RESIDENT AND PATIENT RIGHTS:
1. Prior to or upon admission, the facility will inform the patient/resident orally and in writing
of his/her rights and rules governing patient/resident conduct and responsibilities during
his/her stay in the facility. This shall be done in a language the patient/resident can
understand.
2. The patient’s/resident’s authorized representative or a family member may review this
information with the patient/resident. All patient’s/resident’s rights under the state law shall
be included in this notice.
3. Residents/Patients will be given copies of the Hospital Patient's, Skilled Bed Patient's and
Cedar Living Center Resident's Bills of Rights.

                                    Patient’s Rights
Each Patient in this facility has, at least, the right:

1. To exercise your civil and religious liberties.
2. To be informed of your rights, the rules and regulations of the facility.
3. To be informed of the bed reservation policy for a hospitalization.
4. To be told of all services available and all costs, including those charges covered or not
covered under Medicare, Medicaid, and the basic per diem rate.
5. To be informed of your condition and planned treatment and to participate in or refuse that
treatment.
6. To receive a prompt response to all reasonable requests and inquiries.
7. To be transferred or discharged only after reasonable notice is given and only for medical
reasons, the welfare of other Patients, or for nonpayment. A Patient may not be transferred
or discharged from a Title XIX certified facility solely because the source of payment for care
changes. Thirty (30) days written notice must be given each Patient prior to transfer or
discharge to ensure orderly transfer or discharge. Notification of action to be taken will be
documented in the Patient’s medical record.
8. To be encouraged to exercise your rights as a Patient and citizen; to complain and
suggest without fear of coercion or retaliation.
9. To receive adequate and appropriate health care and protective support services.
10. To be treated courteously, fairly, and with the fullest measure of dignity.
11. To manage your personal affairs, or if this is delegated, to receive an accounting every
three months upon request.
12. To be free of mental and physical abuse and of restraints not documented as medically
necessary.
13. To refuse to serve as a medical research subject.
14. To have your personal and medical records treated as confidential.
15. To be treated with consideration and respect for your personal privacy.
16. Not to perform work.
17. To receive visitors and private mail.
18. To take part in various activities of the nursing home.
19. To have your own clothing and possessions.
20. To use tobacco in accordance with applicable policies, rules, and laws.
21. To consume a reasonable amount of alcoholic beverages.
22. To have privacy for visits with your spouse.
23. To have your choice of pharmacy and physician.
24. To withhold payment for physician visitation if the physician did not examine you.
25. To have ample opportunity to visit with family and friends.
26. To retire and rise in accordance with reasonable requests.
27. To choose your roommate, whenever possible. Spouses who are Patients in the same
facility are permitted to share a room unless one of their physicians documents in the
medical record reasons why such an arrangement would have an adverse effect to the
health status of the Patient.
28. To have any significant change in your health status reported to you.

Each facility shall make available a copy of the rights and responsibilities established under
this section and the facility rules to each Patient or guardian prior to the time of admission to
the facility.

Any Patient adjudicated incompetent under State law or documented by the attending
physician to have a specific impairment regarding capacity to exercise rights shall have
protection of all rights through notification of the contents of this document to the Patient’s
guardian, next of kin, sponsor, responsible party, or sponsoring agency.

          DECATUR COUNTY HOSPITAL PATIENT RIGHTS
Decatur Health Systems Rights Policy
Decatur Health Systems does not exclude, deny benefits to, or otherwise discriminate any
person on grounds of race, color, or national origin, religion or on the basis of disability or
age in admission to, participation in, or receipt of the services and benefits of any of its
programs and activities.

Notice of Patient Rights and Grievance Process
    The patient (or his representative) has the right to be informed of his rights as a patient in
advance of furnishing or discontinuing care, and to be informed of hospital policies and
practices that relate to patient care, treatment and responsibilities.
    The patient may communicate any complaints or concerns verbally, by phone, or in
writing to his/her physician, nurse, or caregiver to file a grievance or complaint. If the
complaint or grievance has not been resolved to your satisfaction by speaking with these
individuals, you may contact the Administrator of Decatur County Hospital at 810 W.
Columbia, PO Box 268, Oberlin, KS 67749 (785-475-2208) to initiate a formal grievance. At
any time, the patient, family member or representative has the right to direct a complaint or
concern to the Kansas Department of Health and Environment Adult Care Services at 1-800-
842-0078 and/or the Kansas Ombudsman 1-877-662-8362.

Exercise of Rights
    The patient has the right to participate in the development and implementation of his plan
of care, and to make informed decisions about his plan of care and treatment, including
plans for care after discharge, and to refuse a recommended treatment or plan of care to the
extent permitted by law and hospital policy and to be informed of the medical consequences
of this action.
    The patient has the right to be informed of his health status, including diagnosis,
treatment, and prognosis.
    The patient has the right to request or refuse treatment, and the right to consent or
decline to participate in research studies.
    The patient has the right to have an Advance Directive (Living Will-Durable Power of
Attorney for Health Care Decisions) concerning treatment or designating a surrogate
decision-maker with the exception that the hospital will honor the intent of that directive to the
extent permitted by law and hospital policy.
    The patient has the right to have a family member or representative and his own
physician notified promptly of admission to the hospital.
    The patient has the right to expect that, within its capacity and policies, a hospital will
make reasonable response to the request of a patient for appropriate and medically indicated
care and services.
    The patient has the right to ask and be informed of the existence of business
relationships among the hospital, educational institutions, other health care providers or
payers that may influence the patient’s treatment and care.
    The patient has the right to expect reasonable continuity of care when appropriate and to
be informed by physicians and other caregivers of available and realistic patient care options
when hospital care is no longer appropriate.
    The patient has the right to examine and receive an explanation of his/her bill regardless
of source of payment.


Privacy and Safety
   The patient has the right to personal privacy.
   The patient has the right to considerate and respectful care.
   The patient has the right to receive care in a safe setting.
   The patient has the right to be free from all forms of abuse or harassment.


Confidentiality and Patient Records
   The patient has the right to confidentiality of his medical records.
   The patient has the right to access information contained in his medical records, and to
have the information explained as necessary. Access to medical record information must be
within a reasonable time frame.


Restraint for Acute Medical and Surgical Care
   The patient has the right to freedom from physical and chemical restraints used in the
provision of acute medical and surgical care unless clinically necessary.


Seclusion and Restraint for Behavior Management
  The patient has the right to freedom from seclusion and restraints used in behavioral
management unless clinically necessary.


Management of Pain
  The patient has the right to expect their pain is recognized and addressed appropriately.


As a patient, you also have the responsibility to:
    Know and follow facility rules and regulations.
    Provide information about past illnesses, hospitalizations, medications, and other matters
relating to your health.
    Cooperate with all facility personnel and to ask questions of your doctor or nurse if you do
not understand any directions or procedures.
    Be considerate of other patients and staff, assist in the control of noise, and comply with
rules regarding smoking, number of visitors, and visiting hours.
    Understand that your visitors must comply with policies and procedures designed to
protect the health and safety of others and to facilitate the safe and efficient operation of the
facility.
    Provide information necessary for insurance processing and to recognize that you, as the
patient, are responsible for your hospital bills and any additional charges owed to other care
providers for their professional services.
    Help your doctor, nurses, and other caregivers in their efforts to return you to health by
following their instructions and medical advice. Be responsible for your actions if you refuse
treatment or care or if you do not follow your doctor’s advice.
    Be respectful of the property of other persons and the property of the facility.
    Understand that the facility is not responsible for your personal property, or for your
valuables unless they are locked in the facility safe.
    Provide a copy of your Advance Directive, if you have one, to the facility, your family, and
your doctor.
    Advise your doctor, nurse, or caregiver of any dissatisfaction you may have with your
care or services.




Go Home                 Take the Resident and Patient Rights Test
              ********************************************************

Risk Management and
Performance Improvement
                                                                                 Go Home
What Is Performance Improvement?
Performance Improvement is a work philosophy that encourages every member of an
organization to find new and better ways of doing things.

Performance improvement benefits everyone:
   Patients and families
    · Higher quality care means better health and greater satisfaction
   You and your co-workers
    · Finding better ways of doing things can lead to greater job satisfaction
   Decatur Health Systems
    · An ongoing focus on improving quality helps DHS stay competitive
   The community
    · When DHS offers high quality services, everyone benefits

Quality comes from teamwork. DHS needs every employee’s ideas and effort—including
yours!

Key Points of Performance Improvement:

“Customers” come first.

In health care, customers may be:
    External –such as patients, residents and families.
    Internal—those inside DHS (such as staff members in another department) who rely on
your performance to do their jobs well.

Customers know best whether their needs and expectations are being met.
Find out from customers how satisfied they are by:
· Asking questions
· Having customers fill out questionnaires
· Listening carefully to both complaints and compliments

People doing the work often have the best ideas.
· That’s because they know their work better than anyone else. The leaders at Decatur
Health Systems provide guidance and support, but they depend on YOU to give ideas for
improvements.

Teamwork and communication are a must.
· Most processes in health-care organizations involve people from different departments and
at different staff levels. Improving processes requires all these people to work as a team and
to communicate effectively with each other.

One-time successes aren’t enough.
· Improvements need to be maintained. In looking for better ways of doing things, it’s
important to find methods that people will be able to keep using. Then, it’s up to everyone to
stick with them.

Performance Improvement is ongoing.
· Being committed to quality doesn’t mean reaching a goal, then quitting. Instead, it means
always asking, “How can we do things even better?” Even when something is working well,
there’s room for improvement!



Identifying opportunities for improvement:
· High risk
· High volume
· Problem prone
· Directly affect outcomes
· Inefficient use of facility resources
· Results of data collection and assessment
· Changing regulatory requirements
· Changes in the environment of care
· Changes in the needs of the community

                 Performance Improvement Model (PDSA)

Planning for Improvement

Plan
Include essential information in your plan:
· Who
· What
· When
· Where
· How
· Measures to be used

Do
· Put the plan into action
· Collect data

Study
· Compare current and past data to find trends
· Identify possible causes of any problems

Act
· Standardize the improvement
· Continuously improve




                  Facility Performance Improvement Plan
Sources of data
1. Annual Department review and Quarterly Reports
2. Patient Satisfaction Surveys
3. Occurrence Reports

Complying With KSA 65-4921
KSA 65-4921, et seq., requires every medical care facility in Kansas to establish and maintain an
internal Risk Management program.


What is a Reportable Occurrence?
1). Any act by a HealthCare provider which is or may be below the applicable standard of care
and has reasonable probability of causing injury to a patient or resident;

OR

2). Any act by a HealthCare provider which may be grounds for disciplinary action by the
appropriate licensing agency;


Who Must Report?
Any facility employee or healthcare provider directly involved in a reportable occurrence.

OR

Any facility employee or healthcare provider having knowledge that a reportable occurrence
has occurred.


To Whom Do I Report?
The law specifies that the report be made to either the Administrator, the Chief of Staff or the
Risk Manager. For our facility, reports are sent to the Performance Improvement Chairman
who is the designated Risk Manager.


What Happens If I Don’t Report?
Willful failure to report are subject to the following penalties:
Revocation, suspension of license, or restrictions of privileges;
Class C misdemeanor—subject to fine


Will I lose my job or be sued if I report?
The law specifically provides protection for those making the report. No employer shall
discharge or otherwise discriminate against any employee for making a report. However,
reports must be made in good faith.




                                      Occurrences
Specific Examples of Occurrences
(Not limited to these)

  Lost/Damaged Items        Dietary Errors     Incorrect Drug Counts
  Transcription Errors     AMA’s      Wrong Test Results       Fires/Potential Fires
  Visitor Injury/Complaint     Staff Injuries   Falls    Digression from P&P
  Burns      Chemical Spills     Skin Prep Injuries     Lack of Proper Consent
  Equipment Malfunctions        Contraband      Procedure Cancellation
  Procedure Delay       Dissatisfied Patient     Dissatisfied Resident
  Unexpected Death        Treatment Errors      Elopements
  Attempted Elopements        Contamination       Medication Errors
  Blood Reactions      Identification Errors    Wrong IV’s, Rate, Drug
  Delivery Complications      Abusive Resident/Patient
  Fights Between Residents        Fights Between Patients
  Improper Labeling      Adverse Reactions        Transfer Injuries
  Unavailability of Blood    Scheduling Problems         Safety Concern
  Lost Order/Report/Specimen          Needle Stick    Equipment Not Available
  Refusal of Treatment      Incident Causing Prolonged Hospital Stay
  Procedures Being Performed on the Wrong Patient

                                Occurrence Reports
Making Occurrence Reports
Reports are made to the Performance Improvement Chairman on the facility’s incident report
form. Forms are available in each department or from the PI Chairman.

When an incident occurs, complete the facility’s Occurrence Report Form as follows:

1: Name of person involved in the event. The blank space to the right of Section A is
provided for an ID label to expedite completion.
2: Status of person involved in the event. Check one.
3: Gender of Person involved in the event.
4: Date of the occurrence.
5: Time of the occurrence. If the exact time of the event is unknown, document the time it
was discovered.
6: Department of occurrence.
7: Location of occurrence.
8: The nature of the occurrence.
9: Describe only the facts of the event.
     List any witnesses of the event.
     Name of person preparing the report
     Department of person preparing the report.
     Date the report was prepared.
10: Completed report is placed into an envelope, sealed and submitted to the PI Chairman.
Tiffany Palmer is our Performance Improvement Chairman. Her office is the Staff
Coordinator office, located next to the Physical Therapy department.

Go Home                                 Take the Risk Management Test
Abuse, Neglect and Exploitation Test                                       Go Home
Decatur Health Systems



1) In accordance with our facility policy, in cases of resident/patient
   abuse you should do ALL of the following EXCEPT:
  a) Remove the aggressor from the area and provide any needed medical
  attention.
  b) Investigate the circumstances leading up to the incident and make
  out an incident report.
  c) Contact your supervisor and then the Charge Nurse who will notify
  the Chief Nursing Officer
  d) File a police report downtown yourself immediately.



2) The Social Service Manager will:
  a) Gather evidence of alleged abuse, hold a press conference and have
  it published in the local newspaper.
  b) Keep all staff member informed of the status of ongoing cases.
  c) Update the local law enforcement agencies on a daily basis
  concerning alleged abuse situations.
  d) Coordinate the investigation of alleged abuse situations and report
  the event to the Kansas Department of Health and Environment at the
  earliest possible time.



3) To prevent abuse or neglect from happening in our facility, all
   personnel are to report immediately any signs of abuse/neglect of
   residents or patients to ANY of the following EXCEPT:
  a) Chief Nursing Officer
  b) Local police
  c) Case Manager
  d) Their supervisor


4) Choose the one that is NOT true about screening procedures for new
   employees:
  a) A mandatory drug screening will be done.
  b) The department manager will conduct reference checks on all job
  applicants.
  c) Human Resources Department will conduct an O.I.G. (Office of the
  Inspector General) check.
  d) A credit history check will be done.
 5) The employee’s annual in-service on abuse and neglect will include ALL
    of the following EXCEPT:
   a) How to put dressings on bruised areas.
   b) Appropriate interventions to deal with aggressive residents.
   c) How to report knowledge of abuse allegations.
   d) What constitutes abuse, neglect and misappropriation of
   resident/patient property.

 6) Which of the following is NOT a sign of physical abuse:
   a) Involuntary seclusion.
   b) Age spots on the skin.
   c) Human bite.
   d) Excessive exposure to heat or cold.


 7) If an employee is accused of participating in alleged abuse in our
    facility the results may be ANY OR ALL of the following EXCEPT:
   a) They will be told to leave the area where the alleged abuse took
   place.
   b) They will be permitted to have unsupervised visits with residents
   or patients while the investigation is going on.
   c) They will be suspended without pay until the findings have been
   reviewed by the CEO.
   d) They may be immediately reassigned to duties that do not involve
   resident/patient contact.

 8) Decatur County Hospital/Cedar Living Center will report alleged
    violations of substantial incidents to
   a) The Kansas Department of Health and Environment.
   b) The Office of the Inspector General.
   c) The Nurses Licensing Board.
   d) The American Medical Association.


 9) Choose the one that is NOT a sign of neglect:
   a) Decayed teeth.
   b) Improper administration of medicine.
   c) Using a walker.
   d) Dehydration and malnutrition.


10) The abuse investigation team includes ALL of the following EXCEPT:
   a) The Social Service Director
   b) The Chief Nursing Officer
   c) The Public Relations Clerk

   d) The Department Manager                                              Go Home
Advance Directives Test                                                    Go Home
Decatur Health Systems



1) In 1991 provisions for the use of documents such as Living Wills and
   Durable Power of Attorney for Health Care Decisions were made by:
  a). Federal and State law.
  b) County Ordinance.
  c) A broad-based committee representing all departments of our
  facility.
  d) A resolution of the Supreme Court Justices


2) When you complete your Advance Directives, you should do ALL of the
   following EXCEPT:
  a) Provide copies to your spouse and/or children.
  b) Lock your only copy in a safety deposit box
  c) Give a copy to your physician and hospital.
  d) Carry a copy with you when you travel.
  .
3) DNR stands for:
  a) Do not restrain.
  b) Do not restrict.
  c) Do not retaliate.
  d) Do not resuscitate.


4) DNR orders can be written only by:
  a) The patient.
  b) The family.
  c) The physician.
  d) The nurse.


5) If I have prepared Advance Directives,
  a) It means I am donating my body to science after my death, in order
  for it to be used in medical education.
  b) It tells which safety deposit box I have used to store my Last Will
  and Testament.
  c) It frees my family of the responsibility and stress of having to
  making difficult decisions, gives directions to my physician and helps
  protect my rights.
  d) It gives authority to withhold a small amount from my paycheck
  to cover my future burial expenses.
 6) Advance Directives are:
   a) Informal agreements about care after minor surgery.
   b) Legal documents that give directions for future medical care.
   c) Indexes of medical terms
   d) Directions to find health ordinances in law books.


 7) A Living Will-Durable Power of Attorney for Health Care Decisions can
    only be created by:
   a) The patient.
   b) The spouse.
   c) The physician.
   d) The family attorney.


 8) Durable Power of Attorney for Health Care Decisions is sometimes
    called:
   a) A “Lemon” law.
   b) A “health care proxy”.
   c) A flexible benefit plan.
   d) A Brown vs. Plessy decision.


 9) All patients have rights. Which of the following is NOT included in
    patient’s rights?
   a) Right to always be scheduled for the first appointment of the day.
   b) Right to Privacy.
   c) Right to Informed Consent and information about your condition.
   d) Right to information about Advance Directives.


10) Which of the following is NOT TRUE about Advance Directives?

   a) Facilities that receive Medicare and Medicaid funds must inform
   patients and residents about Advance Directives.
   b) Advance Directives must be made a year in advance of any major
   medical care.
   c) Living Wills can “speak” for you when you are unable to do so.

   d) Advance Directives can limit life-prolonging measures when there’s
   little or no chance of recovery.




                                                                           Go Home
Benefits Test                                                            Go Home
Decatur Health Systems

1) When is open enrollment for Freedom Claims Management Health Insurance
   and AFLAC Insurance?
  a) Anytime throughout the year when a written application is filed.
  b) March.
  c) Only when you are first hired.
  d) Fall.


2) When is open enrollment for the 401K Plan?
  a) At the end of every month.
  b) Quarterly
  c) Once annually.
  d) Every two years.


3) Short term disability
  a) Is for maternity leave, or when an employee is sick and cannot
  work.
  b) Has a two-week waiting period.
  c) Can be collected at the same time as PTO.
  d) Is paid at 100% of the employee’s normal wage.


4) Claim forms for STD
  a) Are found at the hospital nurse’s station.
  b) Must be obtained from the doctor
  c) Have three sections to be completed by the employee, the employer
  and the physician.
  d) Must be requested in writing and be accompanied by a stamped
  self-addressed envelope.

5) Employees who do NOT choose Direct Deposit for their paychecks:
  a) Are paid cash instead
  b) Get fewer PTO hours.
  c) Have a deposit fee deducted from their pay.
  d) Are mailed their checks.


6) STD is an acronym our Benefits program uses for:
  a) Stay Trim Daily.
  b) Slow Timed Delivery.
  c) Sexually Transmitted Diseases.
  d) Short Term Disability.
 7) AFLAC Insurance:
   a) Is provided cost-free to all employees.
   b) Is available to new hires after a 90-day waiting period.
   c) Only provides an optional accident insurance.
   d) Is mandatory.


 8) Decatur Health Systems 401K Plans
   a) Have employer contributions determined by a tier level basis,
   depending on years of service.
   b) Are funded solely by the employer.
   c) Are available immediately on your hire date.
   d) Are an alternative to Social Security withholding.


 9) Changes or corrections on check in times or requests for PTO or should
    be:
   a) Made directly on the computer screen through a link button.
   b) Put in a letter and delivered to the CEO.
   c) Written on a time correction form at the end of each pay period and
   turned in to the department supervisor for a signature.
   d) Written on a list posted in the back hallway.


10) If you are eligible for Freedom Claims Management Medical Insurance
    Benefits, you may apply
   a) If your department votes unanimously to go together for coverage.
   b) After you are admitted to the hospital following a work injury.
   c) Immediately on being hired, subject to a 90-day waiting period for
   coverage, or after a change of status makes it necessary to change
   your benefit.
   d) If you have a note of approval by the charge nurse.



                                                                            Go Home
Customer Satisfaction Test                                             Go Home
Decatur Health Systems



1) Our customers are:
  a) Dependant on us.
  b) Only the people who pay cash for our services.
  c) The Medical Staff, vendors, patients and their families and my
  co-workers.
  d) Exclusively the patients who carry adequate insurance coverage.


2) Customer service is:
  a) Not in the job description of the CEO.
  b) Expensive to provide.
  c) The cornerstone of a business’s success.
  d) Only the job of the Public Relations Clerk.


3) When handling a complaint from a patient or family member, I should:
  a) Argue that they are wrong.
  b) Ignore the issue.
  c) Inform my supervisor and the CEO.
  d) Tell them to go find someone who cares.


4) During a phone conversation, communication is measured by
  a) Electrical impulses.
  b) What is said.
  c) Who is on the other end.
  d) Words and tone.


5) External customers
  a) Should be treated differently than internal customers.
  b) Purchase our products and services.
  c) Are employees and co-workers.
  d) Are those above you in the chain of command.


6) Customer focus means all of the following EXCEPT:
  a) Listening to the customer.
  b) Pointing out reasons why the customer is wrong.
  c) Anticipating customer’s future needs.
  d) Identifying, meeting and exceeding customer’s needs.
 7) Which is NOT a reason why we provide quality service?
   a) The State of Kansas pays us bonuses to give better care.
   b) Competition demands it.
   c) Customers expect it.
   d) It is a key to the success of the business.


 8) The Hostess Role includes ALL of the following EXCEPT:
   a) Assess the environment.
   b) Acknowledge guests when they are leaving.
   c) Welcome guests and take care of their needs.
   d) Furnish doughnuts and cinnamon rolls for every special occasion.


 9) Which of the following statements is NOT TRUE about good customer
    service?
   a) A professional health care provider is sensitive, sincere and has
   good selling skills.
   b) Treat people as you would like to be treated.
   c) Giving inadequate customer service will provide quality care.
   d) It is necessary to be responsible for your own actions.


10) The concept of “If you hear it, you own it” means:
   a) Inform the appropriate person to handle the issue at hand.
   b) Appearing to listen to customer complaints will solve any problems
   they may have.
   c) When you answer the phone you are entitled to give out any
   information you are asked for.
   d) Casually overheard information may be passed on to close friends.




                                                                           Go Home
Disaster Preparedness/Fire Safety Test                                                Go Home
Decatur Health Systems

1) If you discover a fire, your FIRST response should be:
  a) Rescue anyone who is in danger.
  b) Extinguish it, if the fire is small and confined.
  c) Open any hot doors to provide ventilation.
  d) Run down the hallway immediately, loudly announcing, “CODE RED”.


2) Exit paths:
  a) Need to be used only in case of emergency.
  b) May be used to store unused linens.
  c) Need to have a wheelchair placed in them to aid disabled patients
  d) Need to be unobstructed in hallways and doorways.


3) Immediately after extinguishing a fire, you should:
  a) Fill out an incident report.
  b) Stay in the area until the fire department arrives.
  c) Announce “ALL CLEAR”.
  d) Report to the nurse’s station.


4) Which of the following would be MOST helpful to you in responding to a
   fire emergency quickly and effectively:
  a) Do power lifting to improve your strength.
  b) Have a coworker time your walking speed to various locations with a stop watch
  c) Have your hearing tested annually so when the alarm sounds you will
  be sure to hear it.
  d). Memorize a formula like “RACE”.


5) If you smell smoke coming from behind a closed door:
  a) Put a wet towel around your nose and mouth to protect you from
  smoke and fumes.
  b) Feel the door before opening it.
  c) Put a taped “X” on the door in order to mark it.
  d) Open the door immediately in order to extinguish the flames.

6) When a disaster occurs:
  a) Strictly Fire Department personnel will handle the situation.
  b) The police chief will be in charge of hospital activities.
  c) Off-duty personnel may be required to return to work.
  d) Dietary employees will be called upon to do active nursing duty.
 7) When a disaster drill is conducted,
   a) The administrator will announce it on the intercom.
   b) All employees are required to participate.
   c) A week’s notice will be given so participants may prepare.
   d) Only certain employees are expected to participate.


 8) Access to the facility disaster plan is
   a) Available to all employees within Red Notebooks at several
   locations throughout the facility.
   b) Restricted to Department Managers.
   c) Provided only to those with Internet connections.
   d) Given only to the Health Information Department.


 9) Which of the following is NOT TRUE about the ABC multipurpose dry
    chemical fire extinguishers at our facility:
   a) Employees should use the “PASS” method when it is necessary to use
   them: Pull, Aim, Squeeze, Sweep
   b) They can be used on all types of fires: chemical, grease, electrical
   and ordinary combustibles like wood, cloth and paper.
   c) They are only effective for use in practice fire drills.
   d) Their locations are marked on several different fire exit maps
   throughout our facility.

10) All employees in our facility need to be familiar with their duties
    during a disaster by:
   a) Calling police dispatch and asking for advice.
   b) Finding instructions on an online weather web site after a storm
   watch has been issued.
   c) Reading the facility disaster manual prior to a disaster.
   d) Asking the coworkers with the greatest employment longevity what is
   usually done.




                                                                             Go Home
Haz-Mat Test                                                              Go Home
Decatur Health Systems



1) The OSHA Right To Know program gives you, the employee, the Right To
   Know:
  a) All the facility gossip.
  b) Who is responsible for the hazards in living.
  c) About the potential hazards you face on the job and how to protect
  yourself from those potential hazards.
  d) Who started the gossip.


2) Who is responsible for giving you, the employee, the Right To Know
   information?
  a) The manufacturer of the hazardous material.
  b) Your employer.
  c) The distributor of the hazardous materials.
  d) The State governor.


3) The Hazardous Materials (HazMat) Coordinator for our facility is
  a) The CEO.
  b) The Plant Operations Manager.
  c) The Lab Manager.
  d) The Hospital Chief Nursing Officer.


4) When you encounter a chemical liquid substance in an unlabeled or
   unauthorized container, you should:
  a) Assume it is the juice the kitchen left and serve it out to
  patients and residents.
  b) Do not use it and dispose of it properly according to facility
  policy.
  c) Go ahead and use it to clean sinks and drains.
  d) Smell it so you can determine what chemical substance it is.


5) Hazardous Materials can enter the body
  a) By skin & eye contact; inhaling; swallowing.
  b) By not listening.
  c) By not following the safety instructions in the MSDS.
  d) By carefulness.
 6) You can find information on the hazardous materials you use in your
    work in the facility
   a) In the Materials Safety Data sheets (MSDS).
   b) In the Oberlin City Library.
   c) In the PDR (Physicians Drug Reference) book.
   d) In the Chief Executive office.


 7) The Material Safety Data Sheets (MSDS) for your department are found
   a) In a pile of papers in the Materials Manager’s office.
   b) In the Risk Manager’s office.
   c) In the Housekeepers’ closet.
   d) In a red binder labeled “MSDS” in your department.


 8) Personal Protective Equipment (PPE) must be provided for your
    protection by
   a) The manufacturer of the hazardous materials.
   b) The Risk Management department.
   c) Your employer.
   d) You, the employee.


 9) If you don’t know how to protect yourself from the hazardous materials
    used in your work area, you should
   a) Read the MSDS and ask your department manager.
   b) Call the sheriff’s department.
   c) Consult with the administrator to review our facility’s safety
   policy.
   d) Just use the hazardous materials anyway.


10) Who is ultimately responsible for EXERCISING your RIGHT TO KNOW?
   a) The Hospital Board.
   b) You, the employee.
   c) The Physical Therapy Department.
   d) Everyone in the facility.




                                                                       Go Home
HIPAA Test                                                                Go Home
Decatur Health Systems

1) The criminal penalties for improperly disclosing patient health
   information
  a) Are six hours of community service.
  b). Can be as high as fines of $250,000 and prison sentences of up to
  10 years.
  c) Depend on whether the patient has died and is unable to testify
  d) Are excused for all health care workers.


2) Which of the following is protected health information under HIPPA?
  a) Just the patient’s allergies.
  b) The patient’s name, address and any physical conditions.
  c) Only the patient’s address.
  d) Specifically the patient’s name as it appears in the phone book.


3) Which of the following is NOT a way that employees protect patient
   privacy?
  a) Informing concerned family members about the patient’s latest
  medical treatments.
  b) Knocking before entering a patient room.
  c) Closing patient doors
  d) Using curtains to shield patients during treatment.


4) You are working in the emergency department and see that a neighbor
   has just arrived for treatment after a car crash. You should:
  a) Only share information about what you see and hear with authorized
  medical personnel.
  b) Contact the neighbor’s spouse to alert him or her about the
  accident.
  c) Call the president of the Lions Club so they can organize a
  community benefit.
  d) Inform your closest friend of this incident immediately.


5) Under what circumstances are you free to repeat to others private
   health information that you hear on the job?
  a) After you no longer work at the hospital
  b) After a patient dies
  c) When authorized for business purposes
  d) Only if you believe the patient won't mind
 6) If you suspect someone is violating the facility's privacy policy, you
    should:
   a) Watch the individual involved until you have gathered solid
   evidence against him or her.
   b) Report your suspicions to the privacy official or your supervisor,
   as outlined in the facility privacy policy.
   c) Say nothing. It's none of your business.
   d) Inform your closest coworkers so they can also be witnesses.


 7) Which of the following is NOT a feature designed to protect
    confidentiality
   a) Locks on medical records rooms.
   b) Passwords to access computerized records.
   c) Rules that prohibit employees from looking at records unless they
   have a need to know.
   d) Public access bulletin boards.


 8) Which use of patient information is NOT allowed under HIPAA
    regulations?
   a) The front office may use patient information to post on the room
   register.
   b) The billing department may use information to bill patients or
   their insurance companies for the services they receive.
   c) Physical and respiratory therapists may use patient information to
   determine what services the patient should receive.
   d) Dietitians may use patient information to decide what type of meals
   should be served.

 9) An important phrase to remember when determining who should have
    access to patient information is:
   a) Want to know.
   b) Have good faith.
   c) Need to know.
   d) Have good intentions.


10) Violating patient confidentiality is:
   a) Inconvenient.
   b) Adequate behavior.
   c) Included in good job performance.
   d) A crime.




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Hospital Incident Command System (HICS) Test                                              Go Home
Decatur Health Systems

 1) Select the statement that is NOT TRUE about the Incident Command
    System (ICS):
   a) Once the six step planning is done for an incident, it will never again have to be repeated during an
   incident.
   b) Continuous monitoring of changes in the situation should be done.
   c) Several diverse emergency situations can trigger ICS activation.
   d) When a triggering incident occurs, specific six step planning should take place immediately.


 2) Select the statement which is TRUE in the event of a disaster:
   a) Employees will be required to remain in their current positions of employment.
   b) All of the positions in the Hospital Incident Command Systems (HICS) will always have to be
   filled.
   c) The Chief Executive Officer, Chief Nursing Officer, Chief of Medical Staff OR the current Charge
   Nurse on duty will announce the disaster and become the Incident Commander.
   d) The Kansas National Guard will be called on immediately to take charge.


 3) Select the statement that is NOT TRUE:
   a) The chain of command under the Incident Command System (ICS) will always stay the same as an
   employee observes on a normal day-to-day basis.
   b) Each of the positions in the Hospital Incident Command System (HICS) could be filled with any
   hospital employee who is currently present and qualified to fill the position.
   c) The Incident Commander organizes and directs the Hospital Command Center, gives overall
   direction, and authorizes facility evacuation if needed.
   d) As many as eight Section Chiefs are to report information from their areas directly to the Incident
   Commander.

 4) Select the statement that is NOT TRUE:
   a) The Liason Officer functions as the contact person for representatives from other agencies.
   b) Medical/Technical Specialists make the decision on when to evacuate the facility.
   c) The Safety/Security Officer ensures the safety of persons involved in the emergency situation and
   corrects any hazardous conditions, including any operation that poses an immediate threat to life and
   health.
   d) The Public Information Officer serves as a conduit for information to internal and external persons
   and agencies, including families, staff, and the news media.

 5) Select the statement that is NOT TRUE. The Operations Section Chief:
   a) is in charge of the Security Branch Director who monitors crowd control, traffic control, and
   coordinates the security of the facility with outside law enforcement agencies.
   b) oversees the Infrastructure Branch Director, the Medical Care Branch Director, Hazmat Branch
   Director, and the Business Continuity Director.
   c) supervises the Staging Manager who is in charge of personnel resources, vehicle resources,
   equipment and supplies, and medications and supplies.
   d) grants interviews with local and national news agencies concerning the status of the emergency
   situation.
 6) Select the statement that is NOT TRUE. The Planning Section Chief:
   a). is in command of the Situation Unit Leader who controls the supply of body armor and weapons
   caches in case a riot should erupt.
   b) oversees the Documentation Unit Leader who maintains accurate and complete incident files for
   legal, analytical and historical purposes.
   c) is responsible to prepare an Incident Action Plan (IAP) for each operational period
   d) is in charge of the Resource Unit Leader who keeps track of the location and availability of
   personnel, teams, supplies, and major equipment.

 7) Select the statement that is NOT TRUE:
   a) The Logistics Section Chief oversees the Support Branch Director who ensures the medical care and
   psychological support for staff members.
   b) The Logistics Section Chief is in charge of the Service Branch Director who organizes the services
   to maintain the communication system, food and water supply for staff, and information technology
   and systems.
   c) The Support Branch Director reports information to the Logistics Section Chief about the Labor
   Pool and the credentialing of volunteer help.
   d) The IT/IS Unit that provides computer hardware, software and infrastructure support to staff reports
   directly to the Incident Commander.

 8) Choose the statement that is NOT TRUE. The Finance/Administration
    Chief:
   a) oversees the activities of the Compensation/Claims Leader who receives, investigates and
   documents all claims reported during an emergency incident stemming from an accident or action on
   hospital property.
   b) supervises the use of financial assets and makes an accounting for assets that are used.
   c) is always responsible to appoint someone to fill the Incident Commander position.
   d) is in charge of the Time Unit Leader who documents personnel time records and reports on the
   number of regular and overtime hours worked or volunteered.

 9) Choose the statement that is NOT TRUE:
   a) The structure of ICS is flexible and will change to accommodate the demands placed on our system
   during a disaster.
   b) Once an Incident Commander has assumed the duties of command, that person always remains the
   Incident Commander throughout the duration of an incident.
   c) The Incident Command System is activated by any triggering incident that interrupts and stresses
   the usual operation of our facility.
   d) ICS is an organized structure of positions that will be filled with employees from our facility during
   a disaster.

10) Choose the LEAST IMPORTANT reason for all employees to become well
    acquainted with the Incident Command System (ICS). The ICS structure:
   a) helps avoid overlapping job responsibilities during an incident, thereby eliminating wasted time by
   unnecessary repetition of a job.
   b) is a reason for another area of employee testing on the annual assessment tests.
   c) allows us to address an emergency situation by organizing in a minimum amount of time.
   d) is a way to avoid confusion about who is in charge in case of an emergency incident.
                                                                                          Go Home
Infection Control Test                                                                Go Home
Decatur Health Systems

1) Nosocomial Infection is:
  a) A runny nose.
  b) An infection that occurs during or after hospitalization which
  wasn't present at time of admission.
  c) An infection that you picked up downtown.
  d) An infection which everyone at work has.


2) Universal/Standard Precautions are:
  a) Strategies developed by the Pentagon to protect our country from terrorists.
  b) Making sure every employee has gloves.
  c) Practicing Safe Sex.
  d) Safety measures used by all employees to prevent disease
  transmission through blood or body fluids exposure.

3) The most important means for prevention of nosocomial infections is
  a). Good handwashing and/or using hand sanitizer antisceptic before and after contact with
  every patient.
  b) To send everyone home before 72 hours is up.
  c) To refuse an infected patient admission to the hospital.
  d) To put everyone in isolation


4) The most important person to prevent the spread of nosocomial
   infections is:
  a) The Patient/Resident
  b) The President
  c) You
  d) The CEO


5) If you have an exposure to blood or body fluids you should:
  a) Wait a week or two to see if you get sick.
  b) Ignore it so you don't catch something.
  c) Contact the hazardous material personnel at the police department.
  d) Notify your supervisor; fill out an incident form, exposure form
  and injury form immediately.
 6) When working in a healthcare facility you should have a TB test and
    medical update:
   a) Whenever you remember it.
   b) On hire and annually.
   c) When you get sick.
   d) When the Doctor tells you to.


 7) You should fill out an illness form and turn it in to the employee
    health nurse:
   a) When the boss makes you do it.
   b) When you return to work after you have been off with an illness.
   c) Annually.
   d) When the doctor requires it.


 8) Hepatitis, influenza, and pneumonia vaccinations should be gotten:
   a) When working in a healthcare setting and coming in contact with
   patients/residents.
   b) After you have been exposed.
   c) When the District Court orders it.
   d) After lunch.


 9) In which of the following instances would using hand antiseptic for
    rapid bactericidal action be LEAST effective:
   a) When hands are free of any visible debris.
   b) After a deep injury from a contaminated needle.
   c) As a supplement to hand washing.
   d) Before and after patient contact.


10) The exposure control plan is:
   a) To provide guidelines to follow when exposed to blood or body
   fluids.
   b) To prevent people from coming to work naked.
   c) To keep everyone from getting sunburned.
   d) To protect employees from abusive patients.




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Lifting and Proper Body Mechanics Test                                                 Go Home
Decatur Health Systems



1) When back pain occurs,
  a) You are lifting too light a load.
  b) It is a sign you have been using the correct posture and body
  mechanics.
  c) It is evident that you have been exerting the right amount
  d). Faulty body mechanics and poor posture are generally involved.


2) When transferring a patient or an object from one location to another,
  a) Pivot on your feet, keep your back straight and pelvis slightly
  tucked.
  b) Pivot quickly so you will be able to swing heavy items efficiently.
  c) Be sure to bend and twist at the same time.
  d) Keep your feet planted on the floor without pivoting so you do not
  lose your balance.

3) When transferring a patient who has had a stroke, which of the
   following is NOT an appropriate movement:
  a) To transfer them towards their stronger side.
  b) To support the patient’s weaker knee with your knee.
  c) To place a gait belt around the patient’s waist.
  d) To allow the patient to hold onto you around your neck.


4) Choose which of the following should NOT be done when transferring
   residents from a wheelchair to the bed.
  a) Unlock the wheelchair.
  b) Encourage the resident to assist with the transfer as much as
  possible.
  c) Adjust the height of the bed as close as you can to the same height as the seat
  of the wheelchair.
  d) Have the resident slide to the front of the wheelchair seat.


5) When working in an office area, which would be an INCORRECT chair
   height adjustment?
  a) So your feet are flat on the floor.
  b) So your legs are most comfortable when they are crossed.
  c) So that your thighs are parallel to the floor with your knees bent
  at approximately a 90-degree angle.
  d) So there is enough clearance behind your knees to allow adequate
  circulation to the legs.
 6) Which of the following shows IMPROPER placement?
   a) The mouse placed lower than the keyboard so you need to reach for
   it.
   b) The keyboard placed at near elbow height.
   c) The document holder placed at the same height and distance as the
   monitor.
   d) The height of the wrist rest is the same as the space bar on the
   keyboard.

 7) A computer monitor should be
   a) Above eye level, allowing you to tilt your head back so you can see
   out of your bifocals.
   b) Angled so you need to turn your head to view the screen clearly.
   c) Raised or lowered so the top of the screen is at or just below eye
   level.
   d) Aligned in such a way that your neck has to curve when viewing the
   monitor.

 8) When you are emptying a box,
   a) Carry all the items you are removing in outstretched arms so they
   will be as far away from your body as possible.
   b) Make sure it is placed on the floor so you get the advantage of
   bending at the waist.
   c) Arch your back and rest the box on your stomach while taking items
   out so you can be located closest to your work.
   d) Raise it to a higher level so you don’t have to bend and stretch
   repeatedly.

 9) When vacuuming, which of the following does NOT show proper body
    mechanics:
   a) Shift your weight back and forth between your feet.
   b) Keep your back straight and your pelvis tucked.
   c) Try to stand in one location as much as possible and stretch your
   arms to get to those far-away places.
   d) Move the vacuum back and forth in a small area in front of you.


10) When is it important to maintain the three natural curves in your back
    as much as possible?
   a) Only while standing.
   b) Just while lying in bed.
   c) Just when sitting down suddenly.
   d) As much as possible, whether sitting or standing.




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Phone and FAX Usage Test                                                            Go Home
Decatur Health Systems


1) To retrieve a phone call from Hold:
  a) Push the Feature button, then push the red Hold button.
  b) Lift the hand set, then press the blinking green (for a hospital phone) or red (for a clinic
  phone) light.
  c) Push the Answer button.
  d) Push the Recall button, then the Answer button.

2) When using any facility phone, remember to speak
  a) with a pleasant and professional tone of voice.
  b) loud enough so anyone within the room can understand you.
  c) using all ranges and volumes, from loud to soft and from low to
  high.
  d) quickly.

3) To quickly transfer a phone call to a specific hospital voice mail box,
  a) wait 10 seconds to let the system engage, then dial the extension
  number.
  b) dial EXT (398) plus the extension number from the Departmental
  Extension Number Directory Sheet.
  c) dial a 9 and a 1 preceding the specific extension number.
  d) keep the handset lifted, push the Transfer button, dial the
  specific extension number, push the 7 button, then hang up.

4) Phone calls from the media are
  a) to be answered quickly.
  b) priority calls that take precedent over HIPAA privacy regulations.
  c) to be referred to the department manager, the CEO or the nurse in
  charge.
  d) to be referred to our website for information.

5) Choose the correct way to make an outside long distance phone call
   from the Family Practice Clinic.
  a) Dial O for the Operator, then tell her the town, state and what
  number you wish to reach.
  b) Select an outside line, then dial the complete long distance number,
  including 1, the area code and the seven digit phone number.
  c) Ring the Public Relations Office and request help in completing
  your call.
  d) Dial 9, then dial the complete number, including the 1, area code,
  and seven digit phone number.
 6) Choose the correct way of answering a hospital phone when you have been
    paged that you have a phone call.
   a) Press the Answer button, then press the Speaker button.
   b) Go to any phone, press the Transfer button, then dial the extension
   number assigned to that phone.
   c) Press the PkSet button, then the Hold button.
   d) Lift the receiver, press the Intercom button, then press the *
   button, followed by the numbers which were announced, such as 80.

 7) When a caller on the phone asks for specific information about a
    patient or resident,
   a) you may release any information requested as long as the caller
   identifies him/herself with a name and address.
   b) you may be legally prevented from giving the caller the requested
   information due to HIPAA privacy regulations.
   c) you are allowed to FAX the caller specific health information.
   d) you should transfer the call to an outside line.

 8) Choose the statement that is FALSE about the FAX machine:
   a) FAX numbers are dialed with a 9 preceding the complete number when using a hospital
   machine.
   b) Sheets to be faxed should be placed face down into the top send slot.
   c) The facility face sheet containing the Confidentiality Notice
   should be used preceding the information you wish to fax.
   d) The only FAX machine at our facility is located in Procedure Room 2.

 9) Which is the correct way to forward a caller to a different
    department using a hospital phone?
   a) Press the Message button, press the Redial button, then hang up
   immediately.
   b) Ask your charge nurse or department head to complete the call.
   c) Keep the receiver off the hook, press the Transfer button, then
   dial the extension number you are trying to reach, wait until that
   phone rings before replacing the handset.
   d) Hang up immediately, followed by pressing the Feature button.

10) Identify the type of phone directory NOT used at our facility.
   a) Phone Number Directory Sheets with home phone numbers of employees
   b) Patient/Resident Home Phone Number Data Base
   c) Directory Sheets with departmental extension numbers
   d) Emergency Phone Number Database stored on the facility computer.
                                                                            Go Home
Resident/Patient Rights Test                                           Go Home
Decatur Health Systems



1) Which of the following is NOT included in the Resident/Patient Rights:
  a) The right to be treated with respect and dignity.
  b) The right to confidentiality.
  c) The right to a 30-day wait for a response to an inquiry.
  d) The right to be free of restraints unless medically necessary.

2) Residents/Patients are given a copy of their rights:
  a) When a judge issues a subpoena.
  b) Only when they demand it.
  c) When a patient’s lawyer calls on their behalf.
  d) On admission.

3) Who may call the Ombudsman?
  a) Only a resident of the Long-Term Care Facility
  b) Not only residents of long-term care facilities, but also their
  families and friends, staff members and administrators.
  c) Just the full time employees of the facility.
  d) Exclusively the medical doctor concerned with the case.

4) Which departments are involved in seeing that resident/patient rights
   are maintained:
  a) Nursing
  b) Billing and front office
  c) All departments
  d) Administration

5) Decatur Health Systems has:
  a) An ombudsman on site at all times who is learning about
  resident/patient rights
  b) An office manager who is also the ombudsman.
  c) No place to post information about the ombudsman.
  d) Information posted on how to contact an ombudsman about
  resident/patient rights.
 6) Resident/Patient Rights are:
   a) Not mandated by state regulations.
   b) Only an option in providing quality care.
   c) The ideal we strive for.
   d) Unregulated by federal law.

 7) An ombudsman is ALL of the following EXCEPT:
   a) An advocate for residents of long-term care facilities.
   b) A private investigator of corporate financial records.
   c) An objective investigator of complaints.
   d) A person who is concerned with protecting the civil and human
   rights of elderly persons in long-term care facilities.

 8) Choose the situation where an ombudsman would probably NOT be called:
   a) Settling a dispute about employee’s scheduled work times.
   b) Answering questions or concerns about Medicaid coverage.
   c) Seeking information about long-term care facilities.
   d) Abuse, neglect or exploitation is suspected.

 9) Which statement is NOT TRUE about our facility policy on
    Resident/Patient Rights?
   a) Copies of Resident/Patient Rights are posted in the facility.
   b) It is the responsibility of all staff members to maintain
   resident/patient rights, so everyone should be familiar with them.
   c) Not all departments are responsible for seeing that
   resident/patient rights are put into practice.
   d) Any concerns employees have about resident/patient rights should be
   addressed with a supervisor.

10) Which does NOT appear in Resident/Patient Bill of Rights?
   a) The right not to perform work.
   b) The right to use tobacco in accordance with policies, rules and
   laws.
   c) The right to withhold payment for physician visitation if the
   physician did not perform an examination.
   d) The right to have only a limited time to visit with family and
   friends.




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Risk Management/                                                            Go Home
Performance Improvement Test
Decatur Health Systems



 1) Performance Improvement is:
   a) A work philosophy that encourages every member of an organization
   to find new and better ways of doing things.
   b) An order from administrative level to conserve on materials.
   c) A plan to make sure everyone comes to work on time.
   d) An event that occurs randomly.

 2) Who knows best whether customers’ needs and expectations are being
    met?
   a) The person who is giving the services.
   b) The administrator who oversees hospital activities.
   c) The office person who does the paperwork.
   d) The customers themselves.

 3) Choose the method which would NOT be used to determine customer
    satisfaction:
   a) Asking questions.
   b) Telling customers the facility policy and procedure about a certain
   event.
   c) Listening carefully both to complaints and compliments.
   d) Having customers fill out questionnaires.

 4) Who needs to report incidents?
   a) Just the day shift employees.
   b) All employees who witness, discover or have direct knowledge of an
   incident.
   c) Only those employees directly in charge of patient care.
   d) Only the charge nurse.

 5) Choose which statement is NOT TRUE about Performance Improvement:
   a) One-time successes are not enough
   b) People doing the work often have the best ideas.
   c) Improvements need to be a continual process.
   d). Teamwork and communication are not necessary.
 6) In our facility completed incident reports are to be sent:
   a) First to the charge nurse.
   b) Directly to the Performance Improvement chairperson.
   c) To the front office.
   d) To the police department.

 7) A willful failure to report an incident makes someone subject to ALL
    of the following EXCEPT:
   a) Report time with a probation officer.
   b) Restrictions of privileges
   c) Revocation or suspension of license.
   d) A fine for a Class C misdemeanor

 8) Employees who make incident reports:
   a) May lose their job for doing so.
   b) Will endure job discrimination.
   c) Have legal protection if reports are made in good faith.
   d) Cannot have the same job benefits as other employees.

 9) Performance Improvement is about
   a) Getting results.
   b) Changing a process because change is good.
   c) Testing the same data over and over again.
   d) Reaching one single goal.

10) Choose the one which would NOT be included in an incident report:
   a) Name and gender of the person involved.
   b) Location and nature of occurrence.
   c) A speculation of what led up to the incident.
   d) Date and time of occurrence.




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                                                                    Go Home
Infection Control 2 Test
Decatur Health Systems



 Please select True or False on your answer
                   sheet.
  1) You can get HIV if infected blood touches a break in your skin.

  2) A vaccine is available to protect you from the hepatitis C virus.

  3) A person with inactive TB cannot spread the disease to others.


  4) Standard precautions should only be used with patients who are
     known to have a bloodborne pathogen.

  5) Used sharps should be placed in a leak-proof, puncture-proof
     container.

  6) All PPE (Personal Protective Equipment) should be washed and
     disinfected so it can be used again.

  7) You don’t need to wash your hands after removing your gloves.

  8) Transmission-based precautions are used instead of standard
     precautions.
  9) Patients with scabies should have their own patient care equipment
     when possible.

  10) You must wear a respirator when you are around a patient who is
     suspected of having active TB.

  11) Germs in droplets can contaminate the objects they land on.

  12) If you have a sharps exposure, you can reduce your chances of
     infection by seeking medical attention right away.

                                                              Go Home
                                                                      Go Home
Bloodborne Pathogens Test
Decatur Health Systems

1) Which of the following are the two most prevalent bloodborne diseases in the
   United States?
  a) Mononucleosis and Measles
  b) Tuberculosis and Streptococcus
  c) Hepatitis B and HIV
  d) Staph infection and Mumps


2) Approximately how many new cases of Hepatitis B occur in the United States
   each year?
  a) 10,000
  b) 70.000
  c) 300,000
  d) 3 Million



3) Select True or False on your answer sheet:
   Vaccines do exist that can prevent infection from Hepatitis C and HIV.


4) What is the most important personal hygiene practice for preventing infection
   from bloodborne diseases?
  a) Cleaning your fingernails daily.
  b) Brushing your teeth in the evening before going to bed.
  c) Handwashing.
  d) Gargling with disinfectant.



5) What color must be used as the background on biohazard warning labels?
  a) Yellow
  b) Red/ Orange
  c) Green
  d) Black



6) Select True or False on your answer sheet:
  All types of gloves can be reused after an exposure incident if they are decontaminated.
7) Choose the proper use of gloves.
   a) Enter a patient room. Immediately wash hands, don clean gloves, wash a patient’s face. Remove
   and discard gloves. Wash hands. Leave room.
   b) Enter a patient room. Don clean gloves. Give injection to patient. Leave room. Go to med cart
   and prepare next patient’s medicine. Enter next patient’s room. Don clean gloves.
   c) Enter patient room. Don clean gloves. Give patient a bed bath. Mix breakfast cereal on tray. Feed
   patient. Remove and discard gloves.
   d) Enter patient room. Don clean gloves. Clean toilet bowl. Clean bedside table. Find tube of lip
   gloss in pocket and apply. Remove and discard gloves.




 8) Under Standard Precautions, when should one’s hands be washed?
   a) The only time it is essential to wash one’s hands is after using the toilet.
   b) Hands do not need to be washed before putting on a clean pair of gloves.
   c) Hands should be washed before and after patient care, REGARDLESS of whether gloves are worn
   Wash hands immediately after gloves are removed and between patient contacts.
   d) It is necessary to wash one’s hands once during a work shift.

 9) Select True or False on your answer sheet:
   Soiled linens and laundry may be carried down the hallway in a manner so it touches your uniform.


10) Select True or False on your answer sheet:
   It is the employee’s responsibility to use disinfecting wipes according to manufacturer’s guidelines on
   equipment between patient use.



                                                                                     Go Home
             Handwashing Competency
Performance Checklist Sheet MUST Be Completed, Signed by Preceptor,
                 and Attached to Your Answer Sheet.




                 Cleaning Product Use
         Review Sheet MUST Be Completed and Attached
                    To Your Answer Sheet
2012 Employee Assessment Tests                                    Name____________________
Answer Sheet                                                      Date_____________________

Please circle only ONE answer choice for each question.           Last 4 #’s of SS #__________

Abuse, Neglect and
Exploitation                        Advance Directives                           Benefits

 1.   a   b   c   d                          1.   a   b   c   d                   1.   a   b    c   d
 2.   a   b   c   d                          2.   a   b   c   d                   2.   a   b    c   d
 3.   a   b   c   d                          3.   a   b   c   d                   3.   a   b    c   d
 4.   a   b   c   d                          4.   a   b   c   d                   4.   a   b    c   d
 5.   a   b   c   d                          5.   a   b   c   d                   5.   a   b    c   d
 6.   a   b   c   d                          6.   a   b   c   d                   6.   a   b    c   d
 7.   a   b   c   d                          7.   a   b   c   d                   7.   a   b    c   d
 8.   a   b   c   d                          8.   a   b   c   d                   8.   a   b    c   d
 9.   a   b   c   d                          9.   a   b   c   d                   9.   a   b    c   d
10.   a   b   c   d                         10.   a   b   c   d                  10.   a   b    c   d



                                    Disaster Preparedness/
Customer Satisfaction               Fire Safety                                  Haz-Mat

 1.   a   b   c   d                          1.   a   b   c   d                   1.   a   b    c   d
 2.   a   b   c   d                          2.   a   b   c   d                   2.   a   b    c   d
 3.   a   b   c   d                          3.   a   b   c   d                   3.   a   b    c   d
 4.   a   b   c   d                          4.   a   b   c   d                   4.   a   b    c   d
 5.   a   b   c   d                          5.   a   b   c   d                   5.   a   b    c   d
 6.   a   b   c   d                          6.   a   b   c   d                   6.   a   b    c   d
 7.   a   b   c   d                          7.   a   b   c   d                   7.   a   b    c   d
 8.   a   b   c   d                          8.   a   b   c   d                   8.   a   b    c   d
 9.   a   b   c   d                          9.   a   b   c   d                   9.   a   b    c   d
10.   a   b   c   d                         10.   a   b   c   d                  10.   a   b    c   d


Hospital Incident Command
(HICS)                                      HIPAA                         Infection Control

 1.   a   b   c   d                          1.   a   b   c   d                   1.   a   b    c   d
 2.   a   b   c   d                          2.   a   b   c   d                   2.   a   b    c   d
 3.   a   b   c   d                          3.   a   b   c   d                   3.   a   b    c   d
 4.   a   b   c   d                          4.   a   b   c   d                   4.   a   b    c   d
 5.   a   b   c   d                          5.   a   b   c   d                   5.   a   b    c   d
 6.   a   b   c   d                          6.   a   b   c   d                   6.   a   b    c   d
 7.   a   b   c   d                          7.   a   b   c   d                   7.   a   b    c   d
 8.   a   b   c   d                          8.   a   b   c   d                   8.   a   b    c   d
 9.   a   b   c   d                          9.   a   b   c   d                   9.   a   b    c   d
10.   a   b   c   d                         10.   a   b   c   d                  10.   a   b    c   d
                                                                                           nd
                                                                              Continue on 2 Page
                      Be Sure to Complete All 15 Tests, *Attach Handwashing Compentency Checklist
                                              *Attach Completed Cleaning Product Use Review Sheet
Lifting and Proper
Body Mechanics                              Phone and FAX Usage           Resident / Patient
Rights

 1.   a   b   c   d                          1.   a   b   c   d                    1.   a   b   c   d
 2.   a   b   c   d                          2.   a   b   c   d                    2.   a   b   c   d
 3.   a   b   c   d                          3.   a   b   c   d                    3.   a   b   c   d
 4.   a   b   c   d                          4.   a   b   c   d                    4.   a   b   c   d
 5.   a   b   c   d                          5.   a   b   c   d                    5.   a   b   c   d
 6.   a   b   c   d                          6.   a   b   c   d                    6.   a   b   c   d
 7.   a   b   c   d                          7.   a   b   c   d                    7.   a   b   c   d
 8.   a   b   c   d                          8.   a   b   c   d                    8.   a   b   c   d
 9.   a   b   c   d                          9.   a   b   c   d                    9.   a   b   c   d
10.   a   b   c   d                         10.   a   b   c   d                   10.   a   b   c   d



Risk Management/                           Infection Control 2
Performance Improvement                    1. T F                         Bloodborne Pathogens
                                           2. T F
 1.   a   b   c   d                        3. T F                         1.   a b c    d
 2.   a   b   c   d                        4. T F                         2.   a b c    d
 3.   a   b   c   d                        5. T F                         3.     T F
 4.   a   b   c   d                        6. T F                         4.    a b c   d
 5.   a   b   c   d                        7. T F                         5.    a b c   d
 6.   a   b   c   d                        8. T F                         6.     T F
 7.   a   b   c   d                        9. T F                         7.    a b c   d
 8.   a   b   c   d                        10. T F                        8.    a b c   d
 9.   a   b   c   d                        11. T F                        9.     T F
10.   a   b   c   d                        12. T F                       10.     T F
                                           13. T F


                                            Handwashing                        Cleaning Product
                                            Competency                                 Use

                                           Performance                           Review Sheet
                                           Checklist Sheet                         MUST Be
                                               MUST Be                             Completed
                                              Completed,
                                              Signed by                         and Attached to
                                            Preceptor, and                        Your Answer
                                           Attached to Your                           Sheet.
                                            Answer Sheet.
                                                                           Completed: Y                 N
                                      Completed: Y                N


                      Be Sure to Complete All 15 Tests, *Attach Handwashing Compentency Checklist
                                              *Attach Completed Cleaning Product Use Review Sheet
                        DECATUR HEALTH SYSTEMS
                    CLINICAL PERFORMANCE CHECKLIST

                                  HANDWASHING


NAME: __________________________________________           DATE: ___________

            CRITICAL BEHAVIORS                  COMPLIES      COMMENTS
                                                  Y/N
Make sure that soap, paper towels, and a
wastebasket are available
Push your watch up 4 to 5 inches
Stand away from the sink so that your clothes
do not touch the sink
Adjust the water so that if feels warm and
comfortable
Wet your wrists and hands thoroughly under
running water. Keep your hands lower than
your elbows during the procedure
Apply soap to your hands
Rub your palms together to work up a good
lather
Wash each hand and wrist thoroughly, and
clean well between the fingers. Clean well
under the fingernails by rubbing the tips of
your fingers against your palms
Continue washing for 15 to 30 seconds, using
friction and rotating motions
Rinse your wrists and hands well. Water
should flow from the arms to the hands.
Dry your wrists and hands with paper towels.
Pat dry
Turn off the faucet with the paper towels to
avoid contaminating your hands. Use a clean
paper towel for each faucet.
Toss paper towels into the wastebasket



Preceptor                                                             Date
NAME:                                   DATE:



                             Cleaning Product Use Review

                    Use of CaviWipes disinfecting towelettes (White top):

  1. The guidelines for personal protection when using these wipes are:




  2. To be effective as a disinfectant for hard, non-porous surfaces, label instructions are:




  3. To keep the towelettes moist in the container … keep the lid closed and occasionally rock
     the container to remoisten. True / False




  4. Instructions for disposal are:

				
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