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Applies To: [All HSC Hospitals, CRTC, or UNMH] Component(s): Responsible Department: Title: UNMH Identification Badge System ( ) N/A ( ) All Ages ( ) Newborns Procedure ( ) Pediatric ( ) Adult Patient Age Group: DESCRIPTION/OVERVIEW It is the policy of the University of New Mexico Hospitals (UNMH) and the University of New Mexico Health Sciences Center (UNM/HSC) to control access to its facilities, grounds, and information systems to help assure a secure environment for all patients, visitors, staff, physicians, students, and assets The overall objective of this procedure is to explain the regulations and categories for the color-coded identification badges utilized throughout UNM Hospitals and UNM Health Sciences Center Facilities. To explain the procedures on how access levels are assigned to various staff members To explain the procedures required for staff members to receive a new or replacement identification badge REFERENCES UNMH Security Management Plan UNMH Facility Security Plan UNM Biosecurity Plan UNM/HSC Facility Plan UNMH Access Policy UNMH Infant Security Policy UNMH Pediatric Security Policy UNMH Key and Lock Policy UNMH Information Systems/Sensitive Information Security Policy UNMH Unauthorized Persons on Premises Policy UNMH Admission of a Patient (Patient ID) UNMH Emergency Department Identification Banding UNM Health Sciences Center, Identification Badge Policy UNMH Personnel Policy 325 - SEPARATION OF EMPLOYMENT Joint Commission Standards Federal Bureau of Investigation, Bioterrorism Preparedness Act The Public Health Security and Bioterrorism Preparedness and Response Act of 2002 Code of Federal Regulations (42 CFR 73, 7 CFR 311.3 and 9 CFR 121.3) Select Agent Program UNM Policy 1050 Photo Identification Cards Policy UNM Policy 5010 Key Authorization Policy UNMH Healthcare Industry Representative Protocol _________________________________________________________________________________________________________________ Title: Owner: Effective Date: Page 1 of 11 UNMH Facility Guidelines & Expectations For Contractors UNMH Identification Badge Procedure UNMH Access Authorization Procedure UNMH Patient and Clinic Visitor Access Procedure UNMH Vendor Access Procedure UNMH Staff Access Procedure UNM/HSC Select Agent Laboratory Access Procedure AREAS OF RESPONSIBILITY The UNMH Security Department has the responsibility for the daily control and coordination of this procedure, including all required electronic or written forms. The UNMH Human Resources Department is responsible for administrative procedures for UNMH new hires UNMH and UNM/HSC Administrators, Department Directors, and Managers have the responsibility for ensuring access authorizations are completed for any individual that requires access, other than normal staff access The UNMH Security Systems Staff have the responsibility of coordinating, managing, assigning access levels, and performing audits of the security access and badge systems The UNMH Director of Security has the responsibility over all aspects of daily control and coordination of this procedure and the authority to approve exceptions to this procedure as necessary in consultation with UNMH or UNM/HSC Administrators, Executive Directors, and Department Directors PROCEDURE 1. General Information: 1.1. 1.2. 1.3. 1.4. 1.5. 1.6. 1.7. Identification badges will be worn in full view with photo side facing out The identification badge is an Access Control Credential The issuance, use, and possession are guided by the security department, “Employee Access Control Agreement" and “ K e y and Lock Policy” Defacing an identification badge is prohibited. (i.e.: stickers, pins, etc.) The employee may be responsible for the replacement of the identification badge if it is defaced or made useless by the defacing. There is a Thirty-dollar ($30.00) fee for replacement of lost, missing or defaced badges. Unauthorized possession, use, or reproduction of an UNMH identification badge (access credential) may constitute theft or misappropriation of hospital property. In such a case, the individual(s) involved can be prosecuted to the fullest extent allowed by hospital policy and/or the law. (State Law: New Mexico Statues annotate 1953 Chapter 40A-14-3) 1.8. _________________________________________________________________________________________________________________ Title: Owner: Effective Date: Page 2 of 11 2. Color-Coded Identification System: Provides immediate identification of personnel authorized to enter certain areas for the purpose of performing patient care and/or other authorized duties. 2.2. Patient care providers are issued an identification badge with a red stripe under the picture and a red box to the left of the picture. 2.2.1. Patient care in this context means, staff that perform any invasive medical procedure on a patient. 2.3. Non-patient care staff are issued an identification badge with a blue stripe under the picture and a blue box to the left of the picture 2.4. Infant and Toddler Authorized Transport Staff are issued an identification badge with a Pink Background on the top half of the badge. 2.4.1. Pink badges are for personnel whose main duties include the transport of infants or toddlers throughout the hospital. 2.4.2. Pink badges will also be issued to medical staff assigned in Units that provide care to newborns or toddlers. 2.5. UNM/HSC staff will be issued identification badges based on the same criteria as UNMH Staff 2.6. UNM/HSC Authorized Users of Select Agent Labs will be issued identification badges with letter coding and a printed expiration date 2.7. Contractors performing authorized work at UNMH Facilities are issued an identification badge with a blue background on the top half of the badge and the word “Contractor” in blue. 2.8. Vendors performing authorized work at UNMH Facilities are issued an identification badges with a white background and the word vendor in red. 2.9. Contract Labor Staff performing authorized work at UNMH Facilities are issued an identification badge with a yellow background on the top half of the badge and the words “Contract Labor” in red. 2.10. Contract Labor Staff performing authorized work requiring transport of infants or toddlers will have a Pink Background on the top half of badge and the word “Contract Labor” in red. 2.11. Emergency Department patient visitors are issued white Visitor Badges, with name, issue date, and expiration date. 2.12. After hour visitors are issued visitor badges, which are white and contain the Unit and bed number they are visiting. 3. Badge Status Letters: 3.1. 3.2. A system of lettering was designed to further assist staff members in identifying various types of personnel The Status Letter appears in a white box to the left of the picture 18.104.22.168. "R" for Resident Physician. 22.214.171.124. "T" for contract Temp Workers. 126.96.36.199. "V" for Volunteers. 188.8.131.52. "TC" for TriCore Lab employees. 184.108.40.206. "SoM" for School of Medicine Students. 220.127.116.11. “UPA” for University Physician Associates Employees 2.1. _________________________________________________________________________________________________________________ Title: Owner: Effective Date: Page 3 of 11 “NR” for Nurse Residency Program Attendee Employees “COP” for College of Pharmacy Students “CON” for College of Nursing Students “IST” for Information Systems Transport. “B” for Authorized Users of Select Agent Labs 18.104.22.168.1. Will also have printed expiration date 22.214.171.124. Other letters may be designated as the need arises. 126.96.36.199. 188.8.131.52. 184.108.40.206. 220.127.116.11. 18.104.22.168. 4. Badge Information 4.1. In addition to the Color Code and Status Letter, the front and back of the badge will contain the following information 4.1.1. Manager Position and Above will have First and Last Name of the Manager printed on the badge, same on the back of the badge 4.1.2. Other Staff Positions will have only the First Name of the staff member printed on the front of the badge, however on the back of the badge First and Last Name will be printed 4.1.3. The staff members picture will be printed on the front and back of the badge 4.1.4. The title of the staff member will be printed on the front of the badge 4.1.5. The department of the staff member will be printed on the front of the badge 4.1.6. The hospital component or HSC component will be printed on the front of the badge, i.e. University Hospital, Carrie Tingley Hospital, etc. 5. Access Levels 5.1. 5.2. 5.3. The UNM Hospitals Identification Badge is also a access credential which allows access to various areas throughout UNMH or UNM/HSC Facilities Individual access is determined by the persons‟ job description, department assignment, and actual need. Access to additional areas 5.3.1. Must be approved by the director or manager of that area 5.3.2. Must be based on a work related function or need 5.3.3. Require a signed Access Authorization Form 5.3.4. Must be approved by the Director of Security Access levels have been determined by Administration, Director of Security and Department Managers The Security Technology Coordinator via the appropriate Department Director, Manager or Administrator will resolve issues or questions surrounding authorized access. 5.4. 5.5. 6. UNMH Human Resources Department: 6.1. The HR Department is responsible for administrative procedures for new hires: 6.1.1. Human Resources will forward to UNMH Security all information necessary to issue an ID Badge _________________________________________________________________________________________________________________ Title: Owner: Effective Date: Page 4 of 11 6.1.2. 6.1.3. 6.1.4. Delivering the information necessary to produce the ID Badge in a timely manner If the new employee will be starting work prior to orientation, he/she should bring a memo to the Security Office to that effect, signed by their department manager. UNMH Security will confirm the information with Human Resources Department prior to producing the badge. 7. UNMH Security Department 7.1. The UNMH Security Department is responsible for: 7.1.1. The administration of the Identification Badge Program 7.1.2. The production and distribution of the Identification Badges 7.1.3. The disposal of returned badges 8. UNM Hospitals Staff All UNM Hospitals staff are issued a picture identification badge during the new hire orientation process 8.1.1. New staff members will report to the security department to have the ID Badge produced 8.1.2. Badges will have the proper color code, status letter, and access level based on the job title and assigned department 9. UNM Health Sciences Center & UNM Staff Access to UNM Hospitals 9.1. All UNM & UNM Health Sciences Center Staff requiring access to UNM Hospitals must have a UNMH Identification Badge 9.1.1. UNM/UNM Health Sciences Staff will report to the UNMH Security department to have the ID Badge produced. 9.1.2. A signed “UNMH Access Authorization” form must accompany all request for ID Badges 22.214.171.124. Approved by the Director/Manager of the hospital department. 126.96.36.199. Any request for access after hours or for 24 hour secured areas must be included on the form. 188.8.131.52. The Security Director and the appropriate Department Director will resolve issues/questions surrounding authorized access. 184.108.40.206. If applicable, Security will assign access to authorized areas. 220.127.116.11. Only authorized security personnel can activate the code assigned 8.1. 10. UNM Health Sciences Center Facilities & Staff 10.1. All UNM/HSC staff are issued a picture identification badge during the new hire orientation process _________________________________________________________________________________________________________________ Title: Owner: Effective Date: Page 5 of 11 10.1.1. New staff members will report to the security department to have the ID Badge produced 10.1.2. Badges will have the proper color code, status letter, and access level based on the job title and assigned department 10.2. All UNM/HSC facilities that require card access will follow the same badge identification procedures as UNMH 10.3. UNMH Security Department will coordinate with the individual UNM/HSC Department to ensure proper identification badges are produced and issued to UNM/HSC Faculty, Staff, Students, and other authorized personnel 11. Authorized Users of Select Agent (SA) Laboratories 11.1. Unescorted access authorization to SA laboratories involves nomination by the appropriate approved faculty user of each SA facility, 11.2. Laboratory Director‟s nomination to the Responsible Official or Alternate Responsible Official must be in writing 11.2.1. Nominations must be based on need to routinely access the facility. 11.2.2. To include specifically authorized functions and the hours required to perform the defined job 11.3. Responsible Officials approval, 11.4. Completion and submission of FBI Form FD-961 for back ground check 11.5. Submittal of fingerprints to the Department of Justice (DOJ) 11.6. Receipt of approval from the DOJ for clearance. 11.7. Completion of appropriate medical surveillance per facility used 11.8. Authorized Users must complete all required security, safety and emergency response training prior to being allowed unescorted access to the SA laboratories. 11.9. Laboratory Directors are responsible for insuring that all personnel demonstrate proficiency in standard microbiological practices and techniques associated with the specific SA laboratory facility before authorized users work unescorted in the laboratory. 12. All Other Authorized Personnel 12.1. All other personnel performing an authorized task within UNM Hospitals must have a UNMH Identification Badge this includes but is not limited to: 12.1.1. Volunteers 12.1.2. Contract Labor (Agency Nurses, Temps,) 12.1.3. Students and Work Study Personnel 12.1.4. Emergency Department patient visitors (24 hours) 12.1.5. After Hours patient visitors (for times refer to hospital access policy) 13. Vendors 13.1. The title Vendor in this guideline is used to describe the following: _________________________________________________________________________________________________________________ Title: Owner: Effective Date: Page 6 of 11 13.1.1. Healthcare Industry Representative is any corporate representative visiting UNM Hospitals for the purpose of performing a legitimate healthcare related commercial or business activity. 13.1.2. Pharmaceutical Representatives 13.1.3. Any commercial contractor performing authorized work at UNMH Facilities. 13.1.4. Maintenance Personnel is any person performing authorized work for IT Systems at UNM/HSC and may be able to gain access to protected sensitive information 13.1.5. Any other type of visitor performing authorized work within UNMH Facilities 13.2. All vendors performing authorized work at UNMH Facilities are to follow the UNMH Vendor Access Guidelines. 13.3. All vendors will be issued an identification badge that will be valid for the day of the visit 13.4. A $50.00 fee will be charged to the Vendors Company for lost identification badges. 14. Contract Labor 14.1. Contract Labor includes Agency Nurses, Temp Staff, and other temporary nonhospitals staff performing authorized work within UNMH Facilities 14.2. Contract labor personnel are issued a picture identification badge with a yellow background on the top half of the badge with the word “Contract Labor” in red. 14.3. Contract Labor badges are safeguarded in the appropriate staffing office 14.4. Contract labor personnel will obtain their badge from the appropriate staffing office at the beginning of the assigned work day 14.5. Contract Labor badges must be returned at the end of the assigned workday. 15. Nursing and Health Occupational Students 15.1. The instructor from the student‟s institution must have the student cleared through Nursing Education to insure proper certification and health testing. Nursing Education can be reached at 272-4021. 15.2. Nursing Education will provide the proper form that the student or instructor will be required to bring to the Security office to obtain the „Education Guest' picture Identification badge. 15.3. The badge will only be activated for the period of time specified by Nursing Education. 15.4. The ID badge is the property of UNMH and must be returned when the student completes their rotation. 15.5. The badge must be returned to the Security Department. 15.6. As stated in the 'Affiliation Agreement' in Section II H: The school will pay UNMHSC $100.00 for each badge not returned within ten days of the end of the Student's rotation at UNMHSC. _________________________________________________________________________________________________________________ Title: Owner: Effective Date: Page 7 of 11 16. Volunteers 16.1. Volunteers are issued picture Identification Badges with a white background and a green box with the letter “V” and a green stripe under the picture 16.2. Each volunteer must bring the proper authorization form signed by the director of volunteer services to the security department 16.3. Each volunteer must show proper identification prior to the badge being issued 16.4. The director or manager of the volunteer services department is responsible for ensuring that all volunteers are cleared to work in the hospitals through occupational health. 17. After Hours Visitors 17.1. After hour visitors are issued visitor badges which are white and contain the Unit and bed number they are visiting 17.2. Security personnel assigned in the Emergency Department lobby issue visitor badges beginning at 10 PM through 5 AM 17.3. All visitors must sign in at the security desk in the lobby area 17.4. Visitors may be asked to provide proper identification prior to being issued a visitor badge 17.5. After hour visiting may be suspended by the Administrative Supervisor is conditions require 18. Emergency Department Visitors: 18.1. All persons visiting or escorting patients within the Emergency Department treatment area are required to have a visitor badge issued. 18.2. Security personnel assigned within the treatment area will issue the visitor badges on a 24-hour basis. 18.3. All persons entering the ED Treatment Area may be requested to undergo security-screening process, which can include a search of all packages and metal detection devices. 18.4. Any person who wishes to not participate will not be granted access and will be requested to leave the treatment area. 19. Lost Badges: 19.1. Lost badges must be reported to the UH Security Department immediately. 19.2. There is a $30.00 fee for the replacement of a lost ID badge. 19.2.1. Day shift employees should allow a minimum of 2 hours for Security badging personnel to process a replacement for a lost badge. 19.2.2. Human Resources must be contacted to obtain a new Kronos number. 19.2.3. The employees‟ previous picture will be used to process the replacement badge unless they request a new photo. 19.2.4. Evening/Night shift employees should call Security @ 2-2160 and advise that their ID badge was lost. _________________________________________________________________________________________________________________ Title: Owner: Effective Date: Page 8 of 11 19.2.5. The access will be shut off and employee information will be forwarded to the Day shift badging personnel the following workday. 19.2.6. The replacement badge will be available for pick up when the employee comes on shift again 19.3. Fee assessed for lost ID badge cannot be reimbursed even if the old badge is later found. 19.4. If the badge reported lost is later located, that badge must be turned in to the Security office to be destroyed. 20. Replacement Badges: 20.1. Job Title/Department/Name changes: 20.1.1. The Department Supervisor should submit a personnel action to Human Resources in order for any changes to be processed. 20.1.2. Allow 2 weeks from the time your Manager submits an Action before requesting a new badge from Security. Security cannot process any changes to an employee badge unless the Human Resources Department has processed that change. 20.2. Replacement badge will not be released until the previous badge is turned in to Security. 20.2.1. Evening/Night shift employees need to be aware that change information cannot be verified with Human Resources after 5pm on weekdays. 20.2.2. Employees can call the Human Resources Office during the day to check on the completion of the change. 20.2.3. If the changes have been processed, the new badge will be printed and can be picked up in the Security office. 20.2.4. It is the employees‟ responsibility to contact their manager to check with Human Resources Department on the Action. 21. Terminations: 21.1. Supervisor will send an email to Security during the employee‟s notice period advising of the separation and requesting deactivation of identification badge, and other access control devices effective the final date of employment. 21.2. Badges or any other items which control access to the Hospitals will be collected by the supervisor on the final date of employment and delivered to Security within twenty-four (24) hours where receipt will be confirmed on the exit checklist. 22. Security of Hospital: 22.1. The ID badge is to identify the employee, where they work and in what capacity 22.2. In no instance should an ID badge be loaned to someone else or be out of your possession while on hospital property. 22.3. The ID badge must be worn at all times when on hospital property. _________________________________________________________________________________________________________________ Title: Owner: Effective Date: Page 9 of 11 DEFINITIONS 1. UNMH, means University of New Mexico Hospitals, which includes University Hospital, University Psychiatric Center, University Childrens Psychiatric Center, Carrie Tingley Hospital, and all UNMH Clinical Operations Facilities throughout New Mexico 2. UNMH Employee, means any person that is in the employ of UNMH at any of above named facilities 3. Patient means any person present at any UNMH Facility for the purpose of receiving any medical related services 4. Visitor means any person present at any UNMH Facility for the purpose of visiting, accompanying, or assisting a patient while present at any UNMH Facility 5. Vendor a. Healthcare Industry Representative is any corporate representative visiting UNM Hospitals for the purpose of performing a legitimate commercial or business activity. b. Any commercial contractor performing authorized work at any UNMH Facility. c. Maintenance Personnel is any person performing authorized work for IT Systems at any UNMH Facility or any UNM/HSC Facility and may be able to gain access to protected sensitive information d. Any other type of visitor performing authorized work within UNMH Facilities 6. UNM/HSC means University of New Mexico Health Sciences Center, which is comprised of the School of Medicine (SOM), College of Nursing (CON), College of Pharmacy, Cancer Research and Treatment Center (CRTC), Cancer Research Facility (CRF), Biological Research Facility (BRF), Health Sciences Services Building (HSSB), and any other medical or education facility located on the North Campus of the University of New Mexico 7. HSC Staff means any Physician, House Staff (Resident), Faculty Member or any other person in the employ of the UNM/HSC 8. HSC Student means any person attending any UNM/HSC Facility for educational purposes. This also includes any UNMH Employees or UNM/HSC Staff members attending any UNM or UNM/HSC Facility for educational purpose. SUMMARY OF CHANGES August 1, 2006 - It was necessary to add additional information pertaining to the Health Sciences Center as the responsibilities for badge production for the UNM/HSC has been transferred to the UNMH Security Department. It was also necessary to add information necessary for compliance with regulations and laws relating to the Select Agent Laboratories Review and Revision Dates: 12/98, 9/02, 1/03, 10/03, 10/04, 3/05 Revision 10/31/03 – Changed Section 6 and 20 to reflect HR Policy Deleted 6.1 “Security Department is responsible for Maintaining the Integrity and Security of the ID Badge System” Deleted from Section 20 “20.1 Upon termination, the employees‟ badge must be surrendered to Security.” _________________________________________________________________________________________________________________ Title: Owner: Effective Date: Page 10 of 11 “20.2 The employee must come to the Security office with their Termination Checklist and turn in any items Security has issued to them (badge, keys, parking permit).” “20.3 Security personnel will sign off on all items received.” “20.4 Any items not turned in may be subject to penalties in the form of fees being withheld from their final paycheck.” “20.5 The fees will be in accordance with current Hospital Policies.” 3/17/05 - Revised lost badge fee to $30.00 KEY WORDS (For the Search Index. Separate words with a comma.) RESOURCES/TRAINING The UNMH Security Department should be contacted for general information on this procedure. The Director of Security or Manager for Technical Security Operations should be contacted for interpretations, resolution of problems and special situations at security office main number 272-1757, current e-mails, firstname.lastname@example.org and email@example.com Resource/Dept Internet/Link UNMH Security Department DOCUMENT APPROVAL & TRACKING Item Owner Consultant(s) Committee(s) Nursing Officer Medical Director/Officer Human Resources Finance Legal Official Approver Official Signature 2 Approver (Optional) Signature Effective Date Origination Date Issue Date [Day/Mo/Year] [Day/Mo/Year] August/ 1996 Clinical Operations Policy Coordinator nd Contact Date Approval Vito Capobianco, Director, UNMH Security Department August 1, 2006 Alternate Responsible Official, Biosecurity, UNM/HSC Select Agent Program [Name, Title] [Committee Name(s)] [Name], Chief Nursing Officer [Name, Department (or Chief Medical Officer)] [Name], HR Administrator, [UNMH or UNM] [Name, Title], [UNMH or HSC] [Name, Title], [UNMH or HSC] [Name, Title, Area] [Day/Mo/Year] [Y or N/A] [Y or N/A] [Y or N/A] [Y or N/A] [Y or N/A] [Y or N/A] Y ATTACHMENTS UNMH Employee Access Agreement Form UNMH Security Signature Authorization Form UNMH Access Authorization Form UNMH Access Authorization for Contractors & Vendors Form UNMH Badge Replacement Request Form _________________________________________________________________________________________________________________ Title: Owner: Effective Date: Page 11 of 11
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