non-county workforce comprehensive policy …the code of conduct states the basic standards and...

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NON-COUNTY WORKFORCE COMPREHENSIVE POLICY STATEMENT (CPS)

For purposes of this Comprehensive Policy Statement, a “Workforce Member” shall mean all persons authorized to provide a service or perform duties within any DHS facility/program. “Non-County Workforce Member” shall include, but not be limited to, any person performing services under agreement, contract or on a volunteer basis. The term shall also include rotating postgraduate physicians from formally-affiliating teaching programs, students and visiting personnel.

POSSESSION OF REQUIRED LICENSURE, CERTIFICATION, REGISTRATION AND/OR PERMIT (DHS POLICY 704)

A Non-County workforce member whose position requires a current valid license, certification, registration and/or permit (LCRP) to perform the duties of his/her position shall produce original evidence of the required LCRP to DHS Human Resources upon assignment. The non-County workforce member is responsible to ensure his/her LCRP is kept current and in good standing with the appropriate licensing board or agency. Primary source verification will be conducted at the time of assignment, licensing renewal, contract renewal (independent contractor), transfer to new work location, and during the performance assessment process. Non-County workforce members must provide evidence of renewed LCRP status to their department/service area manager prior to the expiration date. Failure to maintain appropriate LCRP will result in immediate release from assignment.

HEALTH SCREENING –NON-COUNTY WORKFORCE MEMBERS (DHS POLICY 705.001)

Non-County workforce members are required to furnish appropriate documentation of recent medical exam to the appropriate DHS Employee Health Services department prior to working in any DHS healthcare facility. Non-County workforce members must also submit documentation of annual health screening as required by the DHS Employee Health Services department and state, federal, regulatory or accreditation requirements, or as required by their assignment).

CODE OF CONDUCT (DHS POLICY 1000)

The Department of Health Services is committed to conducting its business with honesty, integrity and in full compliance with all applicable laws, rules and regulations. The Code of Conduct is intended to assist the Department in meeting this commitment. The Code of Conduct states the basic standards and principles that workforce members must follow to ensure ethical and legal conduct. Following are some (but not all) of the important points covered in the Code of Conduct:

• Workforce members are expected to be familiar with, and in compliance with, all laws, regulations, contractual obligations and professional standards governing their functions.

• Workforce members and agents of the County are prohibited from knowingly presenting, or causing to be presented, false, fictitious or fraudulent claims for reimbursement.

• All business data, records and reports must be accurate.

• Workforce members must protect the privacy of every patient’s health information.

• The Department provides its workforce a safe and appropriate environment in which to work.

• Workforce members must conduct their affairs in a manner that avoids conflicts of interest or the appearance of conflicts and must report any conflicts of interest to their supervisor.

• The Department does not pay or offer to pay for referrals nor do we accept or ask for payment for referrals that we make. Payment includes any form of compensation, not just money. Federal and State anti-kickback laws strictly prohibit payments that are designed to induce the referral of patients or other healthcare business.

• Workforce members may not accept personal gifts from individuals or organizations that have a business relationship or are seeking to do business with the Department.

All workforce members must follow the standards and principles expressed in the Code of Conduct. All workforce members should have signed an acknowledgment stating that they will abide by the Code of Conduct and understand that non-compliance with the Code of Conduct can result in disciplinary action up to and including discharge from service or termination of assignment. You must report any activity that appears to violate applicable laws, rules, regulations or the Code of Conduct. Anyone who reports a suspected violation in good faith is protected from retaliation by County Code and federal and State laws. You can discuss your concerns with your supervisor/manager, your

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Local Compliance Officer, the Compliance Hotline at (800) 711-5366 or the Chief Compliance Officer (213) 240-7901.

SAFEGUARDING PROTECTED HEALTH INFORMATION (PHI) (DHS POLICY 361.23)

Non-County workforce members shall adhere to the following guidelines when handling a patient’s protected health information: Protected Health Information (PHI) means individually identifiable information relating to past, present or future physical or mental health or condition of an individual, provision of health care to an individual, or the past, present, or future payment for health care provided to an individual. Personally Identifiable Information (PII) is information that can be used to distinguish or trace an individual’s identity, either alone or when combine with other personal or identifying information that is linked or linkable to a specific individual. Non-County workforce members must take appropriate steps to ensure the confidentiality of all PHI/PII.

• Oral Communications – Avoid patient related/identifying conversations in public unless necessary to further patient care, research or teaching purposes. Use lowered voices. Never discuss patient care in an elevator.

• Telephone Communications – Whenever it is necessary for DHS workforce members to discuss PHI via telephone with a patient or patient’s family members or friends, other DHS workforce members, business associates, or other health care providers, workforce members must follow facility guidelines for protecting such information. Release of information over the phone may only be done if the person doing so is absolutely sure of the identity of the person he or she is speaking with and that person has a right to receive the information.

• Internet Communications. If a patient requests receipt of their PHI through the Internet, the workforce members must ensure the information is encrypted. If the information cannot be encrypted, the information must be sent through an alternate secure means of communication.

• Telephone Messages – Telephone messages and appointment reminders may be left on answering machines. Use only the minimum amount of information necessary to convey the message.

• Faxing – o Only fax PHI necessary to meet requestor’s needs. o Particularly sensitive information (e.g., relating to mental health, drug and alcohol abuse,

communicable disease) should not be transmitted by fax except in an emergency. Notify the recipient prior to faxing sensitive information so they may intercept the fax upon arrival.

o Only authorized non-County workforce members may fax PHI. o A non-County workforce member must obtain written permission from the patient before

faxing PHI for any reason other than treatment, payment or health care operations. o A special fax form must be used when faxing PHI. o Misdirected faxes containing PHI must be reported to the supervisor and the facility privacy

coordinator. Attempt to call the recipient to retrieve the misdirected fax, if possible. Internet/Social Networking. Internet/social networking sites must not be used to discuss patients or patient information. Workforce members must remember that although internet/social networking sites (e.g., Twitter, Facebook, YouTube, discussion forums, text messaging, web mail, etc.) can be accessed on their own time from their own computing devices, they should remember that due to the nature of the work and the type of business they work in, just small bits of information, put together, can reveal identifying information about patients and cause them to violate privacy laws.

• Workforce members must not disclose any confidential or proprietary information of or about the County, DHS or any of our affiliates on social networking sites.

• Workforce members must not hold themselves out as representatives of the County or DHS or act on behalf of the County or DHS on social networking sites, unless specifically authorized in writing.

• Workforce members, including former workforce members, may be held liable for damages and potential criminal prosecution for breaching PHI used or exposed to while working for DHS.

• Workforce members must not engage in internet/social networking activities on their personal computing device during County work hours.

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Photographing and Recording Patients. Photographic or audio recordings of a patient may be taken for purposes of treatment, professional education, peer review, publication, research, law enforcement, public relations, marketing and news media only upon obtaining prior written patient consent and photographs must be filed in the patient’s medical record. Disclosure of photographic or audio recordings constitutes the release of medical information and therefore requires prior authorization for use or disclosure of patient health information

• Written patient authorization must be obtained prior to taking photographs, video, or recordings of patients.

• Authorization must contain the specific reason and use. Any other or additional use or disclosure requires a new authorization.

• Only facility-owned cameras, memory cards and other equipment may be used.

• A workforce member’s use of personal photography or recording equipment (including cellular telephones and smartphones) is prohibited.

• Photography of medical records or any other document that contains PHI is strictly prohibited.

• DHS Policy 304 provides guidelines for photographing and recording patients.

Paper Records. Paper records and medical charts must be stored or filed in such a way as to avoid access by unauthorized persons. Some type of physical barrier should be used to protect paper records from unauthorized access.

• Paper records and medical charts on desks, counters or nurses stations must be placed face down or concealed to avoid viewing or access by unauthorized persons.

• Paper records should be secured when the office is unattended by persons authorized to have access to paper records.

• Original paper records shall not be removed from the premises unless permitted by law and they are secured in a manner to protect the PHI and are not to be left unattended.

• Do not store paper records in an area where they can be thrown away or mistaken for trash.

Physical Access

• Persons authorized to enter areas where PHI is stored or viewed must wear an identifiable DHS badge or be escorted by an authorized DHS workforce member.

• Persons attempting to enter an area where PHI is processed must have prior authorization by DHS management.

• Workforce members must not allow others to use or share their badges or keycards and must verify access authorization for unknown people entering an area where PHI is stored or processed.

Visitors and Patients Visitors, vendors, and patients must be appropriately monitored when on DHS’ premises where PHI is located to ensure they do not access PHI. This means that persons who are not authorized DHS’ workforce members should not be in areas in which patients are being seen or treated or where PHI is stored.

Remote Access or Working Offsite/Outside the Secure Work Environment DHS workforce members are discouraged from removing PHI from DHS, however, it is recognized that there are some situations where work outside of the secured environment is necessary. When it is necessary for DHS staff to take patient information home or to another work environment, the following guidelines in accordance with DHS Policy 935.11, “Workstation and Mobile Device Use & Security Policy” should be followed:

• The remote work area must provide adequate privacy and security.

• Confidential information should be secured in locked rooms or a locked storage container when not in use.

• Home computers must comply with DHS standards including County approved anti-virus software and must adhere to County hardware/software protection standards and procedures.

• While on train, bus, airplane or other form of mass transit ensure use of privacy screen as well as all other requirements under section V – Desktop Workstations. Paper documents must be kept out of sight or range of view by other passengers.

• Confidential data may not be saved on removable devices (e.g. floppy drive, CD-ROM, external

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drive, USB/Thumb drive) unless it is approved and appropriate safeguards are in place (e.g., encryption).

• Data/information must not be accessible by unauthorized persons/family members. All completed work, if not remotely accessed, must be saved to the original, encrypted external device AND removed completely from the home computer.

• External devices, portable computing devices, must be encrypted and maintained in a secure location/protected from theft or loss.

Access to PHI is based on the role and job responsibilities of the workforce member. Workforce members will be assigned access to DHS’ networks and systems based on their need to know and the minimum amount of information needed to fulfill their job responsibilities. Minimum necessary also applies to their access to the system. A workforce member with access to a system for completion of certain assignments is not authorized to view, use or access other information in the system not related to their job responsibilities.

• Technical safeguards regarding the protection of PHI maintained in electronic form may include:

• Log off any electronic system containing PHI when leaving the computer, even for a few minutes, or after obtaining necessary data.

• Require computing devices to have a password-protected screen saver or other time-out feature.

• All portable computing devices such as laptops, USB/thumb drives, and other electronic devices containing PHI must be encrypted.

• Workforce members should be familiar with their facility downtime procedures.

• Passwords

• Workforce members are responsible for safeguarding their passwords for access to the County information technology resources.

• Workforce members are responsible for all transactions made using their passwords.

• Workforce members may not provide their password or use their password to provide access to another workforce member; or access the County information technology resource with another workforce member’s password or account.

• Some systems have a universal access password with a secondary password neither of which shall be shared with workforce members who are not authorized to utilize the system.

• Passwords must be changed on a regular basis to ensure security. Strong passwords include at least eight characters, such as a combination of letters, numbers and/or special characters.

• Ensure all areas used to store PHI are properly secured and that only authorized personnel have access to those locations.

Portable Computing Devices

• All portable computing devices that access and/or store PHI or confidential information must comply with all applicable DHS and County IT resources policies, standards, and procedures.

• Generally, DHS prohibits the download or storage of PHI and/or confidential information on portable computing devices. However, DHS Users who, in the course of County business, must download or store PHI and/or confidential information on portable computing devices are required to adhere to DHS policies and procedures for storage and use of PHI and/or confidential information on portable computing devices.

• If PHI and/or confidential information is downloaded or stored on a portable computing device, information must be protected from unauthorized access and, without exception, the information must be encrypted.

• A DHS User who intends to use their County-owned or personally owned portable computing device to access and/or store PHI and/or confidential information is required to obtain prior written authorization from the DHS Information Technology.

E-Mail

• Non-County e-mail such as G-Mail, Yahoo Mail, etc. must not be used for sending DHS-related PHI.

• All DHS users who use e-mail to transmit patient, confidential, and/or sensitive information must:

• have prior authorization;

• have a business need; and

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• the e-mail communication must be encrypted to comply with state and federal privacy laws and DHS policies.

• Replying to e-mail with patient, confidential, and/or sensitive information: DHS users must follow the same procedures when replying to e-mail with patient, confidential, and/or sensitive information in the same manner as if it were originally created by the DHS User.

• Audits of outbound e-mail communications may be periodically performed to ensure that use of e-mail to transmit PHI is in accordance with Departmental policies. Refer to DHS Policy 935.20, Acceptable Use Policy for County Information Technology Resources.”

Online Web-based Document Sharing Services Storing and/or sharing of PHI and other confidential information using non-County approved online web-based document sharing services (e.g., Google Docs, Microsoft Office Live, Open-Office, Dropbox, etc.) is strictly prohibited. Corrective Action Unauthorized viewing, acquisition, access, use, or disclosure of confidential and/or protected health information (including but not limited to medical records) will result in appropriate corrective action, up to and including termination of assignment/contract, as well as possible civil/criminal penalties, fines and disciplinary action against the individual’s professional license, permit, registration, or certificate from the issuing board or agency.

ACCEPTABLE USE POLICY FOR COUNTY INFORMATION TECHNOLOGY RESOURCES (DHS POLICY 935.20)

Access to County information technology resources and accounts is a privilege granted to individual users based on their work duties. These privileges may be modified or revoked by the County at any time. Each user is responsible for the protection of DHS’ County information technology resources. Users must protect all information contained therein as required by local, state and federal laws and regulations. Workforce members have no expectation of privacy with respect to their use of the County information system assets, because at any time DHS may log, review, or monitor any data created, stored, accessed, sent or received. DHS has, and will exercise, the right to monitor any information stored on any workstation, server or other storage device; monitor any data or information transmitted through the DHS network; and/or monitor sites visited on the DHS Intranet, Internet, chat groups, newsgroups, material downloaded or uploaded from the Internet, and/or e-mail sent and received by workforce members. Activities, communications, or computer usage not related to County business are likely to be monitored. Non-County workforce members are prohibited from using County information technology resources for any of the following activities:

• Engaging in unlawful or malicious activities;

• Sending, receiving or accessing pornographic materials;

• Engaging in abusive, threatening, profane, racist, sexist or otherwise objectionable language;

• Misrepresenting oneself or the County;

• Misrepresenting a personal opinion as an official County position;

• Defeating or attempting to defeat security restrictions of County systems or applications;

• Engaging in personal or commercial activities for profit;

• Sending any non-work related messages;

• Broadcasting unsolicited, non-work related messages (spamming);

• Intentionally disseminating any destructive program (e.g., viruses);

• Playing games or accessing non-business related applications, or social networking sites;

• Creating unnecessary or unauthorized network traffic that interferes with the efficient use of County information technology resources (e.g., spending excessive amounts of time on the Internet, engaging in online chat groups, listening to online radio stations, online shopping);

• Attempting to view and/or use another person’s accounts, computer files, program, or data without authorization;

• Using County information technology resources to gain unauthorized access to DHS or other systems;

• Using unauthorized wired or wireless connections to DHS networks;

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• Copying, downloading, storing, sharing, installing or distributing movies, music, and other materials currently protected by copyright, except as clearly permitted by licensing agreements or fair use laws;

• Using County information technology resources to commit acts that violate state, federal and international laws, including but not limited to laws governing intellectual property;

• Participating in activities that may reasonably be construed as a violation of National/Homeland security;

• Posting scams such as pyramid schemes and make-money-quick schemes; or

• Posting or transmitting private, proprietary, or confidential information, including patient information, to unauthorized persons, or without authorization.

• Downloading confidential or patient information or data onto a mobile storage device without authorization from the facility CIO/designee.

• Using Online Web-based Document Sharing Services (e.g., Google Docs, Microsoft Office Live, Open-Office) to store or share DHS data.

• Viewing, accessing, using or disclosing confidential or patient information or data if not authorized as part of the workforce member’s job duties.

Workforce members are responsible for safeguarding their passwords for access to the County information technology resources. Workforce members are responsible for all transactions made using their passwords. Workforce members may not provide their password or use their password to provide access to another workforce member; or access the County information technology resource with another workforce member’s password or account. Some systems have a universal access password with a secondary password neither of which shall be shared with workforce members who are not authorized to utilize the system. Workforce members should be aware that leaving a computer unattended for a brief time, even 30 seconds, may give an unauthorized user enough time to access the system using the previous user’s access. Users are responsible for ensuring that the use of outside computers and networks, such as the Internet, do not compromise the security of any County information technology resources. This responsibility includes taking reasonable precautions to prevent intruders from accessing any County information technology resources. The public Internet is uncensored and contains many sites that may be considered offensive in both text and images. Users will use the Internet for approved County business purposes only such as a research tool or for electronic communications. The County’s Internet services may be filtered, but users may be exposed to such offensive materials and must and hereby do agree to hold the County harmless should they be exposed to such offensive materials. Access to County E-mail services is a privilege that may be wholly or partially restricted without prior notice and without consent of the Workforce member. E-mail messages are the property of the County and subject to review by authorized County personnel. E-mail messages are legal documents. Statements must not be made on e-mail that would not be appropriate in a formal memo. Workforce members must endeavor to make each electronic communication truthful and accurate. Workforce members are to delete e-mail messages routinely in accordance with both the DHS and County E-mail policies. Protected Health Information (PHI) and other confidential and/or sensitive information can only be sent or received if it is encrypted or safeguarded in accordance with DHS Policy No. 361.23, Safeguards for Protected Health Information (PHI), Access to Internet-based e-mail sites (e.g., Yahoo Mail, Google Mail, Hotmail, etc.) is not permitted. Exceptions to this policy must be based upon requirements to perform job-related activities and be approved by DHS management. DHS e-mail systems will be configured to automatically delete messages greater than three years on active e-mail servers. This auto-delete policy applies to messages within all folders (inbox folders, sent file folders, draft file folders, etc.) stored on active e-mail servers. DHS will have three levels of e-mail users. (Level 1 is 3 years, Level 2 is 5 years, and Level 3 is 7 years of retention time)

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All DHS e-mail system users are expected to:

1. Regularly check for new messages; 2. Delete transitory messages as quickly as possible. 3. No Personal Storage Table, (PST) files will be allowed or used by DHS e-mail users. 4. E-mail is not to be used for the storage of patient/protected health record information of any kind,

nor is it to be used as a document storage system. Workforce members must manage and control all recordable mobile devices and removable media that contain PHI or other confidential information. These devices include PDA’s, USB flash drives, personal cell phones, cameras, removable hard disks, CD-R, CD-RW, DVD-R, DVD-RW and floppy disks. The use of recordable mobile devices and removable media must be pre-approved and registered for use by the Facility CIO/designee in accordance with DHS Policy No. 935.11, Workstation Use and Security : Access and Use of Mobile Devices and DHS Policy No. 935.13 Device and Media Controls: Accountability. No workforce member may employ any remote inbound or outbound connections to DHS network resources unless explicitly authorized. Unauthorized Remove Access Services (e.g., LogMeIn, GoToMyPC) are strictly prohibited. Dial-up, DSL, modem, etc. are strictly prohibited. Any Workforce member who is granted remote access to the DHS network must utilize the approved DHS Information Security method for remote access. VPN is the DHS approved remote access solution until further notice. Dial-up, DSL, modem etc. are strictly prohibited. At no time should any workforce member share their remote access privileges with anyone, including other workforce members or family members. At no time should any workforce member share their remote access privileges with anyone, including other workforce members or family members. All non-County workforce members utilizing County information technology resources are held to the following state law: Penal Code Section 502(c) provides: 502 (c) Any person who commits any of the following acts is guilty of a public offense:

1) Knowingly accesses and without permission alters, damages, deletes, destroys, or otherwise uses any data, computer, computer system, or computer network in order to either (A) devise or execute any scheme or artifice to defraud, deceive, or extort or (B) wrongly control or obtain money, property, or data.

2) Knowingly accesses and without permission takes, copies or makes use of any data from a computer, computer system, or computer network, or takes or copies supporting documentation, whether existing or residing internal or external to a computer, computer system, or computer network.

3) Knowingly and without permission uses or causes to be used computer services. 4) Knowingly accesses and without permission adds, alters, damages, deletes, or destroys any

data, computer software, or computer programs which reside or exist internal or external to a computer, computer system, or computer network.

5) Knowingly and without permission disrupts or causes the disruption of computer services or causes the denial of computer services to an authorized user of a computer, computer system, or computer network.

6) Knowingly and without permission provides or assists in providing a means of accessing a computer, computer system, or computer network is in violation of this section.

7) Knowingly and without permission accesses or causes to be accessed any computer, computer system, or computer network.

8) Knowingly introduces any computer contaminant into any computer, computer system, or computer network.

9) Knowingly and without permission uses the Internet domain name of another individual,

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corporation, or entity in connection with the sending of one or more electronic mail messages, and thereby damages or causes damage to a computer, computer system, or computer network.

WORKSTATION & MOBILE DEVICE USE AND SECURITY POLICY (DHS POLICY 935.11)

Department of Health Services (DHS) must ensure workstation security procedures are enforced within each Facility. “Workstations” include County and personal computers, laptops and other mobile devices (e.g., tablet PCs, PDAs, computer carts), modems, printers, and fax machines, etc. that are used for County business. All Users must use workstations and mobile devices in a manner commensurate with the sensitivity of the Information accessed from the workstations.

All Users must take reasonable physical security precautions to prevent unauthorized physical access to sensitive Information from workstations and mobile devices, (including Smartphones, Tablets and any Personally Owned Device). These precautions include taking into consideration the physical attributes of the surroundings (e.g., concealing video displays and securing unattended workstations). Only DHS supplied and supported workstations and mobile devices may be connected to DHS systems and access DHS data. Exceptions to this may include remote access required by vendors and business partners for support purposes and devices approved by the DHS CIO or designee.

Each Facility Help Desk must implement a process to make positive identification of individuals requesting password resets due to forgotten passwords. All Users who use workstations and mobile devices as described above must be trained to exercise proper security practices. Training and documentation must be in accordance with the DHS Policy No. 361.1, DHS Privacy and Security Compliance Program policies and procedures, including DHS Policy No. 361.24, Privacy and Security Training Policy, and DHS Policy No. 935.19, Data Security Documentation Requirement. PROCEDURE:

1. These procedures are intended to include documented instructions delineating the proper functions to be performed by DHS workforce members and the manner in which those functions are to be performed (e.g., logging off before leaving a workstation unattended) to maximize the security of health information

2. Workforce members must have authorization to access a workstation and the appropriate rights

to do so. Users must not access any confidential and/or sensitive information from a workstation unless they have authorization to do so and it is necessary for doing their job.

3. Each User must protect his/her password. Users must not write down their password and place it

at or near the workstation (e.g., a note taped to the monitor or placed under the keyboard).

4. Logging into workstations, networks or applications with another User’s ID and/or password is prohibited.

5. Users must not share their unique User IDs (logon/system identifier) with any other person.

6. Some form of personal information must be used to positively identify a user prior to executing a

password reset request (e.g., ID badge, online challenge question, preset (Personal Identification Number (PIN)), etc.

7. The workforce member agrees that any configuration changes to a personal mobile device are

the responsibility of the workforce member. DHS-IT will provide no technical support of personal mobile devices, and will provide no warranty, guarantee, or support should a personal mobile device experience functional problems or become inoperable.

8. The workforce member is fully responsible for the purchase, maintenance, and backup of a personal mobile device and for all monthly carrier data charges, if applicable. It is understood that DHS is not liable in any way for any device (hardware and software), or for any data and

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overage charges the workforce member may accrue due to syncing their personal mobile device to the County email system.

9. The workforce member agrees to password-protect the personal mobile device and to secure the device at all times.

10. The workforce member agrees to immediately notify DHS-IT if their personal mobile device is lost or stolen and file a security incident report by the end of the next business day. They must also agree to have DHS-IT and/or their wireless carrier remotely wipe/delete data on the personal mobile device. This will permanently erase all email, contacts, calendar, applications, and any/all other data stored on the device. This will reset the personal mobile device back to its factory default settings.

11. The workforce member agrees that by connecting their personal mobile device to the County email system, they are agreeing to cooperate with any legal hold, audit, or data discovery request from counsel, which may include an investigative search of all the data on, and possible confiscation of, the device.

12. The workforce member shall not use the personal mobile device to store confidential or sensitive data when sanctioned by federal (e.g. HIPAA/HITECH, Welfare Institutions Code), state, and/or local government legislation. The workforce member acknowledges that this privilege can be revoked by DHS management at any time.

13. Workforce members must exercise good judgment in determining the amount of necessary data stored on their mobile devices to perform their functions, as the security risk to such data is increased.

14. Access to mobile devices must be protected at all times consistent with the procedures set forth

in the Access and Use of Mobile Devices section above. 15. Mobile devices containing sensitive information (e.g., confidential patient information) must be

encrypted. 16. Use of personal USB drives (aka thumb drives) or other removable storage devices will be limited

to read-only access while connected to a DHS workstation. To ensure proper data security, only DHS standard issued USB drives that are encrypted will be permitted read/write access while connected to a DHS workstation. The only exception to this policy may be in the case that DHS IT has approved and implemented security features on a workstation to ensure the adequate encryption of any personal USB drive device that may be connected to the workstation.

17. When traveling, a workforce member must not leave mobile devices unattended in non-secure

areas. 18. Mobile devices left in cars must be stored out-of-sight and the car must be locked.

INVESTIGATION OF PRIVACY-RELATED COMPLAINTS INVOLVING ALLEGED VIOLATIONS OR BREACHES OF PROTECTED HEALTH INFORMATION (PHI) (DHS POLICY 361.11)

It is the Department of Health Services’ (DHS’) policy to protect the privacy and security of PHI in compliance with the federal Health Insurance Portability and Accountability Act (HIPAA), Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, and other applicable federal and state laws, as well as DHS’ policies and business practices. DHS Workforce Members are required to immediately report privacy or security breaches involving PHI or confidential information to their supervisor or to the facility Privacy Manager. Workforce members who violate state or federal patient privacy laws, and/or DHS policies and procedures will be subject to appropriate corrective action, up to and including discharge. All complaints or suspected violations related to the privacy or security of PHI will be investigated and resolved. In order to determine if and to what extent a breach has occurred, or the security or privacy of PHI has been compromised, the facility Privacy Manager must perform a risk assessment.

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Complaints may be filed against DHS, members of its Workforce, and/or members of DHS’ business associates’ workforce for violations of DHS policy and procedure. Complaints and allegations of privacy-related violations may be reported anonymously through the County Fraud or DHS Compliance Hotline; however, anonymous complaints that do not contain sufficient detail may delay, hinder, or prevent a full investigation. As appropriate, DHS will keep the complainant(s) informed of the complaint investigation and resolution. DHS will not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against its Workforce, including whistleblowers and patients or their representatives, for exercising their rights under State or federal privacy regulations and laws, or for filing a privacy breach or complaint. Workforce members who file a complaint in good faith shall not be subject to disciplinary action or retaliation, as provided for in DHS Policy 361.25, Disclosures of PHI by Workforce Members or Workforce Crime Victims. However, any workforce member who deliberately makes a false accusation will be subject to discipline. Moreover, reporting a violation or complaint does not protect individuals from appropriate corrective action regarding their own misconduct.

SEXUAL HARASSMENT (DHS POLICY 749)

Sexual harassment is a form of unlawful discrimination that is a violation of Title VII of the Civil Rights Act of 1964, as amended, and Chapter 6 of the California Fair Employment and Housing Act. All workforce members have a right to a work environment that encourages workforce members to treat each other with dignity and respect and is free from any form of harassment; therefore, sexual harassment in DHS is unacceptable and will not be tolerated from any workforce member. It is improper and a violation of this policy for a county officer or employee to ask for or receive sexual favors from another workforce member or prospective workforce member in return for, or as a condition of, employment, promotion, job retention, a particular job or duty assignment, or any other action relating to employment/assignment. It is also a violation of this policy if submission to, or rejection of such conduct is used as a basis for employment/assignment decisions, or if it creates an intimidating, hostile or offensive work environment. Additionally, it is also a violation of this policy for an employee, manager, or supervisor to retaliate against an employee for filing a complaint and/or participating in an investigation. Failure to comply with this policy will result in appropriate corrective action in accordance with the DHS Discipline Manual and Guidelines or Comprehensive Policy Statement (non-County workforce), as applicable. It is also the policy of this department to:

1. Dissuade such practices through communication, training and other appropriate methods that will educate all workforce members concerning sexual harassment issues;

2. Investigate all observed or reported instances of sexual harassment and take appropriate

corrective action, including disciplinary action when warranted; and 3. Provide an internal complaint process for workforce members who experience or witness the

violation of the sexual harassment policy which will protect workforce member confidentiality to the extent legally permissible, shield the individual from retaliation, and allow for corrective action.

DEFINITIONS: Sexual harassment is defined as unwelcome sexual advances, requests for sexual favors and/or other verbal, visual or physical conduct of a sexual nature which meets one of the following three criteria:

1. It is an employment/assignment condition: submission to such conduct is made either explicitly or implicitly a term or condition of employment; or

2. It is an employment/assignment consequence: submission to or rejection of such conduct by an

individual is used as the basis for employment decisions affecting such individual; or

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3. It is an offensive job interference: such conduct has the purpose or effect or unreasonably interfering with a workforce member’s work performance or creating an intimidating, hostile, offensive or abusive working environment.

Department head, for purposes of this policy is defined as:

• Hospital Chief Executive Officer

• Comprehensive Health Center Chief Executive Officer

• DHS Human Resources Administrator Retaliation – An adverse employment action against another for reporting sexual harassment or filing a complaint, participating in an investigation, administrative proceeding or otherwise exercising their rights or performing their duties pursuant to this Policy. Supervisor/Manager – Any employee regardless of job description or title, having authority, in the interest of the employer, to hire, transfer, suspend, layoff, recall, promote, discharge, assign, reward, or discipline other employees, or responsibility to direct them, or adjust their grievances, or effectively to recommend this action, if, in connection with the foregoing, the exercise of this authority is not of a merely routine or clerical nature, but requires the use of independent judgment. Workplace/Work Environment – The workplace/work environment includes off-site work-related settings such as business meetings or other County sponsored functions and other work-related events (e.g. retirement parties) with a nexus to the workplace. GUIDELINES:

• Sexual harassment can occur between members of the same or the opposite sex. The aggressor can be male or female.

• Sexual harassment can be committed by any vendor, workforce member, supervisor, or manager.

• A workforce member can be a victim of sexual harassment because sexual harassment exists in the work environment, even if it does not specifically involve or is not directed toward that individual.

• Sexual harassment can be verbal, physical, written or visual in nature. Examples of conduct that is prohibited by this policy: These are a few examples but not a complete list: Sexual propositions, stating or implying that sexual favors may be required as a condition of employment/assignment or continued employment/assignment, preferential treatment or promises of preferential treatment to a workforce member for submitting to sexual conduct; repeated unwanted sexual flirtations, advances, or invitations, unwanted physical conduct, such as touching, pinching, grabbing, kissing, patting, or brushing against another’s body; Sexually oriented or suggestive jokes, comments, teasing, or sounds; unwelcome comments about a person’s body or questions about or discussions of another person’s or one’s own sexual experiences/preferences; sexually derogatory or stereotypical comments; verbal abuse of a sexual nature or based on sex/gender; sex/gender-based hostility; sexual orientation/preference; Offensive leering, unwelcome flirtatious eye contact, staring at parts of a person’s body, sexually oriented gestures; Displays or distribution of offensive, sexually suggestive pictures or objects, drawings, cartoons, graffiti, calendars, posters, printed material, or clothing containing sexually oriented language or graphics; and Inappropriate e-mail usage and transmissions containing sexually explicit messages, cartoons, jokes, and unwelcome propositions; as well as accessing or viewing pornographic websites, computer/video games depicting sexual situations or behaviors.

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Who is Responsible for Reporting Sexual Harassment? It is the responsibility of all workforce members to ensure sexual harassment does not occur in the Department. Any workforce member who believes he or she has been the object of, has witnessed, or has been affected by sexual harassment is strongly encouraged to report the action or incident, as noted in the section below. It is the responsibility of the supervisor/manager to prevent and correct any incidents that may occur in their work areas. Once a supervisor/manager becomes aware of a potential situation, it is the supervisor/manager’s responsibility to take such allegations seriously, meet with the reporting party to obtain additional information, and to make an immediate report to the County Intake Specialist Unit, CEO County Equity Oversight Panel. It is the supervisor/manager’s responsibility to make a report even when a complaining or reporting party requests no action to be taken or if the employee states that he/she has reported or will report the matter themselves. Where do we Report Sexual Harassment? Anyone who experiences, witnesses, or becomes aware of any occurrences of sexual harassment is strongly encouraged to report it to any Department supervisor/manager or the County Intake Specialist Unit at 1(855) 999-CEOP(2367) or website https://CEOP.bos.lacounty.gov. All reported matters will be promptly, fully, and fairly investigated and appropriate corrective action taken, if necessary. Investigative Action – What should you expect? An investigator will visit the worksite and interview potential witnesses mentioned in the complaint. All information obtained from witnesses will only be released on a “need-to-know” basis in order to complete the investigation. During the investigation, the involved parties may be separated or other personnel actions may occur. If it is determined that a violation has occurred, appropriate disciplinary action up to and including termination may be taken. Staff may also be required to attend a sexual harassment training to reinforce the sexual harassment policy. Retaliation It is a violation of this Policy for a workforce member, supervisor or manager to retaliate against anyone for filing a complaint and/or participating in an investigation. There will be no retaliation against anyone who reports a violation of this policy in good faith. However, any workforce member who deliberately makes a false accusation or withholds information will be subject to discipline. Moreover, reporting a violation does not protect individuals from appropriate disciplinary action regarding their own misconduct. Disciplinary Action Failure to comply with this sexual harassment policy will result in appropriate corrective action in accordance with the DHS Discipline Manual and Guidelines and may include discharge from County service or termination of assignment. Training All workforce members are required to be trained on sexual harassment at least once every two years; by California law, supervisors and managers must attend within six (6) months of being promoted or hired to a supervisory position and every two years thereafter. Non-County workforce members who become County employed must be re-trained on sexual harassment within 30 days of entering County employment. Reinforcement This policy will be distributed to each workforce member at the time of new hire/assignment and annually thereafter during the performance evaluation process. The Sexual Harassment booklet shall be provided to each newly hired/assigned workforce member at the time of in-processing, and distributed to each

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workforce member as necessary upon revision.

COUNTY POLICY OF EQUITY (DHR PPG 812, BOS 9.015)

This policy is intended to preserve the dignity and professionalism of the workplace as well as protect the right of workforce members to be free from discrimination, sexual harassment, unlawful harassment (other than sexual), retaliation and inappropriate conduct toward others based on a protected status. Discrimination, sexual harassment, unlawful harassment (other than sexual), retaliation and inappropriate conduct toward others based on a protected status, are contrary to the values of the County. The County will not tolerate unlawful discrimination on the basis of sex, race, color, ancestry, religion, national origin, ethnicity, age (40 and over), disability, sexual orientation, marital status, medical condition or any other protected characteristic protected by state or federal employment law, nor will it tolerate unlawful harassment, or retaliation. As a preventive measure, the County also will not tolerate inappropriate conduct toward others based on a protected status even if the conduct does not meet the legal definition of discrimination or unlawful harassment. All DHS workforce are responsible for conducting themselves in accordance with this policy and its associated procedures. Violation of the policy and/or procedures will lead to prompt and appropriate administrative action which may include release from assignment and listing in the “Do Not Send” database. All DHS workforce members are required to conduct themselves in accordance with the County Policy of Equity and all applicable local, county, state, and federal laws. The following are definitions of prohibited conduct as referenced in this policy: Discrimination: Disparate or adverse treatment of an individual based on or because of that individual’s sex, race, color, ancestry, religion, national origin, ethnicity, age (40 and over), disability, sexual orientation, marital status, medical condition or any other protected characteristic protected by state or federal employment law. Sexual Harassment: Includes unwelcome sexual advances, requests for sexual favors, and other verbal, visual or physical conduct of a sexual nature which meets any of the following three criteria:

• Submission to such conduct is made either explicitly or implicitly a term or condition of an individual’s employment;

• Submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting such individual; or

• Such conduct has the purpose or effect of unreasonably interfering with the individual’s employment or creating an intimidating, hostile, offensive, or abusive working environment.

Unlawful Harassment (Other than Sexual): Unlawful harassment of an individual because of the individual’s race, color, ancestry, religion, national origin, ethnicity, age (40 and over), disability, sexual orientation, marital status, medical condition or any other protected characteristic protected by state or federal employment law is also discrimination and prohibited. Unlawful harassment is conduct which has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile, offensive, or abusive work environment. Third-Person Harassment: Indirect harassment of a bystander, even if the person engaging in the conduct is unaware of the presence of the bystander. When an individual engages in harassing behavior, he or she assumes the risk that someone may pass by or otherwise witness the behavior. The County considers this to be the same as directing the harassment toward that individual. Inappropriate Conduct Toward Others: Inappropriate conduct toward others is any physical, verbal, or visual conduct based on or because of sex, race, color, ancestry, religion, national origin, ethnicity, age (40 and over), disability, sexual orientation, marital status, medical condition or any other protected characteristic protected by state or federal employment law when such conduct reasonable would be considered inappropriate for the workplace. This provision is intended to stop inappropriate conduct based on a protected status before it becomes discrimination or unlawful harassment. As such, the conduct need not meet legally actionable state and/or federal standards of severe or pervasive to violate this policy. An isolated derogatory comment, joke, racial slur, sexual innuendo, etc., may constitute conduct that violates this policy and is grounds for corrective action. Similarly, the conduct need not be unwelcome to the party against whom it is directed; if the conduct reasonably would be considered inappropriate by the County for the workplace, it may

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violate this policy. Retaliation: Retaliation for the purposes of this policy is an adverse employment action against another for reporting a protected incident or filing a complaint of conduct that violates this policy or the law or participating in an investigation, administrative proceeding or otherwise exercising their rights or performing their duties under this policy or the law. Duty to Cooperate: All DHS workforce members are responsible for cooperating fully in any administrative investigation related to this policy. Confidentiality: DHS shall maintain all complaint-related information in confidence to the extent possible given the obligation to conduct a full and fair investigation. Examples of Conduct that May Violate this Policy

• Posting, sending, forwarding, soliciting or displaying in the workplace any materials, documents or images that are, including but not limited to, sexually suggestive, racist, “hate-site” related, letters, notes, invitations, cartoons, posters, facsimiles, electronic mail or web links;

• Verbal conduct such as whistling and cat calls, using or making lewd or derogatory noises or making graphic comments about another’s body, or participating in explicit discussions about sexual experiences and/or desires;

• Verbal conduct such as using sexually, racially or ethnically degrading words or names, using or making racial or ethnic epithets, slurs, or jokes;

• Verbal conduct such as comments or gestures about a person’s physical appearance which have a racial, sexual, disability-related, religious, age or ethnic connotation or derogatory comments about religious differences and practices;

• Physical conduct such as touching, pinching, massaging, hugging, kissing, rubbing the body or making sexual gestures;

• Visual conduct such as staring, leering, displaying or circulating sexually suggestive objects, pictures, posters, photographs, cartoons, calendars, drawings, magazines, computer images or graphics;

• Sexual advances or propositions, including repeated requests for a date;

• Adverse employment actions like discharge and/or demotion, this list is not exhaustive. This policy prohibits discrimination, unlawful harassment, retaliation, and inappropriate conduct toward others based on a protected status in the workplace or in other work-related settings such as off-site work-related events (e.g., retirement parties) with a nexus to the workplace. This policy also applies to the use of any communication system or equipment in the workplace, including but not limited to, electronic mail, internet, telephone lines, computers, facsimile machines, voice mail, radio, cell phones, blackberries and mobile digital terminals. Workforce members may be disciplines in accordance with this policy for using any communication system or equipment to deliver, display, store, forward, publish, circulate, or solicit material in violation of this policy. Reporting Violations of this Policy: Any workforce member who feels they have been subject to conduct that potentially violates this policy is strongly encouraged to report the matter to any DHS supervisor or manager or the County Intake Specialist Unit at 1-855-999-CEOP (2367) or website: https://CEOP.bos.lacounty.gov and is located at: Kenneth Hahn Hall of Administration, 500 West Temple Street, Room #B-26, Los Angeles, CA 90012. Retaliation: This policy absolutely prohibits retaliation. No workforce member will be subjected to retaliation for: making a complaint of conduct that potentially violates this policy, or cooperating in any administrative investigation or otherwise preventing prohibited practices under this policy. DHS will take corrective action to prevent retaliation, including the imposition of appropriate corrective action on any workforce member who engages in retaliation.

IDENTIFICATION BADGES (DHS POLICY 940)

Each non-County workforce member is required to prominently display his/her official facility identification badge at all times while present on any Los Angeles County facility or while otherwise acting in any work related capacity. It is the individual’s responsibility to report a lost or stolen identification badge within five

https://ceop.bos.lacounty.gov/

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business days to DHS Human Resources. Once an affidavit has been completed attesting to the theft or loss, the non-County workforce member will be required to present a copy of the police report and pay a replacement fee for his/her identification badge. The replacement fee is as follows: $25 for the first replacement, $50 for the second replacement, and $100 for each subsequent identification badge replacement. When service is terminated, the individual must immediately return the badge to his/her supervisor, facility Human Resources office, or agency if the non-County workforce member was retained via an agency service. Failure to adhere to the identification badge policy will result in release from assignment.

HAND HYGIENE IN HEALTHCARE SETTINGS (DHS POLICY 392.3, JOINT COMMISSION)

All healthcare workers who provide direct patient care, have contact with patient care supplies, equipment or food, and laboratory and select pharmacy workers must comply with the following hand hygiene guidelines:

• Hand washing with water and plain or antimicrobial soap, or decontaminating hands with an antimicrobial agent must be practiced as necessary and in the manner required by infection control guidelines and policies.

• Non-County workforce members who provide direct patient care, handle patient supplies, equipment and food are prohibited from wearing artificial nails. Natural nails must be clean with tips less than ¼ inch beyond the tip of the finger. If fingernail polish is worn, it must be in good condition, free of chips, and preferably clear in color.

Wearing rings with stones is discouraged, as they can harbor bacteria and tear gloves.

WORKFORCE BEHAVIORAL STANDARDS (DHS POLICY 747.300)

It is the expectation that all workforce members including medical and professional staff conduct themselves in a courteous, cooperative and professional manner. The Department of Health Services (DHS) will not tolerate any disruptive, inappropriate, or unprofessional behavior/conduct by any workforce member towards another workforce member, the public, or patients. Any workforce member, including medical or professional staff, who engage in inappropriate conduct, or exhibit disruptive or unprofessional behavior, or who fail to exercise sound judgment in dealing with other workforce members, patients, or the public may be subject to appropriate corrective action, up to and including discharge. Disruptive behavior may include behavior that interferes with teamwork or safe patient care, or when the behavior has the effect of intimidating or suppressing legitimate input by other workforce members. Disruptive behavior can be obvious, for example, angry verbal outbursts, throwing objects, or disrespectful language. However, it can also be passive or less obvious such as failing to engage in necessary work communication or not performing assigned tasks. There will be no retaliation against anyone who reports a violation of this policy in good faith. However, any workforce member who deliberately makes a false accusation will be subject to appropriate corrective action. Moreover, reporting a violation does not protect individuals from appropriate corrective action regarding their own misconduct.

THREAT MANAGEMENT “ZERO TOLERANCE” POLICY (DHR PPG 620 DHS POLICY 749)

All workforce members are entitled to a safe and healthy work environment. The Department of Health Services will not tolerate any workplace acts of violence or threats in any form directed towards another workforce member, the public or patients. Examples of such behavior include but are not limited to:

• Verbal and/or written threats, including bomb threats, to a County facility or toward any workforce member and/or member of that person’s family

• Psychological violence such as : bullying, verbal and/or written threats against any property of the workforce member

• Items left in a workforce member’s work area or personal property that are meant to threaten or intimidate the workforce member

• Off-duty harassment of workforce members, such as phone calls, stalking, or any other behavior that could reasonably be construed as threatening or intimidating and that could affect workplace safety

• Physical actions against another employee that could cause harm

• Carrying a weapon on County property or while engaged in County business

• Domestic violence/conflicts – restraining orders/injunctions

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• Suspicious activity

• Incidents involving a call of local law enforcement Weapons: Workforce members shall not carry a weapon of any kind while in the course and scope of performing their job, whether or not they are personally licensed to carry a concealed weapon. This includes anywhere on County property or at any County-sponsored function. Weapons include any form of weapon or explosive restricted under local, state or federal regulation. This includes all firearms, illegal knives or other weapons prohibited by law. Provisions of the policies, procedures, and resources described herein are to serve the Department’s managers, supervisors and workforce members in meeting their responsibility to maintain workplace safety and security. Consequences of violating these provisions may include any or all of the following:

• Arrest and prosecution for violation of pertinent laws (Threats of harm are illegal. See Appendix I in Resource Guide for relevant Penal Code sections)

• Removal of the threatening individual from the premises pending investigation

• Departmental discipline up to and including discharge Any workforce member who witnesses any threatening or violent behavior, is a victim of, or has been told that another person has witnessed or was a victim of any threatening or violent behavior is responsible for reporting the incident to his/her supervisor or manager. In the case of community health care workers (such as Home Nursing Attendants or other in-home personal healthcare workers) any incident of violence must also be reported to the State of California Department of Industrial Relations, Division of Labor Statistics and Research – Work Injuries and Illnesses at (415) 703-3020. Licensed workforce members who violate the provisions of this policy may, depending upon the circumstance, be reported to the appropriate license, certificate, registration, or permit issuing agency/board. All workforce members must take all reasonable steps to ensure the workplace is free from violent incidents. PROCEDURE: Safety of workforce members should be foremost in determining the initial response to an act of violence or threat. Each threat, alleged threat, or act of violence must be assessed and managed according to the particular circumstances presented. Based on the clarity, severity, and imminence of the threat or act of violence, the situation may warrant the immediate summoning of emergency resources, or may allow sufficient time to investigate the facts of the incident to determine the most appropriate course of action. Immediate Danger or Imminent Threat of Violence Any workforce member who is a witness or victim to an act of violence or an imminent threat in the workplace, or who is advised of an imminent threat directed at or expressed by another workforce member and believed by the victim or witness to constitute an immediate danger requiring an emergency response, shall take the following actions: • Immediately notify on-site security personnel • Obtain emergency assistance from local law enforcement by calling 911 • Warn potential victim(s) • Seek personal safety • Post event, the victim or supervisor/manager shall contact OSM within 24 hours Non-Imminent Threats If a non-imminent threat is directed at someone within a County facility by an identifiable party currently or not currently at that facility, the following timely notifications shall be made by the reporting workforce

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member, supervisor, and/or manager:

• On-site facility security personnel

• Local law enforcement agency

• A Department supervisor or manager

• The Office of Security Management

• The potential victim(s) Security Incident Report A threat or act of workplace violence constitutes a security incident. The incident shall be reported to OSM via telephone and by completing and delivering the Security Incident Report (SIR) to OSM, 500 W. Temple Street, Room 754, Los Angeles, California 90012 or by sending the SIR via fax to (213) 613-0840 (See Resource Guide for sample reporting form). The SIR shall be sent or delivered no later than the end of the business day following the threat or incident. It is the responsibility of the department head, manager, or supervisor informed of the incident to deliver or send the completed and approved SIR. The report shall be completed by the person reporting or involved in the incident, any supervisor, manager, or the building manager of the affected department. Inquiries regarding this SIR requirement may be directed to OSM. For reporting purposes, a Security Incident is defined as meeting any of the following criteria:

• An incident placing a person or property at risk that requires action by local law enforcement authorities or security guards at a County facility, whether they were summoned or not

• An incident placing a person at risk involving an on-duty (including lunch periods) workforce member while on County property. This includes parking facilities, or while walking to or from an off-site parking facility to start or end a workday

• An incident of a suspicious or unusual nature on County property that places people or property at risk.

Cooperation with Law Enforcement Personnel Law enforcement personnel may be required to enter County facilities to conduct official business, such as serving Court orders on workforce members or investigating a crime that involves a workforce member. Law enforcement agencies shall be given access to workforce members while they are at work. All workforce members are entitled to a safe and healthy work environment. The Department of Health Services will not tolerate any workplace acts of violence or threats in any form directed towards another workforce member, the public or patients. Examples of such behavior include but are not limited to:

ATTENDANCE (DHS POLICY 751)

Every non-County workforce member is expected to adhere to his/her established work schedule for the purpose of providing necessary services in support of patient care. Each non-County workforce member must abide by his/her defined work start and end times, as well as break times and meal periods. In the event that a non-County workforce member will be absent or tardy, he/she must telephone the staffing office or work site supervisor, in addition to complying with contract agency procedures. Any non-County workforce member who is not in his/her assigned work area and cannot be located at any time during his/her shift will be considered absent from the area without authorization, which may result in written notification to the non-County workforce member describing the cause for reprimand and/or termination of service or contract.

SAFE PATIENT HANDLING (DHS POLICY 311.003)

A. Department of Health Services recognizes the critical role that mobility has in a patient’s recuperative process, including its effect on length of stay. In addition, the Department recognizes the value of every healthcare worker and the potential risk of life-changing consequences related to cumulative effects of improper lifting, shifting, repositioning and transferring of patients. The potential unsafe handling of patients has negative financial consequences for healthcare facilities, patient care providers and patients. Therefore, it is crucial that all healthcare professionals practice techniques to provide safe patient handling and use of body mechanics at all times. The provision of state-of-the-art mechanical patient handling equipment and other approved patient aids are being provided as a primary contribution to this effort.

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B. Safe patient handling techniques will be used for all lifts as specified in this policy. During patient handling activities, except in an emergency, staff personnel will perform patient transfers/complex lifts with mechanical assistive devices as appropriate for the specific patient and consistent with the professional judgment and clinical assessment of the registered nurse, who is the coordinator of care.

Patient handling activities include:

1. Repositioning in bed 2. Bed to chair/wheelchair 3. Bed to gurney and return 4. Gurney to treatment table and return 5. Bed to toilet 6. Floor to bed 7. Any other lift where total body movement of the non-ambulatory patient is required

D. Teams of at least 2 staff members who have been trained may perform these transfers using the

designated equipment. EQUIPMENT Equipment available to the staff may include:

A. Mechanical vertical lifting devices B. Mechanical standing/raising/transferring devices C. Air powered lateral transfer mattresses D. Full length slide boards E. Gait belts F. Mechanical weighing devices

PROCEDURES: Except in an emergency, staff will perform complex lifts or transfers on patients with the use of assistive devices as appropriate for the specific patient and consistent with the professional judgment and clinical assessment of the registered nurse, as the coordinator of care.

SAFE AND JUST CULTURE (DHS POLICY 311.4)

PHILOSOPHY: DHS strives to build, maintain, and support a Safe and Just Culture. A Safe and Just Culture is one in which safety is an individual and organizational priority and where errors, near misses, and adverse events can be easily reported and are viewed as an opportunity to learn and improve upon the delivery of care. Reporting will not be impeded by the fear of discipline or retaliation. The health care environment, in all of its aspects, is one in which the occurrence of error is recognized as inevitable, often as a result of flawed systems. A Safe and Just Culture supports the identification and improvement of these flawed systems. POLICY: DHS leadership supports the implementation of a Safe and Just Culture, consistent with The Joint Commission Leadership Standards. Individuals will be accountable for their own performance in accordance with their job responsibilities and DHS core values. However, individuals will not carry the burden for system flaws over which they have no control. Leadership will take steps to address those individuals who engage in the willful and unjustifiable violation of policy or reckless or negligent behaviors that increase the risk for negative outcome. Workforce members are responsible for reporting near misses, adverse events, errors, and system flaws to their facility or DHS in a timely manner. Workforce members are encouraged to report these conditions by way of the Safety Intelligence (SI) online reporting system. Further, any workforce member who has

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concerns about the safety or quality of care provided in any DHS hospital or healthcare facility may also report these conditions to: Office of Quality and Patient Safety The Joint Commission One Renaissance Blvd Oakbrook Terrace, Illinois 60181 Fax: (630) 792-5636 [email protected] Online: http://www.jointcommission.org/ report_a_complaint.aspx Workforce members will not be punished or retaliated against for reporting an error, near miss, adverse event, or safety or quality concerns. Leadership will routinely evaluate progress toward achievement of a Safe and Just Culture, and will modify actions as needed to meet this goal. Leadership will hold workforce members accountable and take appropriate corrective action in concert with DHS Discipline Manual and Guidelines, County Civil Service Rules, and DHS policies and procedures for: • Behavior that knowingly puts patients, visitors or staff at risk of harm. • A conscious or willful disregard of organizational policies and procedures. • Behavioral choices that are disruptive to the workplace environment (e.g., substance abuse). • Repetitive errors or repetitive at-risk behaviors that demonstrate an inability to fulfill legitimate work

requirements. While sound judgment and wise discretion must always be used, leadership’s response to errors, near misses and adverse events should be influenced by the employee’s behavioral choices, not the outcome of the incident. Leaders may choose to evaluate the incident based on the behavioral choices another individual in the same situation would have made.

DRESS CODE (DHS POLICY 392.3, 706.1, MOU)

All workforce members are to dress in a manner that is professional and appropriate for the business atmosphere and health care standards and must not interfere or detract from the DHS mission. It must also be appropriate to the type of work being performed and take in consideration the expectations of our patients, and customers being served. All workforce members are expected to practice personal hygiene that does not interfere with the public and/or coworkers in their work environment. Dress code guidelines are:

• Identification badges must be worn and readily visible at all times.

• Clothing must be clean and pressed and footwear is to be clean and polished.

• Hair and nails (including artificial nails) must be clean and neatly groomed and of a length that does not interfere with work performance, personal safety, and patient care. Hand and nail care are addressed in the Hand Hygiene in Healthcare Settings policy. Mustaches and beards must be small, trimmed, clean and neatly styled.

• Jewelry and cosmetics should be appropriate to a professional business environment. Dangling jewelry, including ornate rings, long necklaces, charm bracelets, or earrings that extend below the ear lobe may not be worn by patient care personnel or staff who operate machinery/equipment with moving parts for safety reasons.

• An appropriate smock/lab coat will be worn, when applicable to job responsibilities. Uniforms and scrubs must be worn in accordance with safety/infection control regulations. The dress code shall be adhered to for clothing worn under lab coats or smocks; lab coat or smocks should be clean and appropriate for the business environment.

Inappropriate attire includes, but is not limited to: revealing clothing, sandals, sweatshirts/pants, oversized or ill-fitting clothing/uniforms, caps or hats (other than as required as part of a uniform), visible tattoos or body piercing ornaments (other than on the ears). It is the responsibility of individual workforce members to comply with the general dress code standards established by this policy and with applicable uniform standards required by individual department/service areas. Exceptions can be made for cultural, religious

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or medical purposes.

NEPOTISM (DHS POLICY 708.000)

A workforce member may not supervise any immediate relative as an immediate supervisor or as a higher-level supervisor, except as otherwise provided in this policy An individual shall not be assigned to a position under the direct or indirect supervision or control of an immediate relative who has or may have a direct effect on the individual’s assignment, progress, performance or advancement. In addition, managers and supervisors should be aware of potentially sensitive situations involving personal relationships within their area(s) of responsibility. Although it is unlawful to discriminate on the basis of marital status or personal relationships, managers/supervisors may reasonably regulate the work situation of individuals in relationships as defined in this policy to ensure fair and impartial treatment of employees relative to employment decisions, safety, security and/or morale. Each workforce member shall be responsible for reporting any relationships he/she may have that may be governed by the provisions of this policy, including personal relationships (as defined herein). Immediate relative includes any relationship formed by blood, genealogy, marriage, adoption, cohabitation, and domestic partnership as defined in California Family Code Section 297 et seq. and Los Angeles County Code Section 2.210, including but not limited to spouse (common laws or otherwise), child, mother, father, sister, brother, aunt, uncle, grandparent, niece, nephew, step-parent, step-child, step-sibling, cousin or legal guardian. Nepotism is generally defined as the practice of a workforce member using personal influence or power to aid or hinder another in an employment setting in securing employment, promotion or other benefits because of a personal relationship. No workforce member may use power or influence to aid or hinder another in securing or advancing in employment due to a personal relationship. Personal relationships include, but are not limited to, those by virtue of blood, marriage, adoption, cohabitation, or any such other relationship which would give rise to a substantial appearance of impropriety or lack of reasonable objectiveness if the person were to be supervised as set forth in this Policy.

CONFLICT OF INTEREST (DHS POLICY 740)

A non-County workforce member is prohibited from:

• Participating in or attempting to influence any County decision in which the non-County workforce member has a personal financial interest.

• Accepting gifts, as an individual, from vendors or potential vendors. Workforce members may never solicit gifts or accept cash or cash equivalents, such as gift certificates. Generally, gifts from patients or persons on behalf of patients to individual workforce members should not be accepted. If the patient insists, unsolicited gifts of little or no monetary value may be accepted so long as acceptance of the gift does not influence the timeliness and quality of care, treatment or services.

• Referring any patient or client for any private reimbursable service to themselves or to any group with which they have a personal financial interest, unless specifically authorized to do so by the Director of DHS or his/her designee (i.e., Chief Medical Officer) after disclosing the nature of the affiliation.

• Confidential and other non-public information gathered through contact with patients, clients, or other workforce members, or from departmental records may only be used for official departmental business.

• Using any County facility, tool, equipment or supply for non-County or personal purposes (e.g., telephones, fax machines, copiers, computers, e-mail, Internet).

ACCEPTANCE OF GIFTS (DHS POLICY 740)

Non-County workforce members shall not accept gifts, money, favors, special considerations or things of monetary value for work he/she would be required or expected to perform in the regular course of his/her duties, which includes activities with persons or vendors doing business with the County.

DUAL COMPENSATION (DHS POLICY 740)

Non-County workforce members shall not receive compensation from other sources for the performance of his/her County assignment.

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SEXUAL ABUSE/INAPPROPRIATE BEHAVIOR TOWARD A PATIENT (JOINT COMMISSION SENTINEL EVENT POLICY AND PROCEDURES, DHS POLICY 321.000)

Each patient in a Department of Health Services (DHS) facility has the right to be free from verbal, mental, physical, and sexual abuse, exploitation, neglect and harassment. Each DHS facility will evaluate all allegations, observations, and suspected cases of abuse, exploitation, neglect, and harassment that occur within the facility and report such incidents in accordance with the provisions of this policy and guidance.

Sexual contact between a workforce member and a patient is:

• Strictly prohibited;

• Unprofessional conduct; and

• Will constitute sexual misconduct and/or abuse. Examples of inappropriate sexual conduct include but are not limited to:

• Intercourse;

• Touching the patient’s body with sexual intent;

• Inappropriately watching the patient undress/dress;

• Making inappropriate comments;

• Conducting physical exams not needed, not within the scope of treatment or not based on the patient’s medical complaint;

• Conducting treatment/exams outside the scope of the health care worker’s license, registration, certificate, or permit;

• Any demeaning or undignified treatment. Sexual conduct that occurs concurrent with the patient-physician or other healthcare provider relationship constitutes sexual misconduct. If a physician or healthcare provider has reason to believe that non-sexual contact with a patient may be perceived as or may lead to sexual contact, then he or she should avoid the non-sexual contact. At a minimum, a physician’s or healthcare provider’s ethical duties include terminating the physician or healthcare provider-patient relationship before initiating a dating, romantic, or sexual relationship with a patient. Sexual or romantic relationships with former patients are unethical if the physician or healthcare provider uses or exploits trust, knowledge, emotions, or influence derived from the previous professional relationship. Unwanted or nonconsensual sexual conduct (with or without force) involving a patient and health care worker, another patient, contract staff, unknown perpetrator or spouse/significant other, while being treated or occurring on the premises of a DHS facility may constitute a criminal act punishable by law. Any workforce member who witnesses or reasonably suspects that a patient was or is being subjected to inappropriate sexual conduct and/or sexual abuse shall report it to his/her supervisor using DHS Policy No. 321.000 Security Incident Report. The Department is prohibited from taking disciplinary action against a workforce member for making a good faith report. However, any workforce member who deliberately makes a false accusation will be subject to discipline. Moreover, reporting a violation does not protect individuals from appropriate disciplinary action regarding their own misconduct.

CHILD ABUSE REPORTING (DHS POLICY 321.100)

As a non-County workforce member of DHS, a public agency that provides direct health care services to children, you are considered a “mandated reporter” for purposes of this Policy. California Penal Code Section 11166.5 requires Los Angeles County Department of Health Services to provide all mandated reporters who commence service on and after January 1, 1985, with the statement contained in the next paragraph. DHS requires the statement be signed by the non-County workforce member as a requisite to working in any of its facilities. Section 11166 of the Penal Code requires a mandated reporter who, in his/her professional capacity or within the scope of his/her work relationship, has knowledge of or observes a child whom the mandated reporter knows or reasonably suspects has been the victim of child abuse or neglect to report the known or suspected abuse immediately or as soon as practicably possible by telephone and to send, fax, or electronically transmit a written report thereof within 36 hours of receiving the information concerning the

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incident. The report may include any non-privileged documentary evidence the mandated reporter possesses related to the incident. If after reasonable efforts, a mandated reporter is unable to submit an initial report by telephone, he or she shall immediately or as soon as practicably possible, by fax or electronic submission, make a one-time automated written report on the DOJ Form SS8572 (see: http://ag.ca.gov/childabuse/pdf/ss_8572.pdf) and shall also be available to respond to a telephone follow-up call by the agency in which he or she filed the report. The report must also indicate the reason why the mandated reporter was not able to make an initial report by telephone. Reports of suspected child abuse or neglect shall be made by mandated reporters to the local law enforcement agency, county probation or county welfare departments. As required by BOS' mandate, if the abuse involves a patient under the authority of and due to a law enforcement agency, a report shall be sent to the Internal Affairs Unit or the Captain of the jail facility where the patient/inmate is housed. Child abuse reports may be made directly to the Los Angeles County Department of Children and Family Services (DCFS) 24-hour hotline at (800) 540-4000, and written reports may be submitted through their website at http://dcfs.lacounty.gov.

ELDER/DEPENDENT ADULT ABUSE REPORTING (DHS POLICY 321.001)

As a non-County workforce member of DHS, a public agency that provides direct health care services to elders and dependent adults, you are considered a “care custodian” for purposes of this Policy. California Welfare and Institutions Code Section 15659 requires Los Angeles County Department of Health Services to provide all “care custodians,” “clergy members,” “health practitioners,” and “employees of an adult protective services agency” or “local law enforcement agency” who enter service on or after January 1, 1995, with the following statement prior to commencing his/her service. Section 15630 of the Welfare and Institutions Code defines mandated reporter as “any person who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that he or she has experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone immediately or as soon as practicably possible, and by written report within two working days, as follows: If the abuse has occurred in a long-term care facility, except a state mental health hospital or a state development center, the report shall be made to the local ombudsman or to a local law enforcement agency. If the suspected or alleged abuse occurred in a state mental hospital or a state developmental center, the report shall be made to designated investigators of the State Department of Mental Health or the State Department of Developmental Services or to local law enforcement agencies.

INJURIES BY FIREARM; ASSAULTIVE OR ABUSIVE CONDUCT; REPORTING DUTIES BY HEALTH FACILITIES (DHS POLICY 321.001)

California Penal Code Section 11160 requires any health practitioner employed in a health facility, clinic, physician’s office, local or state public health department, or a clinic or other type of facility operated by a local or state public health department who, in his or her professional capacity or within the scope of his or her employment, provides medical services for a physical condition to a patient whom he or she knows or reasonably suspects is a person described as follows, shall immediately, or as soon as practically possible, make a report to local law enforcement by telephone and a written report within two working days of receiving information regarding the person and as required by BOS' mandate, all medical personnel shall report all suspicious injuries of patient/inmates to the Internal Affairs Unit or the Captain of the jail facility where the inmate is housed for: Any person suffering from any wound or other physical injury inflicted by his or her own act or inflicted by another where the injury is by means of a firearm, or Any person suffering from any wound or other physical injury inflicted upon the person where the injury is the result of assaultive or abusive conduct.

REPORTING SUSPICIOUS INJURIES (DHS POLICY 321.001)

A suspicious injury includes any wound or other physical injury that either was:

• Inflicted by the injured person’s own act or by another where the injury was by means of a

http://dcfs.lacounty.gov/

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firearm; or

• Is suspected to be the result of assaultive or abusive conduct inflicted upon the injured person. In accordance with California Penal Code Section 11160, DHS requires any health practitioner working in a DHS health facility who in his or her professional capacity or within the scope of his or her assignment provides medical services to a patient/inmate who he or she knows or reasonably suspects has a suspicious injury to report such injury by telephone to local law enforcement immediately or as soon as practicable. Section 11160 requires the reporter to make a written follow-up report within two (2) business days to the same local law enforcement agency (see http://domesticabuse.stanford.edu/documents/calema%202-920%0DV.pdf and http://www.calema.ca.gov/PublicSafetyandVictimServices/Documents/Forms%202011/Numeric%20forms%20listing/Suspicious%20Injury%20Report%202-920i.pdf. If the suspicious injury is to a patient/inmate, per BOS mandate, it must be reported to the Internal Affairs Unit or the Captain of the jail facility where the patient/inmate is housed. The Los Angeles County Sheriff’s Department Internal Affairs Bureau can be reached at (323) 890-5300 or (800) 698-8255, and is located at 4900 S. Eastern Ave., Suite 100, Commerce, CA 90040. It should be noted that the health practitioner’s reporting obligation applies to any law enforcement agency delivering a patient/inmate for intake with a suspicious injury. See DHS Policy 321.001for a list of the Los Angeles County law enforcement agencies in which to report such injuries. Health practitioners working in a DHS health facility who are engaged in compiling evidence during a forensic medical examination for a criminal investigation of sexual assault may be asked to release the report to local law enforcement and other agencies, the reports must be prepared on specific forms as required by statute. Health practitioners must follow DHS HIPAA procedures documenting the release of such information.

AMERICANS WITH DISABILITIES ACT (A.D.A.) (DHS POLICY 189)

The purpose of the ADA is to ensure civil rights protection to individuals with disabilities. It guarantees equal opportunity for individuals with disabilities in public accommodations, employment, transportation, state and local government services, and telecommunications. The Department of Health Services (DHS) does not discriminate on the basis of disability in employment or in admission and access to services, programs or activities. This policy applies equally to DHS workforce members and members of the public who access services through our hospitals, clinics and administrative offices. Title I of the ADA protects qualified persons with disabilities from discrimination in hiring and promotion, pay, job training, benefits, referral, and other aspects of employment. A “qualified” individual with a disability is an individual who meets the skill, experience, education and other job-related requirements of the position held or desired, and who, with or without reasonable accommodation, can perform the essential functions of the job. DHS will provide reasonable accommodations that do not impose undue hardship. Based upon request, reasonable accommodations will be provided for qualified individuals to enable them to perform the essential functions of the job. Title II of the ADA provides that qualified individuals with disabilities may not be denied access to or use of clinic services, programs or activities. A “qualified” individual is one who meets the eligibility criteria for the services being offered. To ensure treatment, a program access standard must be met; each service must be accessible to and usable by people with disabilities when viewed in its entirety. Primary consideration shall be given to the specific auxiliary aid and/or service requested by the person with a disability. Programs and services are designed to accommodate all persons regardless of disability. Persons may elect not to participate in any program or service designed specifically for persons with disabilities. County-sponsored events or activities, including those held at non-County owned facilities, must be accessible to all persons without regard to whether they have disabilities. All access services will be provided at no cost to the user, as long as they do not create undue hardship on County resources.

http://www.calema.ca.gov/PublicSafetyandVictimServices/Documents/Forms%202011/Numeric%20forms%20listing/Suspicious%20Injury%20Report%202-920i.pdf

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Departmental policy, practice or procedure may need to be reasonably modified to accommodate the needs of a person with a disability. Requests for Reasonable Accommodation Members of the general public or a workforce member who have a disability covered under the ADA are entitled to request reasonable accommodations that do not pose an undue hardship to DHS. Individuals who require reasonable accommodations, such as readers or sign language interpreters are required to give advance notice when making a request. A request does not need to be in writing. For additional information on reasonable accommodations, contact the facility ADA/Reasonable Accommodation Coordinator.

SOLICITATION (DHS POLICY 742)

Non-County workforce members shall not solicit in any DHS building or on DHS property for any purpose without prior approval from the Chief Executive Officer or his/her designee. Non-County workforce members shall not solicit for a private vendor or operator the patronage for any County patient or client, nor refer any County patient or client for treatment or service other than as required by the non-County workforce member’s regularly assigned work duties. This policy does not apply to the extent any non-County workforce member, as part of his or her work assignment, is required to distribute literature and/or process enrollment documents for County administered employee group insurance programs or County sponsored fundraising events.

CAPPING (DHS POLICY 743)

Non-County workforce members shall not engage in capping activities on or off County property. Capping is soliciting business for attorneys. A “capper” or “runner” is any person, firm, association, or corporation acting in any manner, or in any capacity, as an agent for an attorney at law in the solicitation of business.

POLITICAL ACTIVITY (DHS POLICY 744)

Non-County workforce members shall refrain from political activities while performing services for the County. A non-County workforce member who engages in the following improper activities shall be subject to immediate corrective action and/or termination of services:

1) Knowingly soliciting or receiving political funds or contributions from County or non-County workforce members or from persons on County eligible lists, except for passage or defeat of a ballot measure affecting the pay, hours, retirement, and service or other working conditions of County employees;

2) Participating in political activities of any kind during working hours or while in uniform; 3) Favoring or discriminating against any employee or person seeking County

employment/assignment because of political opinions or affiliations; 4) Participating in political activities in a manner so as to represent the County or any of its

departments, officers, agencies, or officials, as endorsing a ballot measure, if such endorsement has not previously been given publicly;

5) Directly or indirectly using official authority or influence to interfere with any election; 6) Permitting any person to enter any facility under the non-County workforce member’s control for

purpose of soliciting or receiving political funds or contributions; 7) Using a County office to confer benefits or detriments in return for political activity, votes, or

corrupt considerations; 8) Expending any public resources to promote any partisan position (includes placing signs and

placards of a political nature on County property); 9) Using any County property, including computers and e-mail for political activities.

NON-COUNTY WORKFORCE MEMBER RIGHT TO REFUSE AN ASPECT OF PATIENT CARE (WORKPLACE RELIGIOUS FREEDOM ACT OF 2005)

If an aspect of patient care or treatment is incompatible with a non-County workforce member’s personal cultural values or religious beliefs, it is the responsibility of the non-County workforce member to notify his/her department/service area manager of his/her desire to be excluded from such duty by submitting a written request that includes documentation of the basis for the request. A non-County workforce member may not refuse to participate in an aspect of care or treatment at the time or just before the time to perform the treatment or procedure. DHS will take every consideration to appropriately address a non-

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County workforce member’s request. A request to refuse to participate may be denied in an emergency situation where there is no other alternative or qualified person available to provide the care or when the life of a patient is in immediate danger. Such requests must be reviewed by DHS Human Resources which may consult with the Department of Human Resources and County Counsel. A written response denying or approving the request will be provided to the non-County workforce member within ten business days. The non-County workforce member may be offered temporary reassignment of duties while his/her request is under review. If the request is approved, the non-County workforce member must maintain written documentation of the request on his/her person at all times.

TRAINING AND IN-SERVICE EDUCATION REQUIREMENTS (JOINT COMMISSION, APPLICABLE MOU/CONTRACT)

Non-County workforce members are required to comply with specific training and in-service education standards established for individual job functions by their assigned department/service areas to meet regulatory standards. To ensure competency, individual non-County workforce members may be required to participate in specific training or in-service education programs beyond the minimum required training or training interval. Non-County workforce members are responsible for: signing the participant sign-in sheets for each session attended; and timely submitting verification of all onsite training/in-service education and related external training or continuing education programs completed to their immediate supervisor/manager.

CHILD SUPPORT COMPLIANCE PROGRAM (BOS POLICY 6.040)

The Los Angeles County Board of Supervisors established the Child Support Program to ensure that individuals who benefit financially from the County, through employment or contract, are in compliance with their court-ordered child and spousal support obligations. The County regularly reports employment and identification information (i.e. name, address, Social Security number) to the State Directory of New Hires as required by State and Federal law. Employment and identification information may also be forwarded to the Department of Child Support Services to help in locating and tracking those persons who owe child/spousal support.

SAFELY SURRENDERED BABY LAW (BOS POLICY 5.135)

Los Angeles County has adopted SB 1368, the Newborn Abandonment Law, often referred to the “Safely Surrendered Baby Law,” that provides that no parent or other person having lawful custody of a minor child 72 hours old or younger may be prosecuted for child abandonment if he or she voluntarily surrenders physical custody of a child to any person on duty at a public or private hospital emergency room, or any additional location designated by the Board of Supervisors.

STATEMENT OF CONFIDENTIALITY (CA PUBLIC RECORDS ACT, HIPAA)

Information or records concerning any client/patient may not be released without proper authorization in accordance with California Civil Code Section 56.10, the California Public Records Act (California Government Code Sec. 6251 et. seq.) and the federal Health Insurance Portability and Accountability Act (HIPAA). Unauthorized release of confidential information will subject that non-County workforce member to appropriate disciplinary action, which may include termination of services, in addition to possible civil action.

SMOKING (DHS POLICY 381)

Non-County workforce members and members of the public shall not smoke or carry any ignited smoking device or product inside a County facility, or in an outdoor area within 20 feet of a main exit, entrance, or operable window of a facility. Some DHS facilities are “No Smoking” campuses. All non-County workforce members must abide by the smoking policy of the DHS facility.

TELEPHONE USAGE (DHS POLICY 861.3)

County telephones, which include County cellular telephones, are for County business. Cellular telephones must be turned off in facilities where they may interfere with medical equipment. California law, effective 7/1/08, prohibits drivers from talking on cellular telephones while driving unless the driver is at least eighteen (18) years old and is using a hands-free device. A workforce member who violates this law may be subject to dismissal in addition to any penalties imposed by a state or local agency. It is recommended that workforce members operating a County vehicle not talk on a cellular telephone (even with hands-free device) while driving but should pull over to a safe location or parking lot to conduct a telephone conversation. Personal calls and the conduct of personal business should be on the non-County workforce member’s

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own time (off duty, lunch or breaks) using public telephones or personal cellular telephones. All cellular telephones must be kept in either “vibrate” or “silent” mode during business hours.

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