scc general orientation - trainer general orientation - trainer.pdf · lone star pharmacy senior...

1

Welcome!

2

Agenda/Topics to Be Covered

History of Company & Mission StatementWho’s WhoYou & SCCCompany Policies & ExpectationsRequired PaperworkSummary

3

Welcome…“Experience the Difference”

Who is Senior Care Consultants?Caring for People Who Can No Longer Care For ThemselvesIncorporated July 1978We have 15 facilities in the State of Texas

Independent LivingAssisted LivingSkilled NursingAlzheimer’s UnitsSenior Care RehabilitationLone Star PharmacySenior Care at Home

4

History of Company

Senior Care Consultants is a locally owned and operated company.

Our goal is to enhance the lives of each of our residents by providing personalized care, a comfortable environment and stimulating activities.

Corporate office is in Garland, Texas

5

Mission StatementTreat each resident with dignity and respect and to make a difference in the lives of the elderly that have been entrusted to our care Do whatever it takes to meet the ever changing needs of the residentsAccommodate, to the extent possible, the wishes of the families in meeting the needs of their loved onesCreate a homelike environment with loving, supportive and professional staff who share a common goal Make ethical business decisions which impact the lives of the residents, families and employees

6

Mission Statement - Cont.Deal fairly, honestly, and ethically with all residents, families, employees and vendorsEnhance the quality of life in a healing environment which fosters active participation by the residents in the decision making process Place value on each resident's uniqueness and the wisdom which comes from longevity and a lifetime of experience Provide the resident an opportunity to grow, a time to reflect, and a time for them to make a difference

7

Don Miller President

Shane LewisCFO

Julie SchneiderDirector of

Dietary Services

Harold Hammond

Corp Compliance

Director

Mike HenrieDirector of Operations

Eddie BlackRegional Director

Pam Fitzsimmon

sDirector of

Rehab

Adolfo Quiroz

Controller

Corporate Dieticians

Mary FarmerInternal Auditor

Administrators

Administrators

Rehabilitation

Managers

DeLana HoodOffice

Manager

Paulette Burden

Director of Clinical Services

Cindy Wheeler

Director of HR

Jeff PatelIT Director

Regional Nurses

Jeff TaylorProject

Manager

Susan ScafidiAsst.

Controller

Patsy Guibert

Treasurer

Marisa GonzalesBenefit Admin

Charles Goady

Network Admin

Andrew Iglehart

Jr. Network Admin

Who’s Who at SCC

8

Who’s Who at SCCStaff Dev

MDSCoord

Admissions

Business Office

Marketing Payroll/HR

Mainten-ance

Activities

Social Services

House-keepingLaundry

FoodService

ADMINISTRATOR

9

You & SCC

10

You & SCC

Benefits ReviewStandards of ConductEmployee Dress CodeAttendance & ScheduleMeal Breaks & Rest Periods Performance Reviews

11

Benefits Review

Health/Dental OptionsVacation/Sick/HolidaysDisability & Life insuranceRetirement BenefitsQuestions

12

Health Insurance OptionsPPO through Private Healthcare Systems (PHCS)Nationwide network of physicians & facilities – www.phcs.comBenefits are effective the 1st of the month following 90 days of employmentMedical/Prescription Insurance Plans for Licensed & Management Staff

Premier Plan, Basic Plan, or Value Premier Plan – $750 deductible, 80/20 co-insurance, $35/$50 co-pay, Prescription Plan: $15, $30, $45 co-payBasic Plan – $2,250 deductible, 70/30 co-insurance, $35/$50 co-pay, Prescription Plan: after deductible $15, $40, $60Value Plan – $300 deductible, 70/30 co-insurance, $15 co-pay, Prescription Plan: Discount Card. (limited plan)

13

Health Insurance OptionsMedical/Prescription Insurance Plans for Non-Licensed &Part-Time Staff

PPO through Private Healthcare Systems (PHCS)Nationwide network of physicians & facilities – www.phcs.comBenefits are effective the 1st of the month following 90 days of employmentValue Plan- $300 deductible, 70/30 co-insurance, $15 co-pay, Prescription Plan: Discount Card (limited plan)

14

Dental Insurance OptionsDental Insurance

Offered to all Licensed, Management, Non-Licensed Full-Time (30 Hours Per Week) employeesPPO Network Connection Dental – www.ppousa.com$1000 annual maximum, 100/80/50 Plan$50 deductibleOrthodontic $1,500 maximum (per child ages 6 to 19)

15

Vision Coverage

Vision Benefit

Provided with any of the medical plans for all employees.

Includes routine vision exam benefit www.careington.com or 800-290-0523

16

Life Insurance Licensed / Management Employees:

Basic Life & AD&D InsuranceFull-time employees provided with $20,000 group life and accidental death and dismemberment at no cost to the employee

Voluntary Life InsuranceMay purchase additional coverage in $10,000 increments not to exceed 7 x yearly salary or $300,000May purchase coverage for spouse up to 3.5 x yearly salary not to exceed $150,000May purchase $10,000 coverage for each child as long as you elect coverage for yourself.

If Life insurance is not elected at initial eligibility date, employee must complete an Evidence of Insurability form

17

Life Insurance – Cont.Non-Licensed Full-Time Employee (30 hrs or more per week)

Voluntary Life & AD&D

$20,000 of Basic Life/AD&D coverage for $1.90 per pay period – Employee Only$5,000 for spouseMay include $2,500 for each eligible dependent along with employee coverage for $3.14 per pay period

18

Disability Insurance

Long Term Disability

Payable after 90 days of being disabled

Pays 60% of weekly salary maximum of $5000 per month

19

Retirement Benefits

401 (K) Retirement Plan

All employees at least 21 years old and completed one year of service are eligibleMay enroll the first day of each quarter100% vested after 5 years of employmentSCHR matches 50% of every dollar up to 6% of contributionContact Great West 800-456-5112 or www.gwrs.com

20

Vacation Days

Vacation All professional and supervisory personnel will be granted ten (10) days paid vacation on each anniversary date.All other personnel will be granted five (5) days paid vacation after one year of continuous employment and ten (10) days annually after the continuous employment of two years.

Sick DaysSCC does not offer sick time

21

Vacation Days – Cont.

VacationEmployees are eligible to receive vacation days after one-year of “Full Time” 30 hours per week serviceVacation time does not accrue “Use It or Lose It” must be taken within 12-month period from date of eligibilityMust have Supervisor approval fourteen (14) days advance notice to take vacationHourly employees may request to be paid for vacation time opposed to taking time off.Employees who resign without proper notice will not be paid for any unused vacation days.

22

Holidays

HolidaysRegular full-time employees will receive six (6) official holidays per yearNew Years DayMemorial DayIndependence DayLabor DayThanksgiving DayChristmas Day

23

Holidays – Cont.When a holiday falls on an employee’s regular day off, the employee will receive holiday pay for that day provided they have met their work schedule requirements surrounding the holiday

To receive holiday pay you must not have any unauthorized/unexcused absences the day of, the day before, or the day after a holiday

Salaried employees working on a holiday will be given another day off with pay

Non-Exempt employees will be paid for the holiday and any hours they work on a holiday

New employees within probationary period (90 days) will not be paid for the holiday if it falls on a scheduled day off

24

Standards of Conduct

25

Standards of ConductEmployer Standards – (See Signature Form in Folder)

This organization shall comply with all local, state and federal regulations that apply.The organization does not accept bribes, kickbacks or tips for any purpose.The company is not part of the ownership of any other entity that generates referrals to it.All employees are trained on proper business conduct.All employees are given instruction on the company’s Policies and Procedures.All information regarding our client’s medical condition are kept confidential and only released by signature from the client.All insurance claims reflect products or services that are actually delivered.Exact billing codes that match the Certificate of Medical Necessity Diagnosis will be used on all claims.A licensed physician must order and the supplier completes a CMN for medical equipment.All marketing materials and advertisements are honest, informative and non-deceptive.All potential employees are screened and references are checked.

26

Standards of Conduct – cont.Employee Standards

As employees of this facility, you are expected to act in such away as to reflect the Mission Statement of this facility. You are expected to be honest, courteous, accurate, and professional in all of your daily interactions with residents, families, and fellow workers. Treat others as you expect to be treated, with dignity and respect.You are expected to follow the policies and procedures of the facility as well as to obey local, state, and federal laws.You are expected to follow the chain of command when you encounter a problem that you are not able to resolve, except when you are authorized to contact another person under the facility’s policies.You are expected to follow the Employee Handbook.

27

Standards of Conduct - Cont.You are expected to refuse all gifts, tips, or compensation fromresidents, families, and vendors.You are expected to refuse any remuneration for any referrals to or from outside vendors or sources with which the facility does business and report any offer to your supervisor or the Corporate Compliance Officer.You are expected to refrain from engaging in any activity which is fraudulent or in violation of any law relating to providing of care or receiving reimbursement from the Medicare, Medicaid, or other reimbursement programs.You are expected not to engage in any billing or documentation practices which are fraudulent or dishonest.

28

Standards of Conduct - Cont.You are expected to report any activity which you suspect to be illegal or in violation of any Employee Standards of Conduct through regular reporting channels. Employees who do not feel comfortable contacting someone in the chain of command may contact the Corporate Compliance Officer.You are expected to refrain from any conduct which amounts to abuse or neglect of a resident.You are expected to report any suspected abuse or neglect through designated reporting channels.

29

Dress CodeEmployees are expected to report to work in proper uniforms, neat, wrinkle free, and take personal pride in your appearance

Depending on department uniforms may consist ofSCC “Polo” shirtKhaki pantsScrubsBusiness Casual AttireSneakers, or appropriate shoes

Name badges should be worn at all times

Employees should refrain fromInappropriate JewelryToo much cologneFlip flops, sandals, open toed shoes

30

Attendance Policy

SCC relies on the dedication and the excellent work ethic of its employees to provide our residents with excellent care.

This can only be accomplished with your commitment to them, your team members and SCC.

31

Attendance Employees are expected to contact their supervisor a minimum of30 minutes prior to scheduled work time if they are going to be lateIf going to be more than 40 minutes late or absent, you must give at least 2 hours noticeEmployees must speak with a supervisor – voice mails are not acceptableAttendance StandardsTwo tardies/absences in one pay period = Verbal CoachingAny Subsequent tardies in following pay period = Written

Corrective ActionFurther tardiness may result in additional Written Corrective

Action and/or Termination

32

Attendance Policy - Cont.Absences

Failure to make proper notification is considered a no-call/no showOne no call/no show may be grounds for terminationTwo or more absences may result in coaching or corrective actionTwo or more absences each month for three months may result in terminationRoutine absences that do not fall within criteria above may result in corrective action and/or termination

33

Schedules & Rest BreaksSchedules are posted every month by the department supervisorSee your supervisor for any schedule changes or schedule preferencesEmployees are allowed a meal break each shiftEmployees are allowed one – 15 minute rest break

Rest breaks should be taken after two hours of workEmployees may not leave the premises

34

Performance Reviews

35

Performance Reviews

Purpose of reviewsTo have your performance evaluatedSpotlight your good workCorrect Poor PerformanceAllows management to effectively manage personnelAllows for possible compensation increaseAllows for Company and individual goal alignment

36

Performance ReviewsFrequency and timing of reviews

90 day performance and conduct evaluationReviews are conducted annuallyReviews may be conducted when promoted

Outline the review processManagement will set goals, training scheduled Management will review performance on a daily basisManagement will write a formal review and schedule a time for a discussion

37

Company PoliciesResidents RightsAbuse Prohibition TrainingDisaster Plan Review / Safety ReviewCustomer Service / Phone EtiquetteCorporate ComplianceHIPAA TrainingHarassment Free WorkplaceOSHA / Infection Control & Blood Borne Pathogens/MSDS

38

Resident Rights Training

39

Residents RightsSTATEMENT OF RESIDENT RIGHTSYou, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any nursing facility employee to threaten, coerce, intimidate or retaliate against you for exercising your rights.If anyone hurts you, threatens to hurt you, neglects your care, takes your property, or violates your dignity, you have the right to file a complaint with the facility administrator or with the Texas Department of Aging and Disability Services by calling 1-800-458-9858.You have a right:to all care necessary for you to have the highest possible level of health;to safe, decent and clean conditions;to be free from abuse and exploitation;to be treated with courtesy, consideration, and respect;to be free from discrimination based on age, race, religion, sex, nationality, or disability and to practice your own religious beliefs;to privacy, including privacy during visits and telephone calls;

to complain about the facility and organize or participate in any program that presents residents’ concerns to the administrator of facility;to have facility information about you maintained as confidential;to retain services of a physician of your choice, at your own expense or through a health care plan, and to have a physician explain to you, in language you understand, your complete medical condition, the recommended treatment, and the expected results of the treatment, including reasonably expected effects, side effects, and risk associated with psychoactive medications;

40

Residents Rights - Contto participate in developing a plan of care, to refuse treatment, and to refuse to participate in experimental research;to a written statement or admission agreement describing the services provided by the facility and the related charges;to manage your own finances or to delegate that responsibility to another person;to access money and property you have deposited with the facility and to an accounting of your money and property that are deposited with the facility and all financial transactions made with or on behalf of you;to keep and use personal property, secure from theft or loss;to not be relocated within the facility, except in accordance with nursing facility regulations;to receive visitors;to receive unopened mail and to receive assistance in reading or in writing correspondence;to participate in activities inside and outside the facility;to wear your own clothes;to discharge yourself from the facility unless you have been adjudicated mentally incompetent;to not be discharged from the facility, except as provided in the nursing facility regulations; andto be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat your medical symptoms.to receive information about prescribed psychoactive medication from the person who prescribes the medication or that person’s designee, to have any psychoactive medications prescribed and administered in a responsible manner, as mandated by the Health and Safety Code, 242.505, and to refuse to consent to the prescription of psychoactive medication; andplace in the resident’s room an electronic monitoring device that is owned and operated by the resident or provided by the resident’s guardian or legal representative.Your rights may be restricted only to the extent necessary to protect you or another person from danger or to protect a right of another resident, particularly those relating to privacy and confidentiality.

41

Abuse Prohibition Training

42

SCC Abuse Prohibition Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion

Each resident has the right to be free from mistreatment, neglect, and misappropriation of property

SCHR has developed a seven component abuse prohibition program to assure the facility is doing all that is within our control to prevent occurrences of abuse, neglect, & misappropriation of property

43

SCC Abuse Prohibition

Seven Component Program

1. Screening2. Training3. Prevention4. Identification5. Investigation6. Protection7. Reporting

44


Screening Component:All potential employees are screened for a history of abuse, neglect, or mistreatment of residents.

Reference checks from previous employersLicense verificationNurse Aide Registry search prior to employmentOffice of Inspector General Exclusion List searchCriminal History checks within 24 hours of employmentEmployee Misconduct Registry search prior to employment

45


Training Component:

Abuse Prohibition Training during orientationContinued APT through quarterly training/review Instruction of appropriate interventions to deal with aggressive and/or catastrophic reactions of residentsInstruction of how to report allegations without fear of reprisalHow to recognize signs of burnout, frustration, and stressWhat constitutes abuse, neglect, & misappropriation of property.

46

SCC Abuse Prohibition Prevention Component:

Each employee is expected to act according to the Mission Statement of SCCEach employee receives a copy of the Employee Standards of ConductEmployees acknowledge in writing that he/she has been made aware of the requirement of reporting abuse and of the penalty for not reportingFacility cannot retaliate against employees for reporting abuseEstablished missing items policyProvide “Statement of Resident Rights” to residents, responsible parties, and employees

47


Identification Component:Training to become aware of the signs &

symptoms of potentially abusive situations such as:

1. Suspicious Bruising, Swelling, Pain, or other Injuries

2. Sudden changes in Behavior or Personality3. Resident Fear & Anxiety

48

SCC Abuse ProhibitionProtection Component

Protect the resident/residents from any further harm or potential harmUpon notification of suspected abuse or allegation of abuse concerning a staff member:

1. Facility will immediately remove the perpetrator from the facility pending the outcome of the investigation2. Investigation Outcomes:

Confirmation of abuse – termination from employmentInconclusive – reassignment of staff member with 30-day monitoring in place.

49

SCC Abuse Prohibition Protection Component - cont

Resident-to-Resident abuseFacility will immediately protect the resident being abused and all other residentsIf the initial determination is that the perpetrator is a threat to the health & safety of the residents in the facility it we will follow state guidelinesFacility will continue to monitor the resident one-to-one during the discharge processIf a threat does not exist then an appropriate assessment & interventions will be completed. The behavior will be care planned and interventions put in place to protect other residents

50

SCC Abuse ProhibitionInvestigation Component

SCHR has a “ZERO” tolerance policyAll allegations must be investigated fullyReporting Protocol1. Report to immediate supervisor2. If supervisor is not the charge nurse then supervisor reports to

the charge nurse for the resident3. Charge nurse immediately reports to the Director of Nursing or

the Administrator4. The Administrator or designee will follow state reporting

guidelines5. May always report directly to the Administrator

51


Reporting ComponentFacility will follow the state guidelines as outlined in Provider Letter #06-43.All appropriate reporting forms will be faxed to DADS within 5 working days.Administrator & DON will assess to determine if changes in policy and/or procedure need to be made to prevent any further occurrences of abuse

52

SCC Abuse Prohibition Training Agenda

Risk FactorsWho Abuses &/or Neglect AdultsAbuseExamples of AbuseNeglectExamples of NeglectMisappropriation of PropertyExamples of MisappropriationBarriers to DetectionReportingCriminal PenaltiesCopy of Resident Rights Provided

53

When are Adults at Risk?

Adults who are isolatedCaregiver is stressedOthers depend on the vulnerable adult (e.g. Unemployment of abuser)Prior history of violence in the homeIllness or mental incapacity of the abuser

54

Risk Factors – Cont.

☯ Substance abuse by the vulnerable adult and/or the caregiver

☯ Caregiver’s lack of knowledge of the aging process and/or other disability

☯ Caregiver has poor impulse control (e.g. Power and control model from domestic violence)

☯ Lack of social & emotional support

55

Who Abuses and/or Neglects Adults?

Someone the vulnerable adult knows and SHOULD be able to trust, such as:

Family membersFriendsNeighborsStaff of group homes & nursing homeDoctors, nurses, lawyers, aids

56

Caregiver

“Caregiver” means any person or agency responsible for the care of a vulnerable adult because of:

Voluntary assumption of responsibility for care;Rendering services in an adult workshop or residential program;Rendering services in an institution or in a community-based program.

57

What is Resident Abuse?

The misuse of powerExploiting the vulnerable adult to benefit selfForcing the vulnerable adult to do something she/he does not want to doResult = the vulnerable adult is harmed unnecessarily

58

Elder Abuse(A) Attempting to cause harm, intentionally or knowingly causing harm, or intentionally or knowingly placing another in fear of imminent harm;

(B) unreasonable or inappropriate use of physical restraint, medication, or isolation that causes or is likely to cause harm to a vulnerable adult that is in conflict with a physician’s orders or used as an unauthorized substitute for treatment, unless that conduct furthers the health and safety of the adult;

59

Abuse“Abuse” means the intentional or reckless infliction, by

the vulnerable adult’s caregiver, family member or other individual of:

(A) Injury;

(B) Unreasonable confinement which threatens the welfare and well being of a vulnerable adult; or

(C) Intimidation or cruel punishment with resulting physical or emotional harm or pain to a vulnerable adult.

60

Injury

“Injury” means any harm, including disfigurement, impairment of any bodily organ, skin bruising, laceration, bleeding, burn, fracture or dislocation of any bone, subdural hematoma, malnutrition, dehydration or pressure sores.

61

Injury (abuse) Examples:

Striking (with or without an object)Pushing, shoving, shaking, slappingMay also include inappropriate administration of drugs, physical restraints, force-feeding or physical punishment.

62

Physical Abuse - Signs & Symptoms

Bruises, black eyes, welts, lacerations, rope marksBone fracturesOpen wounds, cuts, punctures, untreated injuries in various stages of healingSprains, dislocations, and internal injuries/bleeding

63

Signs & Symptoms

Broken eyeglasses/framesPhysical signs of being restrainedUnder utilization of prescribed drugsSelf report of being hit, slapped, kicked or mistreatedSudden change in behaviorCaregiver’s refusal to allow visitors to see vulnerable adult alone

64

Examples of Emotional AbuseVerbal assaults, intimidation, humiliation Treating a vulnerable adult like an infant; isolating a vulnerable adult from their family, friends, or regular activitiesGiving a vulnerable adult the “silent treatment”Forced social isolation

65

Emotional or Psychological Abuse -Signs and Symptoms

Being emotionally upset or agitatedBeing extremely withdrawn and non-communicative or non responsiveUnusual behavior usually attributed to dementia (i.e. sucking, biting, rocking)Vulnerable adults self report of being verbally or emotionally mistreated.

66

Neglect

“Neglect” means the deprivation of, or failure to provide the minimum food, shelter, clothing, supervision, physical and mental health care, and other care necessary to maintain a vulnerable adult’s life or health, or which may result in a life-threatening situation.

67

Examples of Neglect

MalnutritionDehydrationHypothermia Decubitus ulcersGeneral health deteriorationExcessive dirt or body odorFailure of caregiver to follow orders for personal medication, and/or physician orders

68

Exploitation“Exploitation” means the reckless or intentional act taken by any person, or any use of the power of attorney, conservatorship or guardianship of a vulnerable adult, to obtain control through deception, harassment, intimidation or undue influence over the vulnerable adult’s money, assets or property with the intention of permanently or temporarily depriving the vulnerable adult of the ownership, use, benefit or possession of his money, assets or property.

69

Examples of Exploitation

Taking Social Security or SSI checksAbusing a joint checking accountTaking property and other resources“Accelerating the will”“Protecting the will”Taking personal property or money from resident for personal use while in a facility

70

Exploitation -Signs & Symptoms

Undue interest in vulnerable adult’s money, possessionsMoney not spent to meet vulnerable adult’s needsBills not being paidUnusual money withdrawalsDisparity between assets and living conditions

71

Barriers to Detection

AgeismDiscrimination based on age

Victim reluctance to report due to EmbarrassmentFear of retaliation, abandonment, removal from home, institutionalizationImpaired cognition, depression, severe illness or immobility

72

Barriers – Cont.

Belief that abuse/neglect is deservedBelief that nothing can be doneDesire to protect the perpetrator

Professionals lack of knowledge & skillsFear of liability Time constraints and complexity

73

Duty To ReportHealth Safety Code, Chapter 242.122

Any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been, or may be adversely affected, by abuse or neglect caused by another person, must report the abuse or neglect. Facility staff must also report conduct or conditions resulting in exploitation of residents, serious accidental injury to residents, or hospitalization of residents.

74

Duty To Report – Cont.

Failure to report abuse may result in criminal liability, ranging from a misdemeanor to a felony, with fines ranging from:

$100 to $5000 Time spent in the Texas Department of Corrections

75

Reporting - Cont.

The basis of the reporter’s knowledgeAny collaborative informationAny other relevant information

Names of all individuals involvedWitnesses that actually viewed the incidentThe resident’s statement concerning the incidentWhen & where the incident occurredAny evidence of injury or abuse present on the residents body or in the resident’s actions

76

Remember

No one deserves to be abused or neglectedHelp is availableVulnerable adult abuse/neglect is preventable and treatableOur vulnerable adults deserve to be honored and respected

77

Disaster Plan / Safety

78

Agenda/Topics to Be Covered

Disaster Plan ReviewFire and Disaster Emergency CodesSafety RulesDrugs, Alcohol, FirearmsWork Injury ProgramWorkplace ViolenceBody MechanicsReporting Maintenance Items

79

Disaster Plan

Written PlanRe-setting Fire AlarmEmergency Evacuation PlanFire DrillExterior Safety Features

Fire LaneFire Hydrant

Use of Fire Extinguishers

80

Disaster Plan Review

The purpose of the Disaster Plan is to provide general guidelines for mitigation of and response to natural, technological and manmade hazards that endanger the residents and staff of Senior Care Health and Rehabilitation Center.

81

Responsibility: It shall be the responsibility of the administrator to assure that all personnel are aware of the plan and have training to execute the plan in relation to the disaster or impending disaster.

Delegation of Authority: The Administrator shall have the power to delegate the authority of implementing these policies and procedures, or any part thereof, to other responsible and competent person(s). In the absence of the Administrator, the Senior Nurse, or persons in charge of the shift, for example the 10 – 6 Charge Nurse, shall have this authority until designated otherwise.

Orientation: All personnel will undergo an orientation program including the Emergency Management Plan within ten (10) working days of employment. Records shall be kept to verify that appropriate orientation was provided


82

Emergency Power: The facility is equipped with an emergency power

generator that will provide illumination for means of egress, nurse stations, medication rooms, dining and living rooms, areas immediately outside of exit doors, exit signs and exit directional signs, generator set location and resident room night lights if required.

It additionally supplies power to equipment to maintain the fire detection, alarm, extinguishing systems, life-support systems, nurse calling systems, all facility telephone equipment, and selected red duplex receptacles, which are included in resident corridors, nurse stations, medication rooms.

The generator is diesel powered and is equipped to run continuously for 24 hours on a tank of fuel.


83

Heat: Heat will be furnished by electric space heaters that will be operated from the identified emergency electrical outlets. Space heaters will be supplied by the local Home Depot when the need exists. Space heaters are to be placed in common areas where they will have the most benefit. The facility has ample blankets in supply to accommodate residents.Air: Circulating air will be furnished by circulating fans that will be operated from the identified emergency electrical outlets. Circulating fans will be supplied by the local Home Depot when the need exists. Circulating fans are to be placed in common areas where they will have the most benefit.


84

Supplies: The facility at a minimum maintains a 72-hour supply of nursing supplies and food.

Water: An emergency supply of water for dispensing medication, dietary service and conducting patient care will be provided by United Supermarket and as per written agreement. For additional water, the water heaters and commode tanks will be drained.


85

Fire Alarms: Our facility is equipped with manual fire alarm pull stations that automatically sound the fire alarm when activated. The facility is equipped with smoke detectors which automatically register the designated area (zones) in which the smoke is detected. A master fire alarm is provided at each nurse station. The Fire Alarms System is installed with a stand-by battery and power generator. The alarm is hooked up directly to Total Fire and Safety Company, who calls the Fire Department as needed.

If the fire alarm system, for whatever reason, is out of service for more than four (4) hours in a 24-hour period, the administrator will notify the local fire authority and the DADS regional office of the outage. The facility will immediately begin a fire watch for all parties in the building until the fire alarm system has been returned toservice.


86

Sprinkler System: Our facility is equipped with an automatic “sprinkling system” strategically placed in case of fire.

If the automatic sprinkler system, for whatever reason, is out of service for more than four (4) hours in a 24-hour period, the administrator will notify the local fire authority and the DADS regional office of the outage. The facility will immediately begin a fire watch for all parties in the building until the automatic sprinkler system has been returned to service.


87

In Case of a Fire Sound the alarm.Remove residents from immediate danger.Call 911 and give your name, name of home, location and distinct part of building fire is in.Evacuate residents.Be sure all doors and windows to all rooms are closed.The HVAC system will shut down automatically so fans will not pick up smoke in return air ducts.In removing residents, remove ambulatory first, semi-ambulatory second, w/c residents also, and bed-fast residents last, to avoid confusion.If evacuation or transfer of residents is necessary, use evacuation route plan.


88

Tornado or High Winds Warning ProceduresWhen a TORNADO or HIGH WINDS WARNING has been issued, for this area, the following procedures shall be implemented immediately:

Move all patients to hallways. Leave bed-fast residents in beds. Place beds against wall. Keep away from windows.Have ambulatory and wheelchair patients sit against hallway wall. Keep away from windows.Close all doors to patient rooms.Give each patient a blanket. This will keep them warm and protect them from flying glass.Make sure exits are clear.Keep flashlights readily available.Follow all instructions issued.Remain calm. Reassure patients that they will be safe. Remain with patients. Remain in hallways until an “ALL CLEAR” alarm has been sounded by the person in charge.


89

Bomb Threat ProceduresUpon notification of a bomb threat or that a suspicious looking object has been found, the following action will be taken:

If a bomb threat caller is still on another telephone talking with another employee, dial OPERATOR and report.

Your name and the name of the facilityA bomb threat is being received.The telephone number the caller is using.Request an emergency trace of the call.

Call the Police and/or Fire Department at 911.Commence immediate evacuation of all residents to an open area at least 50 feet from the facility.


90

Bomb Threat – Cont.Call off-duty personnel to assist.Evacuate staff personnel from facility.Meet the local law enforcement personnel and escort to the facility.Provide building plans if possible, to the local law enforcement bomb disposal unit. These are kept in the Administration Office.Have person receiving the bomb threat complete the attached form as soon as possible and remain available.Do not re-enter the building unless cleared by the local law enforcement bomb disposal unit.


91

Suspicious Object Located:Call the Police and Fire Departments at 911 and report exact location and description of the object.Commence evacuation of the residents, starting with those nearest the object. Evacuate to an open area at least 500 feet from the object.Call off-duty personnel, leaving as many windows and doors open to minimize blast and fragmentation damage if explosion occurs.If explosion occurs before evacuation is complete, see page titled “Explosion”.Do not permit re-entry into the building until it is declared safe to do so by the bomb disposal unit or the local law enforcement agency.


92

Bomb Threat Telephone ProceduresBe calm Be courteousListen. Do not interrupt the caller Notify the nearest person if available, by pre-arranged signal while call is on the line.

The signal is: Hold up card stating “BOMB THREAT, TRACE, POLICE.”


93

Pretend difficulty with hearing. Keep caller talking if caller seems agreeable to further

conversation. Ask questions like:

When will it go off? Certain hour___? Time remaining___? What kind of bomb? Where is it located? Building____ Area____ What is your name and address?____ If building is occupied, inform caller that detonation could cause injury or death. Did caller appear familiar with plant or building by his description of the bomb location?____ Write out the message in its entirety and any other comments on a separate sheet of paper and attach to checklist.


94

In the event of an explosion, the following procedures applyPull nearest fire alarm pull station and dial emergency 911.Render first aid as necessary without placing yourself in immediate danger.Call public utilities about gas, electricity, etc.Call physicians, as required.Set up Disaster Control Center to coordinate activities.Recall off-duty personnel as needed.Establish security of area until police arrive.


95

Have all areas of the facility inspected for damage.Have gas, electricity, water and oil systems checked for damage.Have damaged or potentially damaged utilities shut off at main controls.Evacuate patients as necessary.Activate the Triage Unit, if necessary.Establish the Treatment Room, if necessary.Arrange for transportation of fatalities if needed.Identify injured and fatalities.Notify responsible party of disposition of loved one.


96

Discovering A Patient On Fire - ProceduresShould a patient catch on fire, either from a fire, smoking articles, etc. immediately implement the following procedures:

DO NOT LET THE PATIENT PANIC AND RUN.COVER the patient with a blanket.Wrap the blanket around the patient and PAT the fire area. DO NOT FAN. This will only cause the fire to spread and cause additional injuries.IF A BLANKET IS NOT AVAILABLE, ROLL the patient over and over until the fire is out.ONCE THE FIRE IS OUT, COVER THE PATIENT WITH A CLEAN SHEET, TOWEL, etc.DO NOT ATTEMPT TO REMOVE CLOTHING, ETC. FROM THE BURN AREA.Report such incidents to your supervisor immediately.Provide emergency medical treatment as outlined in our NURSING SERVICE PROCEDURES for burn victims.Inspect the area to ensure that sparks have not created another fire, or fire is not present in the area in which the patient was discovered.


97

Chemical Spills Procedures - OutsideThe following action should be taken by facility staff in the event of an outdoor chemical spill:Shut down outside intake ventilation.Close all doors to the outside and close and lock all windows.Maintenance staff should set all ventilation systems to 100% recirculation so that no outside air is drawn into the building. When this is not possible, ventilation systems should be turned off. This is accomplished by pulling the fire alarm.Turn off all heating systems.Turn off all air conditioners and switch inlets to the “closed” position. Seal any gaps around window type air conditioners with tape and plastic sheeting, wax paper or aluminum wrap.


98

Turn off all exhaust fans in kitchens and bathrooms.Close all internal doors as possible in the building.Use tape and plastic food wrapping, wax paper or aluminum wrap to cover and seal bathroom exhaust fan grills, range vents, dryer vents, and other openings to the outside.If the gas or vapor is soluble or partially soluble in water, hold a wet cloth over your nose and mouth if gases start to bother you. For a higher degree of protection, go to the bathroom, close the door and turn on the shower in a strong spray to wash the air.If an explosion is possible outdoors, close drapes, curtains or shades over windows. Stay away from external windows to prevent injury from flying glass.Tune into the Emergency Broadcasting System on the radio or television for further information and guidance.Law enforcement agencies will make a determination regarding possible evacuation of residents.


99

Fire ExtinguishersFive and/or ten pound, ABC, fire extinguishers are located in all wings to where there is no more than 75 feet of travel in any direction to reach one. These extinguishers are to be used on Class A, B, and C fires such as wood, paper, trash, cotton, clothing, oil or grease fires, electric motors and etc. Five and/or ten pound, ABC and K, fire extinguishers are available in the kitchen and ABC extinguishers in the laundry area. These may be utilized if needed. All personnel will have training on the use of the extinguishers


100

Fire Extinguisher Usage ProcedureRemove fire extinguisher from holder on wall.Hold the fire extinguisher upright.Pull the pin on the handle of the fire extinguisher.Point the nozzle of the hose towards the base of the flame.Squeeze the lever until the fire is out.


101

Specific Job Assignments

During disaster or emergency situations, specific job assignments become necessary.

Each department shall have specific job assignments and shall be expected to carry out such assignments to the best of their ability.


102

Dietary PersonnelTurn off gas and machinery.Help as directed, reporting to maintenance supervisor.

Laundry PersonnelAssemble blankets and protective clothing.Help as directed, reporting to maintenance supervisor.


103

Response to Fire Alarm and FireGeneral Instruction (Department

Responsibility):When alarm sounds, nurse on Station One will go immediately to fire panel, get zone number from the panel, pick up the intercom and relate zone to Station Two. If nurse is not near Station One, medical or other aide will check fire panel and relate zone to other station.Nurse responsible for zone where fire is located will conduct search for fire and the evacuation of residents in that area, using aides and any other personnel in that area. If more help is needed, use intercom or send someone for help.


104

The nurse and aides assigned to different wings shall stay in their assigned areas to stand by for evacuation procedures unless ordered by person in charge to assist in the immediate areas of danger.

Dietitians, housekeepers, janitors, and maintenance personnel will see that their respective duties are carried out. Dietary staff will see that gas to stove is turned off in the kitchen area and assist in controlling or removing patients from dining area if ordered to do so, and see that kitchen area is closed off and also the dining area.

Housekeepers and janitors shall see that all storage areas, such as housekeeping and janitor’s room, utility room, linen room, etc. are closed off and assist in other ways as requested. Maintenance Supervisor should check daily to be sure all emergency equipment is operable for all emergencies.


105

Maintenance Supervisor will see that the fan system is turned off immediately to alleviate the danger of smoke spreading over the home in the event of a fire and see that emergency lighting system is operable for all emergencies. When Maintenance Supervisor is not on duty, a competent person will be assigned his duties.


106

Fire CausesUnsupervised Patient SmokingLaundry FiresElectrical FiresArson

REMEMBER – R.A.C.E.Rescue – anyone in the immediate area of the fireAlert the staff by activating the fire alarm system using Dr. RedConfine the fire by closing all doors and windows in the areaEvacuate the residents to a safe area – Ambulatory, wheelchairs, bed bound

107

Emergency Codes

Dr. Red – FireDr. Wind – Tornado What other Codes are at your facility?

108

Tour of facility noting fire doors, fire extinguisher locations, etc.Demonstration of how to operate the fire panel & fire extinguisher


109

Work Injury ProgramAll injuries should be reported to administrator/manager regardless of how small by the end of your shiftIn the event of life threatening emergency call 911If you need non-emergency care, please see your administrator or manager for the approved facility and/or physician If medical treatment is sought, a drug test will be required within 24 hours of treatment regardless of injury

110

Drugs, Alcohol, Firearms

The sale, purchase, transfer or position of any illegal drugs or alcohol while in the facility is prohibitedThe consumption or being under the influence of drugs or alcohol is prohibitedPlease let your supervisor know if you are taking any prescribed medicine that may effect your job dutiesFirearms are not allowed on the premises

111

Workplace ViolenceSCC wants a safe working environment for all its teammembers, residents and guests

Making threats or engaging in violent behavior oractivities is strictly prohibited

Report all dangerous situations to a supervisor, administrator, or Human Resources

ZERO Tolerance

112

Body MechanicsErgonomics

The applied science of equipment design, as for the workplace, intended to maximize productivity by reducing operator fatigue and discomfort. Also called biotechnology, or human engineering

Knowledge of basic ergonomics principles is important for both workers and employers because both share responsibility for a safe work environment. One can easily imagine the potential hazards in manufacturing settings where equipment is operated and heavy materials are handled, but hazards exist in other environments, too. And technology (especially computer use) has brought about widespread changes in how work is accomplished.

Attention to ergonomics principles helps to reduce workplace injuries and illnesses that result in workers' compensation costs, medical claims, and lost work time. Many disorders and injuries are preventable when work conditions are designed for human safety and comfort.

113

Body Mechanics - ContSitting at the PC

Refocus eyesStretchHave equipment properly aligned

Transferring or Moving ResidentsGet TrainedTeam Lifting

Lifting Heavy ItemsUse the Proper toolsTeam Lifting

114

Handling and Storage of Regular and Liquid Oxygen

Storage of Oxygen cylinders should be secured with chains, carts or stands whether in use or not – never leave an oxygen cylinder free standingTurn off Oxygen cylinders when not usingDo not store Oxygen cylinders with other combustible gases or flammable materialsOxygen cylinders must be tagged of the contentsKeep tools used for Oxygen cylinders clean and free of greaseNO SMOKING or open flames in areas where oxygen is being administeredNo Smoking signs should be visible where oxygen is being usedOxygen cylinders are not to be stored in resident’s roomsDo not drag Oxygen cylinders

115

Handling and Storage of Regular and Liquid Oxygen – Cont.

No smoking signs must be securely placed on the residents bed or on the door to the room when oxygen is in useOnly licensed personnel may remove a No smoking signAll oxygen cylinders will have a “no smoking” sticker on themAll electrical devises should be plugged in prior to administering Oxygen and Oxygen should be turned off if unplugging something electricalLotions, oils, alcohol or other flammable compounds shall be strictly prohibited from use on resident during oxygen use and these materials will be removed from area before oxygen is usedReport all violations immediately

116

Reporting Maintenance Items

Do not use any equipment that is broken, appears to be broken, or is not working properlyReport any equipment failure to the maintenance department or your immediate supervisorLog broken equipment in the equipment log book at the nurse stationTag the equipment and remove from the work area

117

Customer Service & Phone Etiquette

118

Customer Service

Who is your customer?The ResidentYour co-workerThe VendorThe Resident’s familyPeople who call on the phone

119

Customer Service

Develop a Customer Friendly Attitude!

View your customers as the most important part of your job….not as an interruptionCommunicating and establishing relationships are the essence of your jobRemember….you only have one chance to make a first impression

120

Customer ServiceSelf evaluation – discover the quality of service you provide

0=Rarely 1=Sometimes 2=Often 3=Almost always___ When having a conversation with a customer, do I give him or her my complete attention and avoid doing other

activities, (working on the computer, writing unnecessarily, reading emails etc?

___ Do I make eye contact when speaking with a customer to show that I am paying attention?

___ When speaking to a customer over the phone, do I make an effort to use inflection in my voice to convey interest and concern?

___ Do I pick up the telephone by the third ring?

___ When I need to put a customer on hold, do I ask there permission and wait for a response for doing so?

___ Do I avoid technical jargon and use language that the customer can understand?

___ When I cannot provide my customer with exactly what he or she wants, do I suggest options and alternatives?

___ Do I sincerely apologize to the customer when a mistake has been made by me or SCC?

___ When a customer is voice a complaint, do I remain calm and understanding – even I think they are wrong?

___ Do I view customer complaints as an opportunity to improve service rather than as a problem that is taking up valuable time?

121

How did you do on the survey?0-12 points – Bronze Medal

Are you new to customer service?This class will help you!

13-22 points – Silver MedalGreat start – solid understandingWork on being consistent with your customer service

23 to 30 points – GOLD MEDALCongratulations – you are a professionalContinue to challenge yourself

Now – retake the test and change customer to team member – how did you do?

Customer Service

122

Body LanguageKnow what your body language tells someoneIf over or under done, body language can create a negative impression

Name that feelingYou are walking up to the bank teller with rolled coins and theyroll there eyes?You go to speak to a resident and their family member is there with their arms crossed

Great Body Language SkillsEye ContactFacial expressionsBody posture and movementHand gesturesTouchingPhysical Distance

Customer Service

123

Customer ServiceWhat to do with a difficult customer

Let the customer ventAvoid getting trapped in a negative filterExpress empathy to the customerBegin active problem solvingMutually agree on the solutionFollow upALWAYS THINK – WHAT DOES THIS CUSTOMER NEED AND HOW CAN I PROVIDE IT?

124

The Tone of your Voice! Over the phone – 86% is how the message is received and ….Face to Face – 38%

What do these tones say?MonotoneSlowHigh Pitched and EmphaticAbrupt and LoudHigh pitch with drawn out speed

Customer Service

125

Phone EtiquetteCreate a Good First Impression

Try to answer the phone within 3 rings. Start with a Good Morning, Good Afternoon or Good Evening – this sets the toneNext – announce who you are – this is Suzie in Dietary, how may I help you?Smile - it shows, even through the phone lines Ask the caller for their name, even if their name is not necessary for the call.Use their name if you know it. Speak clearly and slowly. Never talk with anything in your mouth, Even GUM…

126

Phone EtiquettePutting Callers on Hold

When putting a caller on hold, always ask permission.If they ask why, provide them with the answer. Examples:"Would you mind holding while I get your file?""Can you hold briefly while I see if Mr. Jones is available?“When taking a caller off of hold, always thank them for holding

127

Phone Etiquette

Transferring a CallerIf the caller needs to speak to another person or department, please transfer the caller directly to the desired person's extension, not to the operator. When transferring a caller, tell them who you are transferring them to, and announce the caller to the person you are transferring them to.

128

Phone EtiquetteTaking Phone Messages

When taking a phone message for someone, always be sure to include the following information:

Caller's name and company name if applicable Time and date of call What the call is regarding If the caller wants a return phone call, and if so, Obtain a phone number that is best to return the callGO THE EXTRA MILE!

129

Phone EtiquetteLast Impressions

Before hanging up, be sure that you have answered all the caller's questions Always end with a pleasantry: "Have a nice day" or "It was nice speaking with you" Let the caller hang up first. This shows the caller that you weren't in a hurry to get off the phone with them

130

Corporate Compliance

131


What is Corporate Compliance?Who Does It?When Do We Need This?How Does Corporate Compliance Happen?

132

Corporate ComplianceWhat is Corporate Compliance?

Corporate Compliance is a term that refers to the rules, processes, or laws by which businesses are operated, regulated, and controlled. The term can refer to internal factors defined by the officers, stockholders or constitution of a corporation, as well as to external forces such as consumer groups, clients, and government regulations.

133


Who Does It?We are all responsible for corporate compliance and adhering to rules and regulations.The SCC corporate compliance officer is Harold Hammond.Harold and a committee of 4 corporate staff members oversee SCC corporate compliance program.Facility Staff Members are responsible for reporting any suspected violations of Federal, State, or Local laws.

134


When do we need this?Every team member is responsible for daily compliance.Corporate Compliance regularly visits each facility to audit compliance.Corporate Compliance is essential to ensure each facility and the entire corporation is following the laws and regulations set by Federal, State, & Local agencies.

135

Corporate ComplianceHow Does Corporate Compliance Happen?

Internal & External AuditsInternal Audits – Harold Hammond and Mary Farmer,

Corporate Directors, Etc.External Audits – Performed by contracted vendors,

DADS, Department of Health, etc.Customer Service SurveysResident & Family Surveys sent by corporate office to

monitor services and receive feedback Vendor Credentialing All vendors are credentialed through a process of

obtaining copies of licensure, certification, insurance, OIG verifications, etc.

136

Harassment Free Work Place

137

Harassment is a form of unlawful discrimination that includes all types of physical or verbal conduct showing hostility toward a person because of that person’s sex, race, color, religion, national origin, age, or disability.

Title VII of the Civil Rights Act of 1964 and 1991

EEOC agency protects employees rights

What is HarassmentHarassment Free Workplace

138

Sexual Harassment

Receives the most attention from the MediaInvolves: unwelcome sexual advances, requests for sexual favors, verbal/physical conduct of a sexual natureHostile work environmentQuid pro quo

Harassment Free Workplace

139

Occurs when unwelcome, sexual conduct unreasonably interferes with an individual’s job - creates intimidating, hostile or offensive work environment

Examples:Continuously asking someone out on a dateInappropriate sexual languageInappropriate sexual reading materials, screen savers, calendars, etc.Unwanted touching, pinching, groping, gestures, etc.Inappropriate name calling: Honey, Baby, Sweet Cheeks, Darling

Hostile Work EnvironmentHarassment Free Workplace

140

Quid Pro Quo Sexual HarassmentVery seriousOccurs when someone in the position of authority promises or threatens an employment action based upon an employee’s willingness or unwillingness to participate in a personal or sexual relationship.

Examples:Asking for sexual favorsPromises of promotions or raises for sexual favors


141

Harassment FactsHarassment can occur:employee to employeeemployee to managementmanagement to employeefemale to malemale to femalefemale to femalemale to male


142

Harassment Free WorkplaceHarassment by Non-EmployeesWitnesses or OnlookersHarassment away from work

What is your responsibility?Abide by harassment free policyRefrain from engaging in inappropriate conductInform company of any incidents of harassment


143

Reporting Harassment

Who should I tell?Supervisor, Manager, Human Resources, AdministratorAll reports will be kept as confidential as possibleAn investigation will begin with every report

Fact Gathering, witness interviewingAppropriate action will take place


144

Retaliation

Retaliation is against the law

This includes: negative personnel actions, undesirable transfer, demotion, or termination

All reports of retaliation should be reported to Human Resources or the Administrator


145

HIPAA Training

146

What is HIPAA?

Enacted to accomplish a number of health care policy goals:

Ensure health insurance portabilityIncrease resources to combat fraud and abuse through AccountabilityEncourage health care businesses to use electronic transactionsCreate national resident record standards.

HIPAA Privacy and Security

147

Accountability and EnforcementOffice of Civil Rights under the Department of Health and Human Services and the Department of Justice under the U.S. Attorney’s Office are charged with the enforcement of this new federal program.

Penalties of $100 per violation up to a maximum of $25,000 per person for all identical violations in a calendar year.

For knowingly disclosing individually identifiable health information, the statute establishes a fine up to $50,000 or imprisonment up to one year; with criminal intent, $250,000 and ten years.

148

Protected Health Information

Information that identifies an individual and describes his/her medical condition or treatmentSpecifically includes:

a. Clinical information.b. Information on payment.c. Basic demographic information.d. Name, address, and telephone number

Applies to all verbal, written, and electronic communication in any form.

149

Use and Disclosure of Protected Health Information

Information is used by our staff members for treatment, payment, and health care operations such as

Collection of information by nursing staffReview of resident records by nursing staffCompletion of billing forms by corporate billingAccounting and bookkeeping entries

Information is disclosed by our staff members when it is shared with others such as

Transmission of information to a health planTransmission of information to a billing serviceTransmission of prescriptions to a pharmacyConsultation with an independent providerReporting to government agencies

150

Keep It To The Minimum Necessary

Definition--HIPAA limits use and disclosure of protected health information to the ‘minimum necessary’ to accomplish an intended purpose. Examples:

Any information requested for treatmentAny information in a standard transactionInformation required by administrative taskInformation specified in request form

Law enforcement officialsRegulatory officialsSubpoena or court order

Request for protected health information should contain two things:A specific description of the requested informationAn explanation of why the information is needed. Why should include enough information to allow the person who receives it to confirm that the information

151

Obtaining Authorization for Use and Disclosure of Protected Health Information

Required for uses and disclosures other than for TreatmentPaymentHealth Care OperationsCompliance with legal mandates

Signed by the resident or resident’s personal representative.

Examples of use and disclosure that require authorization are research studies and the sale of mailing lists to other organizations.

An authorization must identify the information to be disclosed or used, how the information will be used, and who will use it. The authorization must be signed by the resident or by the resident’s representative if the resident is unable to sign.

152

Notice of Privacy Practices

A notice given to each resident describing how the facility will use and disclose the resident’s health information and outlining the resident’s rights under HIPAA.

The notice describes the rights of residents toauthorize certain uses and disclosures of informationrequest an accounting of certain uses and disclosuresinspect their own recordsrequest corrections in informationrequest confidential communications

Acknowledgement-Written documentation must be maintained that the notice was provided to a resident, either signed by the resident or completed by a staff member explaining why the resident did not sign. “Good faith effort”.

Notice must be posted in the facility and on the facility web site.

153

Handling Suspected Violations of Privacy Policies and Procedures

Two types of violations of privacy policies and procedures:Technical violations that do not result in the use or disclosure of protected health information; andViolations that do involve the use and disclosure of protected health information.

Two types of violations that involve use and disclosure:Unintentional or accidental uses or disclosures; andIntentional and deliberate uses and disclosures.

The severity of penalties varies based on the type of violation.Most severe—apply to intentional disclosureLeast severe—apply to unintentional technical violations where there was no disclosure.

154

Examples of Violations

Technical—When obtaining an authorization, the staff member fails to notice that the form is not dated.

Accidental—Information on two residents is accidentally mixed-up, and the wrong information is sent to third party payers.

Intentional—Staff member provides a drug company representative a list of residents with an identified medical condition without obtaining the resident’s authorization for disclosure.

155

HIPAA Incident Report and Investigation

Incident Reporting and Investigation. Reporting is designed to detect and resolve in a timely manner any adverse event that would affect the security of our resident information.

Reporting Requirements. All staff members must immediately report actual or suspected security intrusions, incidents and violations to their supervisors who will then evaluate and determine if there is a breach of privacy or security. If so, then the administrator must be notified. The Corporate Security and Privacy Officer must be investigated. Adverse events may result in the following:

unauthorized access to information systems and resident informationunauthorized alteration, damage, or destruction of informationunauthorized release of datadisruption of information system operation that may impair access to resident information.

156

HIPAA Incident Report and Investigation – Cont.

Violations will be documented in the employee’s personnel file with penalties ranging from transfer to another position, written reprimand, suspension, or termination of the employee.

There will be no retaliation against any employee who reports violations of the privacy/security standards.

157

Physical Configuration of Work Areas. Work areas are maintained so that equipment can be positioned to prevent unauthorized persons, including residents and vendors, from viewing resident information that may be displayed on a workstation monitor.

Workstation Configuration. All workstations (i.e., computers connected to the corporate network server) must require users tolog on before accessing resident information. Workstations will display a warning that reminds users of the facility’s security requirements before permitting them to access resident information.

Workstation Usage. All staff members must comply with the following requirements to protect the security of information accessed from a workstation:

Workstation Security

158

Workstation Security – Cont.Do not permit another staff person to use his or her workstation without first logging off and having the other staff person log on using his or her own user ID and password unless the logging off and on would endanger the health and safety of a resident, and only when the other staff person is known to be authorized to access resident records

Log off of his or her workstation whenever it will be left unattended for any length of time

Shut down his or her workstation at the end of the business day

Promptly report any virus alerts to the Corporate Security Officer

Install and use only software that has been approved by the Corporate Security Officer ( personal software, hardware components, screen savers, etc. not approved by the Corporate Security Officer should not be used or installed)

Access should only be used to access information needed to do your job—minimum necessary

Workstations will be protected from power surges with appropriate surge suppression devices

Smoking, drinking, and eating is prohibited in the immediate vicinity of computer equipment and information storage media

159

Workstation Security – Cont.E-mail use is to be used for business purposes only—sending or receiving offensive content or attachments is strictly prohibited. Sharing or opening attached files from an unknown source can open the door to viruses and hackers. Never send confidential information about a resident in an e-mail over a public network unless it is encrypted. Always double check the address line just before sending the message to ensure that it doesn’t go to the wrong person. Your e-mail sent outside of the network system must contain a confidentiality statement to direct the person if the e-mail is sent to the wrong person

Internet use is to be used for business purposes only—downloading offensive material is strictly prohibited.

Protected resident information downloaded from the computer shall be kept confidential and disposed of in accordance with facility policy

Before a computer is discarded, all resident health information must be removed from the hard drive

160

Workstation Security – Cont.Laptop computers must never be left in unattended vehicles and disks with resident health information must not be stored with the computer in case of theft. Report all thefts immediately to yoursupervisor

Faxed resident health information needs to be faxed to a secure location. Verification should be made to ensure that the person received the fax. Do not allow faxes to remain on the machine unattended. Always ensure that the number you are faxing to is correct before pushing the start button. Dispose or file the fax before others can see it. Always ensure that the fax you are faxing has a confidential fax cover sheet that states what to do with the fax if it is sent to the wrong party. Notify your supervisor if this happens

All workstation users have signed a confidentiality agreement that they will not disclose or compromise the confidentiality of resident information during their employment at the facility or corporate level and after that relationship has been terminated.

161

User Password PoliciesPasswords will be established and maintained by the user.

Rules for Password Selection. A user password must contain at least four characters. The password must not contain the user’s ID and must be different from the user’s previous password. (The network staff will implement measures for automatic password validation and will enforce this policy)

Users should select passwords that do not contain a users name or nickname, a family member’s name, a pet’s name, social security number, or a birthday or anniversary.

Users should not select passwords that can be easily guessed because they refer to a hobby, favorite sports team, musical group, or personal characteristic. The password should not merely be a variation of the previous password and be so complicated that they must be written down. Most important, users should not write down their passwords or post them on their monitor or walls. Never share or disclose their password to other staff members.

162

User Password Policies – Cont.Updating and Maintenance of Passwords. A user will change his or her password every thirty (30) days when prompted on his or her computer to do so. A reminder will be issued to the staff member to update his or her password fourteen (14) days prior to the password’s expiration date. This warning will be repeated every day when the user logs onto the system. Failure to do so will cause you to lose your access.

Validating Passwords. Our information system is protected by passwords and the user’s account will be locked out if more than three (3) incorrect attempts are made to log on. A user whois locked out must contact the Corporate Security Officer to request a new password.

163

User Password Policies – Cont.

Issuance of New Passwords. A user who has forgotten his or her password, who believes that his or her password has been known to another user, or who has been locked out of the system, must contact the Corporate Security Officer. The password administrator will confirm the identity of the user and reset the password in a manner that will require the user to select a new password the next time he or she logs on.

164

Disaster and Recovery PlansSenior Care maintains a contingency plan for responding to natural disasters, vandalism (including computer viruses), system failures, power failures or other events that would disrupt normal operation of the resident’s information systems

Contingency Plans. The network system is maintained at the corporate office. The Corporate Security Officer has in place procedures that will provide backup hardware in case of equipment failure. Backup procedures are in place to ensure that critical applications and information backup regularly to prevent permanent loss of information due to any system failure or natural disaster. A disaster recovery plan is also in place to ensure that restoration of informational services is restored immediately after a disaster occurs. This plan will be implemented by corporate staff under the direction of the Corporate Security Officer.

165

Maintaining Records

All protected health information in your possession must be safeguarded at all times. This means not leaving this information in a heavily trafficked area unattended and always returning the information to a secure area.

Never discard paper resident health information intact into a wastebasket. This information should be either be shredded or locked in a secure location prior to shredding or disposal.

166

HIPAA Conclusion

Effective date of the HIPAA Privacy Rule is April 14, 2003 and the effective date for the security portion of the HIPAA Security Rule is April 21, 2005. Harold Hammond, Corporate Privacy Officer, has been designated as responsible for the development and implementation of privacy policies and procedures for all Senior Care facilities. He is the contact person for further information and receiving complaints about privacy practices.

Jeff Patel, Corporate Security Officer, has been designated as responsible for the establishment, development, implementation and adherence to policies and procedures that guide and support the provisions of information security services for all Senior Care facilities. He is the contact person for further information and receiving complaints about security practices.

167

OSHA / Infection Control & Blood Borne Pathogens

168

Why Are We Here?

OSHA Blood Borne Pathogen standardanyone whose job requires exposure to BB pathogens is required to complete trainingemployees who are trained in CPR and first aid

The more you know, the better you will perform in real situations!

169

What is a Blood Borne Pathogen?

Microorganisms that are carried in the blood that can cause disease in humans at can cause disease in humans

170

Common BB Pathogen Diseases

Hepatitis B(HBV)Hepatitis C(HCV)Human Immunodeficiency Virus (HIV)

171

HIV is the virus that leads to AIDS

HIV depletes the immune system

HIV does not survive well outside the body

No threat on contracting HIV through casual contact

Human Immunodeficiency Virus (HIV)

172

Hepatitis B (HBV)

1—1.25 million Americans are chronically infectedSymptoms include: jaundice, fatigue, abdominal pain, loss of appetite, intermittent nausea , vomiting

May lead to chronic liver disease, liver cancer, and deathVaccination available since 1982HBV can survive for at least one week in dried bloodSymptoms can occur 1-9 months after exposure

173

Hepatitis C (HCV)

Hepatitis C is the most common chronic blood borne infection in the United States

Symptoms include: jaundice, fatigue, abdominal pain, loss of appetite, intermittent nausea, vomiting

May lead to chronic liver disease and death

174

Potentially Infectious Bodily Fluids

Skin tissue, cell culturesAny other bodily fluidBloodSalivaVomitUrineSemen or vaginal secretions

175

Transmission Potential

Contact with another person’s blood or bodily fluid that may contain bloodMucous membranes: eyes, mouth, noseNon-intact skinContaminated sharps/needles

176

Your Exposure Potential

Incontinent Care of ResidentsCleaning Resident Bedding Administering First AidHandling Returned ProductPost-accident cleanupJanitorial or maintenance workHandling of any waste productsIndustrial accident

177

Universal Precautions

Use of proper PPETreat all blood and bodily fluids as if they are contaminatedProper cleanup and decontaminationDisposal of all contaminated material in the proper manner

178

Personal Protective Equipment (PPE)

Anything that is used to protect a person from exposure

Latex or Non-Latex gloves, goggles, CPR mouth barriers, aprons, respirators

179

PPE Rules to Remember

Always check PPE for defects or tears before using

If PPE becomes torn or defective remove and get new

Remove PPE before leaving a contaminated area

Do not reuse disposable equipment

180

Decontamination

When cleaning up surfaces use a chlorine or bleach based disinfectant

Do an initial wipe up

Notify Housekeeping to disinfect

Dispose of all material used in biohazard containers

PPE should be removed and disposed of in biohazard containers

181

Hand WashingWash hands immediately after removing PPEUse a soft antibacterial soapA hand sanitizer can be used but wash with soap and water as soon as possible.

182

Regulated Medical Waste

Liquid or semi-liquid blood or other potentially infectious material(OPIM)Contaminated items that would release blood or OPIM when compressedContaminated sharpsPathological and microbiological waste containing blood or OPIM

183

Signs & LabelsLabels must include the universal biohazard symbol, and the term “Biohazard” must be attached to:

containers of regulated biohazard wasterefrigerators or freezers containing blood or OPIMcontainers used to store, transport, or ship blood or OPIM

184

Exposure IncidentA specific incident of contact with potentially infectious bodily fluid

If there are no infiltrations of mucous membranes or open skin surfaces, it is not considered an occupational exposure

Report all accidents involving blood or bodily fluids

Post-exposure medical evaluations are offered

185

Post-exposure EvaluationConfidential medical evaluation

Document route of exposure

Identify source individual

Test source individuals blood (with individuals consent)

Provide results to exposed employee

186

Hepatitis B Vaccination

Strongly endorsed by medical communities

Offered to all employees

Provided at no cost to employees

Declination form

187

RecordkeepingMedical records include:

Hepatitis B vaccination statusPost-exposure evaluation and follow-up results

Training records include:Training datesContents of the trainingSignature of trainer and trainee

188

In ConclusionBB pathogen rules are in place for your health and safety.Failure to follow them is a risk that does not need to be taken.

189

Hazard Communication

190

Hazard Communication

In order to ensure chemical safety in the workplace, information must be available about the identities and hazards of the chemical

OSHA’s Hazard Communication Standard, (HCS) requires the development and dissemination of such information

191

Hazard CommunicationChemical Manufacturers and Importers are required to evaluate the hazard of the chemical they produce or import

Prepare labels and materials safety data sheets (MSDS) to convey the hazard information to their customers

All employers with hazardous chemicals in their work place must have labels and an MSDS for their exposed workers; in addition train them to handle the chemicals appropriately.

192

Hazard CommunicationThe MSDS binders are located in each department and in each nurses station

They will provide information and instructions for safe use, identify health risks, and describe first aid and safety precautions.

Remember:Never use unlabeled productsKeep all chemicals secured, in-sight, and away from residentsKeep them properly stored and away from any food or beverages

193

Required Paperwork

194

Required Paperwork

New Hire Employee FormsI9 and documentationW4Handbook Signature formsFacility Signature forms8850

scc general orientation - trainer general orientation - trainer.pdf · lone star pharmacy senior...

Documents