Orientation Documentation

Memorial Hospital and Manor is committed to providing excellent care and quality service to our patients and their families, our guest and visitors, and our employees. To help us provide the highest level of service, we have a defined belief system that all employees of this facility are encouraged to embrace and exhibit. We will communicate this belief system through handouts, flyers, information boards, emails, orientation classes, and annual training classes. All current employees and potential new employees are required to sign a statement agreeing to live by our Belief System. This statement summarizes the definitions of our Belief System, and is an acknowledgement and agreement to abide by these standards and live the values of our facility.

Mission:: Our community, our hospital – where we deliver courteous, respectful, safe and quality care to every patient, every time.

Values: Everyone at this small rural Georgia community hospital is committed to providing the best care for every patient, every time. We achieve this focus through our shared values of:

Accountability: is expected. Everyone is held accountable for their role in achieving our mission. Together we take ownership of our work, are responsible for our own decisions and behaviors, and actively empower each other to be jointly responsible for all actions.

Integrity: is never compromised. Acting with integrity allows us to gain the confidence of our patients, our co-workers, and the community we are here to serve. Each one of us uses our knowledge and understanding of each situation to do the right thing at all times.

Trust: is earned. Trust is the key to all successful relationships. Our goal is to work to earn the trust of our patients, our co- workers, and our community each and every day which creates an environment of safety, reliability, and mutual support of our mission.

Teamwork: is required. Teamwork across the organization allows for the merging of diverse ideas which can improve our ability to achieve the mission. We all interact with others in a manner which is positive and productive for a safe and collaborative culture where all voices are valued.

Innovation: is supported. A passionate belief is each other and the mission of the organization is what drives our innovative spirit in problem solving and continuous improvement. Each one of us has unique talents which are valued and utilized to create innovative solutions to the challenges we face.

Compassion: is necessary. Compassion is what defines the healthcare we provide. Everyone faces challenges that we may or may not know or understand. We provide warm and caring services at all times.

Excellence: is a commitment. Our belief in what we do drives us to be the best rural community hospital in the country. In order to provide for the best outcomes and award winning care, we strive at all times to rise about the ordinary through personal and team efforts.

I attest that I have read and understood the contents of this document, and that I further agree to live the values of this facility and follow all established and acceptable standards of conduct. I further agree that I will be a valuable member of the Memorial Hospital and Manor team. I pledge my support to this facility, and my co-workers, and agree to be an active participant in the daily operations of this facility and patient care. I will provide teamwork and assistance as requested, and will willingly seek ways that I can go above and beyond my normal scope of duties to be a helpful member of this team. I also understand that if I am found to not be living the values of this facility, or if I am not following the Belief System, that I may be subject to disciplinary action up to and including termination of employment.

As an employee of Memorial Hospital and Manor, I understand that I will be working with information that is extremely confidential. I understand that the information I may be exposed to during the course of my work is confidential and may not be discussed with anyone outside of my department or this facility, except on an approved as need to know basis. Information that I may come in contact with could be patient, employee, and/or financial records or files; internet information; e-mail information; memorandums; access/security codes and etc. All of this information is considered confidential and should not be discussed with other employees or with anyone outside of this facility, except on an approved as need to know basis.

Electronic and/or paper medical records are sensitive material and extremely confidential. Only those employees directly responsible for a patient’s care should access the information contained within the electronic and/or paper medical record. Copies of medical records should not be made for patients, but a signed authorization from the patient should be submitted to Health Information Management for the release of medical record information. Employees should not view the electronic or paper medical record of anyone not directly related to a specific function of his/her job, and should never view his/her own record or records of family members and/or friends unless directed by the physician for patient care reasons. Regular audits will occur and any violations will result in disciplinary action up to and including termination.

I understand that I may be given a private/personal security code for access to the facility’s computer system; this access/security code is considered extremely confidential and should not be shared or released to anyone other than approved personnel. If I suspect that my security code is being used by someone other than myself, I understand that I am required to report this immediately to my Supervisor. I also understand that releasing, discussing, or divulging my access/security code with anyone could be grounds for disciplinary action up to and including termination. There may be occasions where authorized computer personnel will need my access/security code to enter my computer system and repair or evaluate problems, update software, or review system information; I understand that in these circumstances, I can release some of my security codes to those individuals with the responsibility of repairing or reviewing my computer system. I understand that at no time should I give these designated computer personnel my access/security code that is used to access patient electronic medical records.

By signing this statement, I not only agree to maintain the highest level on confidentiality in all facets of my job, but I also agree to comply with all Facility Privacy Policies and Procedures including those implementing the HIPAA Privacy and Security Rule. I also understand that divulging, discussing, or viewing unauthorized confidential information is grounds for immediate discharge, without prior notice and no accrued benefits will be payable. Confidentiality applies not only while I am employed with this facility, but even after my employment or other relationship with this facility has terminated.

I,_________, an employee, volunteer or other member of the Workforce of Memorial Hospital and Manor, acknowledge that I have completed training on the facility’s privacy policies and the privacy regulations issued under the Health Insurance Portability and Accountability Act of 1996 (also known as the HIPAA Privacy Rule).

• I understand that all patient information, including billing and financial data, is confidential.
• I agree to keep patient information confidential.
• I agree to comply with all Facility Privacy Policies and Procedures including those implementing the HIPAA Privacy Rule.
• I understand that if I violate patient confidentially by using or disclosing patient information improperly, I may be subject to disciplinary action up to and including termination of my employment or termination of my relationship with this facility.
• I understand that if I have any questions or concerns about the Privacy Rule and/or the proper use or disclosure of patient information, I should ask my Supervisor, the Facility’s Privacy Officer, or the Facility’s Compliance Officer.
• I understand and agree that the Facility’s Privacy Policies and Procedures will apply to any patient information I have access to at this facility even after my employment or other relationship with this facility has been terminated.

I do hereby certify that I have received and read the MHM Substance Abuse and Testing Policy. I understand that if my performance indicates it is necessary, or in the case of post-accident testing I will submit to a substance abuse test. I also understand that failure to comply with a substance abuse test request, or a positive result, may lead to termination of employment and denial of unemployment benefits. I understand that failure to submit to a substance abuse test, or a positive result, may affect my right to obtain workers’ compensation benefits. I further agree to and hereby authorize the release of the results of said tests to the company. Nothing in this consent form is to be construed as a contract between parties.

As an employee, volunteer, contractor, or medical staff member of Memorial Hospital & Manor (MHM) or any subsidiary or affiliate thereof, I understand that access to certain information is required for me to perform my duties. Some of this information may concern patients being treated at MHM or it may concern the operations of MHM.

I understand that any patient medical information belongs to the patient. I am only permitted to access patient medical information (whether maintained electronically, on paper, or otherwise), to the extent that it is necessary to provide patient care and perform my duties and in accordance with applicable laws. I also understand that all medical and personal information regarding patients is confidential by law and may not be revealed or discussed with other patients, friends or relatives, or anyone else within or outside of the hospital except as authorized by MHM or required by law.

I also understand that other information regarding the operations of MHM, whether maintained electronically, on paper, or otherwise is confidential. This information may concern information about employees, financial operations, strategic or business plans, quality assurance, utilization review, risk management, research, contracting, procurement, and credentialing of staff. I understand that I am only authorized to access this information if it is required for me to perform my duties. This information should not be discussed with others within or outside MHM except to the extent that this discussion is necessary to perform my duties.

I understand that I am required to protect MHM patient or operations information from loss, misuse, unauthorized access, or unauthorized modification. I also understand that my use of the system may be monitored.

I understand that I may be given a USERID/Password to the MHM network and/or computer system(s). I will safeguard the USERID/Password given to me. I acknowledge that I am strictly prohibited from disclosing my USERID/Password to anyone, including my family, friends, fellow workers, supervisors, and subordinates, for any reason. I agree to contact the Information Technology Service Desk immediately if I suspect that my password is known and/or being used by another person and that I may be required to reveal and/or relinquish my USERID/Password to the Director of Information Technology, or his/her designee. This is the only exception to the use/sharing of passwords.

I understand that I may only use my USERID/Password to perform my duties. I agree that I will not use anyone else’s USERID/Password to obtain access to any MHM computer system(s). I understand that I will be held accountable for all work performed, changes made to the system or databases, or information accessed under my USERID/Password and that I am not to allow anyone else to access the MHM network/computer system using my USERID/Password.

I understand that I may have or be permitted to use portable devices or have remote access to systems containing electronic information for the hospital (i.e., laptop computer, tablet computer, mobile telephone, portable hard disks, terminal services, VPN, etc.). I understand that I must report the loss, theft or misuse of these portable devices or remote access tools regardless if they are my personal property or MHM issued devices or remote connections. I agree to contact the Information Technology Service Desk immediately if I suspect my portable device or remote connection has been compromised.

I understand that failure to follow this policy regarding the confidentiality of information is cause for: termination of employment; termination of an independent contractor relationship; revocation of medical staff membership and privileges; revocation of access to all MHM network/computer systems; and possible legal action by any patient or other person injured by my breach of this policy.

My signature below indications my understanding of the aforementioned mandates regarding the use of any USERID/Password I am assigned pursuant to my responsibilities with MHM, and that I have read and understand the MHM Access to Information Systems Policy.

MHM is committed to providing a safe work environment and to fostering the well-being and health of its employees and patients. That commitment is jeopardized when any MHM employee illegally uses drugs on or off the job, comes to work under their influence, possesses, distributes or sells drugs in the workplace, or abuses alcohol on the job. Therefore, under authority of Georgia Law (O.C.G.A. 34-9-410) MHM has established the following policy:

POLICY:

1. It is a violation of company policy for any employee to use, possess, sell, trade, offer for sale, or offer to buy illegal drugs or otherwise engage in the illegal use of drugs on or off the job.
2. It is a violation of company policy for any employee to report to work under the influence of or while possessing in his or her body, blood, or urine illegal drugs in any detectable amount.
3. It is a violation of company policy for any employee to report to work under the influence of, or impaired by alcohol.
4. It is a violation of company policy for any employee to use prescription drugs illegally, i.e., to use prescription drugs that have not been legally obtained or in a manner or for a purpose other than as prescribed. (However, nothing in this policy precludes the appropriate use of legally prescribed medications.)
5. Refusal to submit to a drug and alcohol test constitutes will result in termination or no offer of employment.
6. 6. Violations of this policy are subject to immediate termination.

PROCEDURE:

Notification of Convictions

As a condition of employment, employees must abide by the terms of this policy and must notify MHM in writing of any conviction of a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction.

Employee Assistance

MHM offers resource information on various means of employee assistance in our community, including but not limited to a list of names, addresses, and telephone numbers of employee assistance programs and local drug rehabilitation programs. Employees are encouraged to use this resource file, located in Human Resources. In addition, we will distribute this information to employees for their confidential use.

General Procedures

An employee reporting to work visibly impaired will be deemed unable to properly perform required duties and will not be allowed to work. If possible, the employee's supervisor will first seek another supervisor's opinion to confirm the employee's status. Next, the supervisor and the HR Manager or Representative will consult privately with the employee to determine the cause of the observation, including whether substance abuse has occurred. If, in the opinion of the supervisor, the employee is considered impaired, a drug and alcohol test will be conducted and the employee will be sent home or to a medical facility by taxi or other safe transportation alternative - depending on the determination of the observed impairment - and accompanied by the supervisor or another employee if necessary. An impaired employee will not be allowed to drive. If an impaired employee insists on driving while under the influence, law enforcement will be notified.

Opportunity to Contest or Explain Test Results

Within 5 working days after receipt of a positive confirmed test result from the laboratory, the applicant/employee will be informed in writing of such positive test result, the consequences of such results, and the options available to the employee or job applicant. A copy of the test results will be provided to the employee or job applicant, upon request.

Employees and job applicants who have a positive confirmed test result may explain or contest the result to the company within five (5) working days after the company contacts the employee or job applicant and shows him/her the positive test result as it was received from the lab in writing.

Confidentiality

The confidentiality of any information received by the company through a substance abuse testing program shall be maintained, except as otherwise provided by law.

Pre-Employment Drug Testing

All job applicants at MHM will undergo testing for the presence of illegal drugs as a condition of employment. Any applicant with a confirmed positive test result will be denied employment. Applicants will be required to submit voluntarily to a specimen test at a laboratory chosen by MHM, and by signing a consent agreement will release MHM from liability. If the physician,Medical Review Officer (MRO), company official, or lab personnel has reasonable suspicion to believe that the job-applicant has tampered with the specimen, the applicant will not be considered for employment.

MHM will not discriminate against applicants for employment because of a past history of drug abuse. It is the current abuse of drugs preventing employees from performing their job properly that MHM will not tolerate.

Individuals who have failed a pre-employment test may initiate another inquiry with the company after a period of not shorter than six (6) months; but they must present themselves drug-free as demonstrated by urinalysis or other specimen test selected by MHM.

Employee Testing

MHM has adopted testing practices to identify employees who use illegal drugs on or off the job or who abuse alcohol on the job. It shall be a condition of employment for all employees to submit to substance abuse testing under the following circumstances:

• When there is reasonable suspicion to believe that an employee is using illegal drugs or abusing alcohol. "Reasonable suspicion" is based on a belief that an employee is using or has used drugs or alcohol in violation of the company's policy drawn from specific objective and articulable facts and reasonable inferences drawn from those facts in light of experience. Among other things, such facts and inferences may be based upon, but not limited to, the following:
1. Observable phenomena while at work such as direct observation of substance abuse or of the physical symptoms or manifestations of being impaired due to substance abuse;
2. Abnormal conduct or erratic behavior while at work or a significant deterioration in work performance;
3. A report of substance abuse provided by a reliable and credible source;
4. Evidence that an individual has tampered with any substance abuse test during his or her employment with the current employer;
5. Information that an employee has caused or contributed to an accident while at work; or
6. Evidence that an employee has used, possessed, sold, solicited, or transferred drugs while working or while on the employer's premises or while operating the employer's vehicle, machinery, or equipment.
• When employees have caused or contributed to an on-the-job injury that resulted in a loss of work time, which means any period of time during which an employee stops performing the normal duties of employment and leaves the place of employment to seek care from a licensed medical provider. The company may also send employees for a substance abuse test if they are involved in on-the-job accidents where personal injury or damage to company property occurs.
• As part of a follow-up program to treatment for drug abuse when an employee has involuntarily entered a rehabilitation program because of a positive confirmed test result. The frequency of such testing shall be a minimum of at least once a year for a two year period after completion of the rehabilitation program. Advance notice of testing shall not be given to the employee.
• When a substance abuse test is conducted as part of a routinely scheduled employee fitness-for-duty medical examination that is part of the company's established policy or that is scheduled routinely for all members of an employment classification or group.

Employees with a confirmed positive test result may, at their own option and expense, have a second confirmation test performed on the same specimen. An employee will not be allowed to submit another specimen for testing. Every specimen that produces a positive confirmed test result will be preserved by the certified laboratory that conducted the confirmation test for a eriod of one year after the result of the test was mailed or otherwise delivered to MHM. During the period after written notification of a positive test result, the employee or job applicant who has provided the specimen may be permitted to have a portion of the specimen retested, at the employee's or job applicant's expense, at another approved laboratory, chosen by the employee or job applicant. The second laboratory must test at equal or greater sensitivity for the drug in question as the first laboratory. The first laboratory that performed the test for the employer is responsible for the transfer of the portion of the specimen to be retested, and for the integrity of the chain of custody during such transfer. The employee will be required to pay for any and allcosts incurred by any additional test(s).

If the physician, company official, MRO or lab personnel has reasonable suspicion to believe that the employee has tampered with the specimen, the employee is subject to disciplinary action up to and including termination.

Alcohol Abuse

The consumption or possession of alcoholic beverages on MHM's premises is prohibited. An employee whose normal faculties are impaired due to the consumption of alcoholic beverages, or whose blood alcohol level tests positive while on duty/company business shall be guilty of misconduct, and shall be subject to discipline up to and including termination. Failure to submit to a required substance abuse test will result in termination.

It is the responsibility of the MHM's supervisors to counsel employees whenever they see changes in performance or behavior that suggest an employee has a drug or alcohol problem. Although it is not the supervisor's job to diagnose personal problems, the supervisor should encourage such employees to seek help and advise them about available resources for getting help. Everyone shares responsibility for maintaining a safe work environment, and co-workers should encourage anyone who has a drug problem to seek help.

The goal of this policy is to balance our respect for individuals with the need to maintain a safe, productive, and drug-free environment. The intent of this policy is to offer a helping hand to those who need it, while sending a clear message that the illegal use of drugs, and the abuse of

Postings

A posting with the following comments will be displayed where it may be easily seen by employees and persons seeking employment: “Because of our concern for the best interest of our employees, it is the desire and intent of Memorial Hospital and Manor to maintain a safe and drug and alcohol free workplace environment. Accordingly, applicants for employment will be required to undergo a drug screen before consideration for employment.”

Application Form

The employment application form includes the following language: “I understand that any offer of employment is conditioned on the successful completion of a test for drug and alcohol abuse and I will, upon request, sign all necessary consent forms. Failure to sign the necessary consent forms will be considered a withdrawal of my application from employment.”

Acceptable use of information systems includes, but is not limited to:

• Using computing resources only for authorized purposes.
• Protecting your computer equipment, user-ID, and password from unauthorized use.
• You are responsible for all activities associated with your user-ID or that originate from your credentials.
• Accessing only files and data that are your own, which are publicly available, or to which you have been given authorized access.
• Using only legal versions of copyrighted software in compliance with vendor license requirements and as approved by the MHM IT department.

Unacceptable use of information systems includes, but is not limited to:

• Using another person’s user-ID or password.
• Using another person’s system, files, or data without permission.
• Attempting to circumvent or subvert system or network security measures.
• Engaging in any activity that might be harmful to systems or to any information stored thereon, such as creating or propagating viruses, disrupting services, or damaging files.
• Using MHM systems for commercial, political, or extensive personal use.
• Installing or using illegal copies of copyrighted software, or any other software provided by the IT department.
• Using mail or messaging services to intimidate or otherwise harass another person.
• Engaging in any other activity that does not comply with the general principles presented above.
• No data shall be shared with any entity that is not on the MHM Business Associates Agreement (BAA) list unless required by law.
• To verify BAA status for a vendor, contact the HIPAA Security Officer or the HIPAA Privacy and Compliance Officer.

It is the responsibility of all users to read Acceptable Use Policy and sign the Acceptable Use Policy Signature Sheet. Employees will sign the form as part of the new hire/orientation package and the form will be maintained as part of the permanent employee file. All existing employees must read the policy and sign the signature sheet as part of the annual evaluation process.

MHM takes protection of our patients’ Protected Health Information (PHI) very seriously. In order to protect our patients’ and employees’ privacy, use the following best practices:

• Access patient records only as needed for your job duties.
• If someone you know is receiving care in your area and you do not feel comfortable participating in their care, notify your supervisor of the relationship to the patient, discontinue care, and do not access that patient’s records.
• Do not access your own records—contact Health Information Management to request a copy of your records.
• Share PHI only with Business Associates, other healthcare providers for continuum of care, or with other entities as required by law.
• Store and transmit PHI only using applications or network locations designated for those purposes. If you have a use case not covered by the list, contact IT and work with them to find an appropriate solution.

• Do not store information such as password, pin numbers, patient health information or any other type of sensitive information on notebook computers or PDA’S as these devices are high risk for theft.
• All portable devices should be password protected.
• While using portable devices, if there is a need to leave the device to perform other duties, lock or enable a password protected screen saver.
• Do not leave portable devices in unsecured areas.
• Do not leave portable devices in a locked or unlocked car, unlocked offices or desks.
• Do not leave portable devices in high volume patient areas, keep close proximity or carry the device with you.
• MHM's owned equipment should be stored in a secure area while not in use.

Use caution when utilizing public Internet Access Points or “Hot Spots” as these public services are usually not secure and are a common ground for hacker and security breaches.

• Utilizing Internet services that is in a manner deemed inappropriate by the guidelines that MHM has put in place is strictly prohibited.
• Failure to comply with MHM’s usage policies, introduces risk and potential security threats or breeches to the organization’s network infrastructure. Compliance Policies and Procedures must be followed while using MHM’s owned equipment.
• If personnel feel that their portable device or password has been compromised in any way contact the IT department immediately.
• Report all thefts to the Human Resources department.

By signing below, I acknowledge that I have received, read and understand the Memorial Hospital and Manor Code of Conduct and Employee Security & Confidentiality Agreement (See Above). By signing this page, I agree to comply with all terms of this Agreement and the Memorial Hospital and Manor Code of Conduct, as may be amended from time to time, as a condition of my continuing employment.