POLICY:Signage and Posting Policy / POLICY NUMBER: 100.102
Original/Rewrite: 12/05/2011
Revised: 06/113/2012
Originating Dept:Administration
Applies to Depts:All
POLICY:
This policy establishes guidelines for the creation, installation, and maintenance of all required District signage in order to ensure conformance with required codes and regulations for TVHD throughout all District sites. The policy pertains to interior and exterior signs.
All interior and exterior campus signs must conform to the established standards in the TVHDand be approved by Administration prior to posting.
IV. Responsibility
A. Implementation of new or revised exterior directional signs, identifying signs, monument signs and all other exterior signage shall be coordinated through the Maintenance Department.
B. Directional signs for the primary internal circulation corridors at each campus site are the responsibility of the Maintenance Department.
C. Departmental signs are the responsibility of individual departments. Departments should order signs through the Maintenance Department.
D. As new construction is implemented or renovation of departmental space occurs, Maintenance Department is responsible for including required signage in capital improvement project budgets and for coordinating the architectural design of projects with the District signage standards.
E. Walkabout rounding will be conducted by designated staff to assure signage is appropriate and in compliance with this policy. This signage review will take place at minimum weekly and be incorporated into the Hospital Departmental Performance Improvement Program.
Current INTERIOR Required SignageTitle of Sign / Picture / Location(s) / Comments
2011 Critical Access Hospital NPSG / 2011 Critical Access Hospital National Patient Safety Goals
The purpose of the National Patient Safety Goals is to improve patient safety.
The Goals focus on problems in health care safety and how to solve them.
Identify patients correctly
Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the medicine and treatment meant for them.
Make sure that the correct patient gets the correct blood type when they get a
blood transfusion.
Improve staff communication
Quickly get important test results to the right staff person…………………………………… / Outside of ER in Hall and Med Surg / The Joint Commission
Title of Sign / Picture / Location(s) / Comments
Better Business Bureau / Annual membership letter from BBB / x1 in Lobby / None
Charge Master Availability / Charge Master Information Available
A Charge Description Master (CDM), also known as a “chargemaster,” is a comprehensive and hospital-specific listing of each item that could be billed to a patient, payers or other health care provider. TVHD’s Charge Description Master is available for review by appointment during normal business hours – 8 a.m. to 4 p.m. by calling 661-823-3036.
Información de aranceles disponible
Una lista de aranceles (CDM, por sus siglas en inglés), es una lista exhaustiva y específica del hospital de todos los ítems que se pueden facturar a un paciente, pagador u otro proveedor de cuidado de la salud.La lista de aranceles de TVHD se encuentra disponible para ser revisada en una cita durante el horario laboral normal- 8 a.m. a 4 p.m. llamando al 661-823-3036. / Post a clear and conspicuous notice in ED, admissions office, clinics, and billing office / Make available a written or electronic copy of its charge description master…
Also post a clear and conspicuous notice in ED, admissions office, and billing office that informs patients that the hospital’s charge master is available.
CHA Consent Manual, Chap. 8.6-8.7
Charity Care and discount payment policy notice / ATTENTION PATIENTS
If you do not have health insurance, you may qualify for financial assistance.
Tehachapi Valley Healthcare District has a program to assist uninsured, low-income patients with payment of hospital bills.
For more information, please ask
any receptionist or call:
(661) 823-3036.
Atención Pacientes
Si usted no tiene seguro médico, es posible que califique para recibir asistencia económica.
Este Tehachapi Valley Healthcare District tiene un programa para ayudar a los pacientesde bajos recursos sin seguro con el pago de las facturas hospitalaras.
Para mayor información, por favor preúntele a las recepcionistas del hospital o llame al: (661) 823-3036. / Hospital Lobby cabinet
ED Dept, if any, and other outpatient settings
Billing Office, clinics x3 / “Each hospital should provide both inpatients and outpatients with written notice that contains information about availability of the hospital’s discount payment and charity care policies, including: Eligibility and contact info.
Must be posted in locations visible to the public, including, but not limited to, all of the following:
ED Dept, if any, and other outpatient settings
Billing Office
Admissions Office
CHA Consent Manual, Chap. 8.6-8.7
Cell Phones Prohibited / / Main Lobby Desk, Triage, ER Hall
RHCs: Tehachapi, Mojave and Cal City / Adopted by TVHD
Title of Sign / Picture / Location(s) / Comments
Cell Phones not
permitted in Patient care areas.
(English/Spanish) / Use of Cellular Phones are not
permitted in Patient care areas.
Visitors ARE permitted to courteously use cellular phones at Tehachapi Valley Healthcare District in the waiting room(s) and outside the building.
Taking family photos with your phone MAY be allowed in limited situations; please check with Nurse Supervisor/Clinic Staff
Thank you for your cooperation!
______
El uso de teléfonos celulares no está
permitido en áreas de cuidado del paciente
Las visitas SI pueden utilizar sus teléfonos celulares gentilmente en Tehachapi Valley Healthcare District en la(s) sala(s) de espera y fuera del edificio.
Tomar fotos familiares con su
teléfono PUEDE estar permitido en algunas situaciones; por favor consulte a la
Supervisora de Enfermería/personal de la clínica.
¡Gracias por su cooperación! / Main Lobby Desk, Triage, ER Hall
RHCs: Tehachapi, Mojave and Cal City / TVHD Cell phone policy
Certificate of Occupancy / Only Cal City clinic
COLA notice to consumers / / Lab and Main Lobby / §493.1233 Standard: Complaint Investigations. Lab must have a system in place to ensure it documents all complains and problems reported to the Lab. Per COLA this complies with CMS.
DeT Norske Veritas (DNV Accreditation / / Hospital Lobby and Clinics / DNV
Title of Sign / Picture / Location(s) / Comments
Directory Information (Directory preference) / Directory Information
Unless you notify us, we legally may disclose to persons who ask for you by name, your location in the facility and your condition in general terms (e.g. good, fair).
You may ask the patient registration staff to keep your information out of the directory.
Thank you.
Informacion Directoria
Si usted nos notifica, podemos legalmente no dar su nombre y information o condiciones generales (e.g. bueno, fair).
Usted podria preguntar a registacion que mantengan su information del directoria
Gracias / Main Hospital Lobby / 45 CFR 164.510(a).
Emergency Physician’s Bill is Separate…
(English/Spanish) / / EmCare billing notice at each outpatient/ED registration station and in Hospital Lobby cabinet. / Must be kept away from entrance where ED patients would see upon arrival.
EMTALA
(English/Spanish) / / Locked cabinet in Main Hospital Lobby. On ED bathroom door, Lobby
Within view of all ED gurneys, and Triage. / Must post conspicuous signs in the dedicated ED (on and off campus) and other places which ER patients may present (such as the entrance, waiting rooms, admitting area, and treatment rooms). Must be clearly readable at distance of at last 20’.
RHC are exempt from posting even if within the 250 yards.
Evacuation Maps (English/Spanish) / All District buildings / Adopted by TVHD
Financial Assistance
(English/Spanish) / / Locked cabinet in Main Hospital Lobby
RHCs: Tehachapi, Mojave and Cal City
Rehab Dept / HSC §127410(a)):,Notice of the hospital's policy for financially qualified and self-pay patients shall be clearly and conspicuously posted in locations that are visible to the public, including, but not limited to, all of the following:(1)Emergency department, if any.(2)Billing office.(3)Admissions office.,(4)Other outpatient settings.
Title of Sign / Picture / Location(s) / Comments
HMO: Need Help with HMO (English/Spanish) /
Posted black/white version / Cabinet in Main Lobby
and Clinics / Providers Must Post Health Plan Notices in Waiting Areas
Health care providers, beginning Nov. 20, 2003 must display a notice in reception and waiting areas informing consumers of their rights regarding health plans. The notice must instruct subscribers and enrollees on how to contact their plan; file a complaint with the plan; obtain assistance from the Department of Managed Health Care (DMHC); and seek an independent medical review.
DMHC recently posted a "final statement of reasons" on the regulation requiring contracts between health plans and providers to include the
notice requirement.
The regulations require the notice to be displayed in English and in any language spoken in 10 percent of the homes in the ZIP code area where the reception or waiting area is located.
Multilingual waiting room notices will be available at on or before Nov. 20, the effective date of the regulation.
The regulation, final statement of reasons and responses to comments are available at Title 28, Section 1300.67.8
Hotline – Privacy and Compliance / HOT LINE
To report concerns and complaints regarding compliance issues or confidentiality,
please call confidential line:
(661) 823-3029 / Hospital Lobby, Clinics x3, and ED Hall / Compliance and HIPAA Regulations
Title of Sign / Picture / Location(s) / Comments
Grievance Policy/Procedure
(English/Spanish) / Your Health is Our First Concern
It is the policy of this hospital to make reasonable efforts to resolve patient grievances as quickly as possible. Information obtained in resolving grievances will be used in the hospital's performance improvement process to prevent similar concerns from arising in the future.
Patients are encouraged, if they are dissatisfied with any aspect of their care, to express complaints/issues or grievances to a caregiver or the manager of the department providing the services. Any patient or patient's representative (as allowed / Main Hospital Lobby (framed)
(Brochure also available in Lobby) / DHHS does not specify how hospital must inform patients.
CHA Consent Manual
Chapter 1.
Interpreter Signs / Notice of Interpreter Services
If you do not speak the English language or are hearing impaired, you may ask for an interpreter to assist you. Please tell one of the staff that you need an interpreter and help them by identifying the language you speak.
Language services over-the-telephone are available for 160 languages and TDD/TTY services (661 823-2098) for the hearing impaired, 24 hours a day, 7 days a week.
If you are unable to get the staff to provide you with an interpreter or are not satisfied with the interpreter services that is provided to you, please call the number listed below for assistance: TEHACHAPI VALLEY HEALTHCARE DISTRICT, (661) 823-3010.
You may also contact the Department of Health Services:
Bakersfield District Office, 4540 California Avenue, Bakersfield, California 93309
Phone: (661) 336-0543, Toll Free: (866) 222-1903, FAX: (661) 336-0529
Aviso sobre el Uso de Servicios de Interpretes
Si Usted no habla el Idioma Ingles, o si Usted párese Incapacitado por problemas de Oír: Ud. puede pedir la asistencia de in Interprete. Simplemente, avisar a un miembro de nuestro equipo que necesitas la ayuda de un Interprete (Señalando a este Aviso) y indica en Idioma que hablas.
Tenemos a nuestro deposición, Los Servicios de Interpretación de hasta 160 diferente Idiomas y Servicios TDD /TTY(661 823-2098) para personas Incapacitados del Oído, los 24 horas al día, 7 días por semana.
Si Usted tiene dificultad con estos servicios o con alguien de nuestro equipo proveyendo estos servicios, Puede llamar a las siguientes números telefónicos para asistencia y para registrar su queja.: CENTRO DE SALUDAD DEL DISTRICTO DEL VALLE DE TEHACHAPI, (661) 823-3010.
Además, Usted puede ponerse en contactar con el:
Departamento de Servicios de Salud:
Oficina del Distrito de Bakersfield, 4540 California Avenue Bakersfield, CA 93309
Tele (661) 366-0543,ó Linea Libre “Toll” (866) 222-1903,
FAX: (661)336-0529 / Hospital Lobby
Outside of ER in hall and Med Surg Hall / “Hospital must develop and post in conspicuous location notices that list the languages for which interpreter services are available and that advise patients and their families of the available of interpreters, the procedure for obtaining an interpreter, the CDPH telephone numbers where complaints can be filed (including TDD number for hearing impaired) and local CDPH address. At minimum, these notices must be posted in the ED, admitting area, the entrance and outpatient areas”. CHA Consent Manual, 1.11
Languages Available / / Hospital Lobby
Outside of ER in hall, Med Surg / Not mandated by regulation/law. See above.
License, Department of Public Health / RHCs: Tehachapi, Mojave and Cal City,
Hospital Lobby
Title of Sign / Picture / Location(s) / Comments
Licenses, Provider Licenses / RHCs: Tehachapi, Mojave and Cal City
Phlebotomy Station, Rehab Dept
Non-Discrimination Policy
(English/Spanish) / NONDISCRIMINATION POLICY NOTICE
TEHACHAPI VALLEY HEALTHCARE DISTRICT
As a recipient of Federal financial assistance, Tehachapi Valley Healthcare District, does not exclude, deny benefits to, or otherwise discriminate against any person on the ground of race, color, national origin, on the basis of disability or age in admission to, participation in, or receipt of services and benefits of any of its programs and activities or in employment therein, whether carried out by Tehachapi Valley Healthcare District directly or through a contractor or any other entity with whom the Tehachapi Valley Healthcare District arranges to carry out its other entity with whom the Tehachapi Valley Healthcare District arranges to carry out its programs and activities.
This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Regulations of the U.S. Department of Health and Human Services issued pursuant to the Acts, Title 45 Code of Federal Regulations Part 80, 84, and 91.
Provider Name: Tehachapi Valley Healthcare District
Contact Person/Section 504 Coordinator: HIPAA Officer
Telephone Number: (661) 823-3010
TDD Number: (661) 823-3083 / Locked cabinet in Main Hospital Lobby
RHCs: Tehachapi, Mojave and Cal City / ”requirements for schools, colleges, and state and local governments that receive federal funds to issue notices of non-discrimination…”
Notice to Consumers
(English – no Spanish available) / NOTICE TO CONSUMERS
Medical doctors are
licensed and regulated by
the Medical Board of California
(800) 633-2322
/ Posted in Main Lobby and Clinics / June 27, 2010: The purpose of this new requirement is to inform consumers where to go for information or with a complaint about California medical doctors.
Physicians may provide this notice by one of three methods:
Prominently posting a sign in an area of their offices conspicuous to patients, in at least 48-point type in Arial font.
2 additional options for providing. 16, California Code of Regulations section 1355.4
Notice of Reduction in Medi-Cal Benefits / / RHCs: Tehachapi, Mojave and Cal City
Hospital Lobby / Welfare and Institutions Code section 14131.10. Starting July 1, 2009, Medi-Cal no longer pays for some benefits.
Title of Sign / Picture / Location(s) / Comments
Ombudsman Notice / Long-Term Care Ombudsman Program
Kern County Long-Term Care Ombudsman Program
C/O Greater Bakersfield Legal Assistance, Inc.
(661) 323-7884
Outside (661) area, use:
(888) 292-4252,ext. 1109 / Next to Activities Door and by Room 5 / All long-term care facilities are required to post, in a conspicuous location, the phone number for the local Ombudsman office and the Statewide CRISISline number 1-800-231-4024. This CRISISline is available 24 hours a day, 7 days a week to take calls and refer complaints from residents.
Rapid Response Team
(English/Spanish) / Rapid Response Team
You Can Help Too!
Patients and families can call for help by initiating a “rapid response team”. The Rapid Response Team (RRT) is made up of designated members of the hospital’s healthcare team, who come to the patient’s bedside in an emergency and manage the situation.
The reasons to call the Rapid Response Team:
• A report from a family member or visitor to a healthcare provider (i.e. nurses, physicians) of a serious noted change in the patient’s condition.
• An emergency situation where a noted change in the patient’s condition has occurred.
To call the Rapid Response Team, please call the operator by dialing “O” from any hospital telephone. Ask the operator to page the Rapid Response Team. The operator will ask for the caller’s name, location, and patient name. The operator will immediately activate the Rapid Response Team where a team of health care professionals are alerted and will arrive in the room to assess the situation. Additional clinical supports will be called in as needed. / Posted in patient rooms / Institute of Healthcare Improvement initiative adopted by TVHD
Rights, Patient
(English/Spanish) / / Locked cabinet in Main Hospital Lobby, hall outside of ED, Observation room x 3 next to each ER gurney x3, Room 1 and 2, MS Nursing desk area.
RHCs: Tehachapi, Mojave and Cal City / DHHS does not specify how hospital must inform patients.
CHA Consent Manual
Chapter 1.
Title of Sign / Picture / Location(s) / Comments
Rights, Resident / / Provided to resident upon admission
Hall outside of Room 5
And outside of Activity Room /