Fill - Free fillable Volunteer Annual HIPAA and Safety Test PDF form

1 HIPAA Test 11/3/20

Volunteer Annual HIPAA and Safety Test

Please read this document. Complete the self test on pages 9, 10 and 11. Then read and sign the

confidentiality statement on page 12. Return pages 9-12 (test and signed confidentiality

statement) to the Volunteer Department [Gray/Bigelow Basement 015]. This becomes part of your

volunteer file. Each volunteer needs to complete the Annual HIPAA and Safety Test each year.

Thank you.

The MGH community is committed to keeping our environment safe for patients, staff,

volunteers, and visitors. Each year we ask you, as MGH volunteers, to review the key principles

from the hospital’s most important policies. Included are some questions and the MGH

statement on patient confidentiality. MGH makes an unwavering commitment to patient

confidentiality, upholding and safeguarding the privacy and confidentiality of all patients and

their medical information in every way.

Your contributions throughout the year support our patients, their families, and our staff. You

help in countless ways every day, and we are most grateful.

IMPORTANT HOSPITA

• Universal Mask Policy/Hand Hygiene

• Standard Precautions

• Fire Safety

L POLICIES

• Police and Security

Protocols

• HIPAA

• Patient Confidentiality

Please be aware of the signs and instructions that are posted throughout the hospital, particularly

in clinical areas. They are there to support and guide you. Remember to look for them

whenever you might be unsure about protocols. Never proceed with a task if you are unclear.

Stop and ask a staff member for help.

Use of facemasks may reduce the transmission of SARS-CoV-2 and is recommended by the

CDC and Massachusetts Department of Public Health (MDPH) for healthcare workers.

Facemasks are also recommended by the CDC and MDPH for the general public in situations in

which 6 feet of distance cannot be reliably maintained.

All staff must adhere to the Universal Mask policy AND wear mask properly.

UNIVERSAL MASK POLICY/HAND HYGIENE

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In addition to Universal Masking, health care workers are required to wear personal protective

equipment to prevent contact with blood, body fluids, and moist body surfaces. The use of

particular personal protective equipment is based on the task, to be performed, and the likelihood

of body-fluid contact. The decision to use personal protective equipment is dictated by the task,

and is not based on any patient information regarding diagnosis or demographics. The wearing

of personal protective equipment applies to volunteers based upon the tasks the volunteers are

performing.

Universal Mask Policy

1. You will be required to wear only a hospital-issued mask during your entire shift.

2. No other masks are allowed.

Hand Hygiene:

Please adhere to the MGH hand hygiene policy.

Hand Hygiene-hand sanitizing procedure:

• Use an alcohol-based hand sanitizer that contains at least 60% alcohol.

• Put enough sanitizer on your hands to cover all surfaces.

• Rub your hands together until they feel dry (this should take around 20 seconds).

• Do NOT rinse or wipe off the hand sanitizer before it’s dry; it may not work well

against germs.

Hand Hygiene: hand washing procedure: [paper towels first!]

When hands are visibly soiled-hand washing is preferred

• Wet your hands with clean, running water (warm or cold), turn off the tap, and

apply soap.

• Lather your hands by rubbing them together with the soap. Lather the backs of

your hands, between your fingers, and under your nails.

• Scrub your hands for at least 20 seconds. Need a timer? Hum the “Happy

Birthday” song from beginning to end twice.

• Rinse your hands well under clean, running water.

• Dry your hands using a clean towel or air dry them.

Eating and Drinking at MGH (see attachments)

Eating and drinking in clinical areas is permitted only in designated locations such as

breakrooms, workrooms, call rooms, and conference rooms.

In these locations, if staff need to eat or drink, they must ensure that they are at least 6 feet away

from others, perform hand hygiene, remove the mask, eat/drink, and then replace the face mask

and perform hand hygiene again when finished eating and drinking

In nonclinical settings where eating and drinking is not restricted, employees must still maintain

6 feet of distance while unmasked for eating and drinking.

STANDARD PRECAUTIONS

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Removal of facemask to eat or drink:

• Perform hand hygiene with soap and water or an alcohol-based hand rub.

• Remove the face mask and place it on a clean surface such as a paper towel, paper bag or

paper tray.

• Perform hand hygiene with soap and water or an alcohol-based hand rub before eating;

soap and water is recommended before eating because alcohol-based hand rub leaves a

residue on the hands.

• After finishing eating or drinking, replace the mask, taking care to avoid touching face or

eyes.

• Perform hand hygiene with soap and water or an alcohol-based hand rub.

Personal Protective Equipment (PPE)-Gloves/Gowns (if applicable)

 Volunteers may enter a isolation room ONLY if they have approval

from the patient’s nurse and have received education about the use of

PPE for the specific type of isolation.

 Volunteers must use PPE as outlined on the Isolation sign posted on

the room.

• Gloves: Required for entry into a room of a patients on

contact isolation or contact isolation plus.

• Gowns: Required if you will come in contact with the

patient or surfaces in the room (glove cuffs pulled over

sleeves of gown).

 PPE must be removed on exiting the room

 Disinfect hands immediately after removing gloves to avoid transfer

of organisms to other patients.

Procedures and Training: Infection Control

 For the safety of our patients, staff and yourself it is important that you do not come

to volunteer if you are sick.

 Before coming to volunteer, please call Occupational Health Services (OHS) (617-

726-2217) and they will assess your symptoms and let you know if you should

come in to volunteer.

If you have any of these symptoms……

• Please call Occupational Health Services (OHS-617-726-2217) and the Volunteer

Department (617-726-8540):

• Skin lesions and/or rash, especially if lesions are

weeping or fever is present

• Non-intact skin or dermatitis

• Conjunctivitis or “pink eye”

• Diarrheal illness

• Cough of more than two weeks (unless explained by a

non-infectious disease).

• Prolonged cough may be a symptom of tuberculosis or

Pertussis.

• New onset of jaundice

• Exposure to any contagious condition (COVID 19, TB,

chicken pox, etc.)

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The code word for fire at MGH is CODE RED- which means that there is a fire alarm

activation in a <specific location>. The Fire Department and the hospital staff are responding.

Please avoid this area and wait for further instructions from the overhead announcement system.

NEVER say FIRE.

The safety of patients, employees, and volunteers is enhanced by the modern construction of the

MGH buildings and by the safety systems in place:

• Fire Barriers • Alarms connected directly Boston Fire Dept

• Fire Doors • Routine Testing of Detectors and Alarms

• Smoke and Heat Detectors

There are bell codes and alarm systems to identify the location of a Code Red. An alarm will

sound in the upper floors of the building in which the Code Red is occurring. A tone,

accompanied by an overhead announcement, will sound in the basement of connected buildings,

and will identify the building in which the Code Red is occurring.

When a Code Red is called in your area, remember the acronym RACE for the following:

Rescue : Remove anyone in danger of flames or smoke

Alarm: Activated automatically. If the alarm fails, call ext. 6-3333 & report code red in

your area

Confine: Close all doors & windows

Extinguish or Evacuate: Put out fire; and if ordered, leave the area

Volunteers play an important role by serving as support and by remaining alert to conditions in

their environment.

When appropriate - use a fire extinguisher. The best way to remember how to use a fire

extinguisher is the acronym PASS.

FIRE SAFETY:

Pull

Pull the Pin located at the top of the extinguisher

Aim

Aim the extinguisher at the base of the fire

Squeeze

Squeeze the extinguisher handle

Sweep

Sweep the extinguisher from side to side across the base of the fire

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Evacuation Terms

Zone of Refuge: A safe location to which your unit evacuates in the event of a Code Red. The

Nurse Manager or Supervisor/Manager may order evacuations in the unit where you are

volunteering.

Horizontal Evacuation: Leaving your unit and walking into the adjoining building where you

will be safe behind the fire door and fire wall. Because certain stairwell doors are locked for

security purposes, horizontal evacuation is often the safest way to leave the site of a Code Red.

Vertical Evacuation: Leaving your unit and the building, and walking down the stairs to reach

the outdoors. Staff, patients, and volunteers will gather in a pre-determined location. Only the

Chief of the Boston Fire Department with MGH Administration may order vertical evacuations.

A Code Red remains in effect until the Page Operator announces that the Code Red is over.

The Police & Security Department is available to the MGH community 24 hours a day. Their

Operations Center is located in the basement of the Gray Building.

When Help Is Needed Immediately:

If you need help in a hurry and you do not want to alert others close by, use the Police &

Security Code: “Doctor Johnson Code.”

From your desk or the nearest “house telephone"(phones mounted on wall, typically located in

hallways)

1. Call extension 6-2121

2. State, “I need to page Dr. Johnson,” and give your exact location

3. The security dispatcher will verify that this is NOT a page and will ask you a few basic

questions that require only YES or NO answers.

4. Even as you are being questioned by the security dispatcher, a second security officer is on his

way to you

5. If possible, stay on the line until the security officer arrives at your location.

Code Pink:

Code Pink means there is a child, infant, or newborn missing from a unit in the hospital. The child

is with a <specific description of suspect>. Volunteers should NOT become directly involved. If

you see this individual, please immediately alert hospital staff to contact Policy and Security.

Code Silver:

There is a report of a life threatening security situation. Police and hospital security staff are

responding. All patients, visitors and staff are asked to secure their area and to shelter in place

until help arrives.

POLICE & SECURITY: Call 6-2121

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What is HIPAA? (Health Insurance Portability and Accountability Act)

• A Federal Law on Privacy and Security

• Enforced by the Federal Office of Civil Rights

• National legislation that ensures personal health information is protected

Why is HIPAA important to Massachusetts General Hospital?

• Maintaining patients’ trust in their caregivers is critical to obtaining a complete history, medical

record, and carrying out an effective treatment plan

• HIPAA supports hospital's mission

• It’s the right thing to do ethically and legally

Protecting Patient Privacy:

• Healthcare volunteers are accustomed to being around sensitive information.

• We must remember to keep patient information private and confidential.

What is “Protected Health Information (PHI)”?

• Any information that identifies who you are (as little as name, address, social security number or

medical record number), together with:

• Past, present or future physical or mental health diagnoses, prognoses; Type of treatment,

services provided, and/or cost

• Documents containing PHI must be shredded or put in a confidential blue recycling bin

Who is Responsible?

• We are all responsible!

• Anyone who cares for patients, works in the hospital environment, or is responsible for using

identifiable information in order to perform their jobs

What can MGH Volunteers do?

• Be on your guard (Be aware, not defensive.)

• Honor our patient’s trust.

• Don’t divulge patient information in an informal atmosphere or social setting.

• Respect everyone as if they were a member of your family.

• Report privacy concerns or breaches to the Privacy Office.

Any person to whom information is communicated must: be authorized to receive the information

and have a legitimate need to know.

What can you do to determine a “legitimate need to know”?

HIPAA

SafeGuarding Information – Practical Considerations

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• Verify the person’s identity and employee badge when they come to a unit or ask for

information.

• Access to information on the computer does not imply that it is appropriate to search for patient

information simply to satisfy curiosity.

Access to electronic medical record

• All access are logged. Access starts with a search for a name.

• Never search for patients you do not have a “need to know”.

• Access violations will result in termination of your volunteer job.

Faxing

• Faxes are the least controllable type of communication.

• ALWAYS use a cover sheet with a confidentiality statement and your location and phone

number even on internal faxes.

• Never leave faxes sitting on fax machines unattended.

Computer Security

• Sharing user accounts or passwords is PROHIBITED.

• You will be responsible for misuse or wrongful disclosure of confidential information and

failure to safeguard your password.

• Always click on the yellow lock at the bottom right corner of your screen when leaving a

computer workstation.

• Workstations should be placed so that displays cannot be seen by unauthorized users.

Volunteer Practical Applications of HIPAA

• If we do not have a “volunteer service-related” need-to-know, we don’t know!

• We are not careless with paperwork.

• We are not careless with our conversations.

• We are not careless with computer access.

• We follow changes required in normal operating practices.

• We honor and respect patient trust in us.

How to Report a Privacy Concern or Breach

• Contact the Compliance Hotline to report a breach anonymously: (617) 724-1446 or Contact

the MGH Privacy Office (617) 726-1098.

What to tell a patient or family member when there has been a privacy concern or breach?

• A patient or family member can contact the MGH Privacy Office at (617) 726-1098.

Keep Your Actions Reasonable

• All health information is protected whether it is spoken, written in a record or written and

stored electronically.

• View every decision about use and disclosure of health information through the lens of:

treatment, payment, hospital operations, and minimum necessary information to get the job

done.

• If you see someone you know being treated as a patient at MGH, this must be kept confidential.

• Whether you know a patient personally (friend, neighbor, etc.) or through the media (sports

player, politician, etc.), it is a violation of federal law to tell others who you have seen.

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Remember Boundaries

• Boundaries are important to pay attention to – they keep us and our patients and families safe.

• It is not appropriate to share personal information (phone, email, Facebook) with patients and

their families.

• It is not appropriate to visit with patients and families outside your volunteer role or shift.

• It is not appropriate to buy gifts for patients (this includes books, magazines, coffee, etc.)

• If a patient expresses a need for goods that must be purchased, that need should be expressed to

the patient’s nurse.

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Volunteer Annual–Self Test –Please return pages 9-11 to the Volunteer Department,

Please answer the following questions:

1. What is the code that the MGH uses to alert employees and volunteers of a fire?

2. What does the acronym RACE stand for?

3. What is the telephone number for MGH Police and Security?

4. What is the single most important measure you can take to prevent infections in the hospital?

5. When you need the immediate assistance of a Security Officer, and you do not feel you can

speak freely and openly, what should you do?

6. What is a Code PINK?

7. What is a volunteer's role in a Code PINK?

8. Give an example when a volunteer would need to wear gloves?

9. Is it necessary to wear gloves for routine transportation such as transporting a patient to their car?

YES

a) After ANY physical contact with a patient or a patient’s environment of care

YES NO

b) After removing your gloves YES NO

c) After remaining in the hallway & talking to a patient in his room YES NO

Name:

Date:

Volunteer ID #:

10. After which situations should you wash your hands?

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TRUE FALSE

11.

can wear any mask while I am serving in the hospital.

12. I must wear the mask the entire time I am serving in the

hospital.

13. Twenty (20) seconds is the length of time I should scrub/rub

my hands when washing or sanitizing.

TRUE

FALSE

14. HIPAA privacy rules protects a patient’s fundamental right to privacy and confidentiality

for:

a) Patient information in electronic form

b) Patient information in paper form

c) Patient information communicated orally

d) All of the above

15. Health information is considered confidential if it relates to:

a) A person’s past, present, or future physical or mental health condition

b) A person’s present health condition only

c) A person’s past and present condition only

16. Which statement best reflects the meaning of the “minimum necessary” guidelines under

the HIPAA’s privacy rule?

a) Any information besides a patient name, address, e-mail, social security number and

diagnosis

b) No information can be disclosed to our Business Associates

c) The least amount of health information people need to know about patients in order

to do their jobs

17. If a patient expresses a need for items that must be purchased, I should:

Buy what the patient needs

Ask the Volunteer Department to purchase the items for the patient

Let the patient’s nurse know of his/her needs

18. If you have computer access, you will not be held responsible if someone else who uses

your logon to access patient information. TRUE FALSE

19. Hospital staff and volunteers are permitted to use Protected Health Information (PHI)

for treatment, payment and health care operations. TRUE FALSE

20. Identifiable health information should always be shredded or put in a confidential blue

recycle bin. TRUE FALSE

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neighbors know he/she is being treated at MGH. TRUE FALSE

21. If my neighbor is a patient whom I see during my volunteer shift, it is ok to let other

22. How can you report a Privacy Concern or Breach?

23. Who can a patient or family member of a patient contact if they have concern of a

privacy breach?

�

Mass General Brigham

CONFIDENTIALITY AGREEMENT

Mass General Brigham, Its affiliates and joint venturers, have a legal and ethical responsibility to safeguard

the privacy of all patients and to protect the confidentiality of their health information. Additionally, Mass

General Brigham, its affiliates and joint venturers, must assure the confidentiality of its patient, fiscal,

research, computer systems, management and other business information. In the course of my

employmenUassignment at a Mass General Brigham organization/practice, I may come into the possession

of confidential information. In addition, my personal access code [User ID and Password] used to access

computer systems is also an integral aspect of this confidential information.

By signing this document, I understand the following:

Access to confidential information without a patient care/business need-to-know in order to perform

my job - whether or not that information is inappropriately shared - is a violation of this policy. I

agree not to disclose confidential or proprietary patient care and/or business information to outsiders

(including family or friends) or to other employees who do not have a need-to-know.

I agree not to discuss confidential patient, fiscal, research, computer systems, management and

other business information, where others can overhear the conversation, e.g., in hallways, on

elevators, in the cafeterias, on the shuttle buses, on public transportation, at restaurants, at social

events. It is not acceptable to discuss clinical information in public areas even if a patient's name is

not used. This can raise doubts with patients and visitors about our respect for their privacy.

I agree not to make inquiries for other personnel who do not have proper authority.

I know that I am responsible for information that Is accessed with my password. I am responsible for

every action that is made while using that password. Thus, I agree not to willingly inform another

person of my computer password or knowingly use another person's computer password instead of

my own.

I agree not to make any unauthorized transmissions, inquiries, modifications, or purgings of data

in the system. Such unauthorized transmissions include, but are not limited to, removing and/or

transferring data from Mass General Brigham's computer systems to unauthorized locations, e.g.,

home.

I agree to log off a Mass General Brigham workstation prior to leaving it unattended. I know that if I

do not log off a computer and someone else accesses confidential information while the computer

is logged on with my password, I am responsible for the Information that Is accessed.

Mass General Brigham, its affiliates and joint venturers, have the ability to track and monitor access to on-

line records and reserves the right to do so. Mass General Brigham, its affiliates and joint venturers, can

verify that those who accessed records did so appropriately.

I have read the above special agreement and agree to make only authorized entries for inquiry and

changes into the system and to keep all information described above confidential.

understand that

violation of this agreement may result in corrective action, up to and including termination of employment

and/or suspension and loss of privileges. I understand that in order for any User ID and/or Password to be

issued to me, this form must be completed.

83268 Updated 08/20

Signature

Date

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Fillable Volunteer Annual HIPAA and Safety Test

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