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ACKNOWLEDGEMENT CARD AND RECEIPT OF HANDBOOKI have been notified that Palms of Pasadena Hospital utilizes a Student Handbook that Imust read. In addition I must complete the post test and required paper work in the back of thehandbook for submission to the Staff Development Department.The purpose of this handbook is to provide students with general information regarding thepersonnel guidelines that are followed in most cases. The Company reserves the right torescind, modify or deviate from these or other guidelines, policies, practices or proceduresrelating to student matters from time to time as it considers necessary in its sole discretion,either in individual or organization-wide situations, with or without notice.As part of this handbook I have reviewed the Biomedical Waste Plan for Palms of PasadenaHospital. By my signature below I certify that I have read and understand the Palms of PasadenaHospital Biomedical Waste Plan and the information in the Student Orientation Self Study Packet.I UNDERSTAND THAT NEITHER THIS HANDBOOK NOR ANY PROVISION OF THISHANDBOOK IS AN EMPLOYMENT CONTRACT OR ANY OTHER TYPE OF CONTRACT.Do you have any question about this information? YES NOIf you checked Yes please call 727 341-7828 and make an appointment to meet withStaff Development and have your questions answered.Galen College of Nursing, Tampa BayEducational Institution NameStudent Printed NameStudent SignatureDate
Student Orientation POST TESTName:Date:School: Galen College of Nursing, Tampa Bay1.For the safety and security of everyone staff, students and temporary staff must always weara visible identification badge.True2.FalseFill in the correct code for each of the following codes utilized to indicate specific eimplies a mass casualty (internal external disaster)implies a fire related situationimplies an MI patient is in the EDimplies a situation involving a bombimplies a threat with a weaponimplies an weather related situation or eventimplies a significant change in patient conditionimplies a situation involving a cardiac or respiratory arrestimplies a patient my be having a strokeimplies that an infant abduction is suspected or reported. Aresponse by Security is necessary. All hospital personnel mustbe aware of suspicious circumstances.For immediate response from the operator dial3.The Emergency Preparedness Procedures Binder provides information about:a.b.c.d.4.from any phone.What the Fire Department will do in a fire.The first steps staff will need to take during a disaster/any type of Emergency SituationEmergency services offered by the hospitalEmergency support the county provides to POPHBacteria, viruses and other germs that are carried in the blood stream could result in(a general category of organism)being present in the body.
5.Standard Precautions are designed to provide barrier protection against body substances ofall patients regardless of their infection status.True6.Preventing fires can be accomplished by everyone by:a.b.c.d.7.Reporting and removing faulty cords and equipment from serviceNever blocking smoke or exit doorsKnowing where all of these are located: the closest fire extinguisher, pull station, gasshut off and closest exitAll of the aboveYour role in an emergency situation is to report to your instructor / department director andfollow instructions.True8.c.d.Reporting and tracking of occurrences out of the ordinaryProviding trending reports to patient care areasEvaluating and taking corrective measures related to actual or potential injurysituationsAll of the aboveUnusual happenings or unsafe situations involving patients, employees, visitors or hospitalproperty require an Occurrence (STARS) Report to be completed.True10.Values and principlesHeritage of idealsCommitment to patients, community and colleaguesAll of the aboveA red armband indicates that the patient is at risk for a fall or has had a recent fall.True12.FalseThe patient’s room number is one of the approved patient identifiers.True13.FalseThe Code of Conduct reflects Palms of Pasadena Hospital’sa.b.c.d.11.FalseRisk Management plays an integral part in improving patient and staff safety througha.b.9.FalseFalseHand gel has been placed throughout Palms of Pasadena Hospital as part of a plan toimprove hand hygiene and reduce the incidence of hospital-acquired infections.TrueFalse
14.A patient’s perception of their hospital experience is based on how competent the staffwere who cared for them.True15.It would be appropriate to release information to:a.b.c.d.16.The patient’s (non-attending) physician brotherThe transferring hospital’s personnel checking on the patientThe respiratory therapy personnel doing an ordered procedureA retired physician who is a friend of the familyAs a student it is not necessary to follow hospital protocols and procedures because you arenot staff.True17.FalsePatients should be identified by asking them their name and birthdate before performing anyprocedures or treatments.True18.FalseFalseYou will find MSDS: (circle one)a. On line on your home computerb. In Human Resources in a blue bookc. In the Employee Health officed. Hospital computer on-line under favorites, and listed as Hazsof
STANDARDS OF CONDUCTAbove all else, we are committed to the care andimprovement of human life. In recognition of thiscommitment, we strive to deliver high quality, costeffective healthcare in the communities we serve.As an employee or student, I will ALWAYS :Provide high quality care and strive to exceed the expectations of our patients, families and my co-workers bybeing respectful and courteous.Take pride in my work.Keep patients, families and co-workers informed and respondto requests with: “Let me look into thatand I WILL get back with you”.Advocate for patient, visitor and employee safety by reportingmy concerns. Create a quiet and healing environment.Engage with others in a positive and friendly way by saying hello, making eye contact and keeping a“smile” in my voice. Knock on a patient’s door, introduce myself and ask how they want to beaddressed.Discuss patient information or hospital business in private areas only with those who need to know.Take pride in my appearance and work place by keeping my work area and the facility clean and clutter free.All Palms of Pasadena Hospital personnel representing the hospital directly or indirectly, inany capacity including students are expected to fulfill these Standards of Conduct listedabove. I have read and understand the Standards of Conduct and I agree to practice them.StudentName(PRINT): Signature:School: Galen College of NursingProgram: ADNDate:
EXHIBIT ASTATEMENT OF RESPONSIBILITYFor and in consideration of the benefit provided the undersigned in the form of experience in aclinical setting at Palms of Pasadena Hospital, the undersigned and his/her heirs, successors and/orassigns do hereby covenant and agree to assume all risks and be solely responsible for any injury orloss sustained by the undersigned while participating in the Program operated by Galen College ofNursing, Tampa Campus at Hospital unless such injury or loss arises solely out of Hospital's grossnegligence or willful misconduct.Signature of Program Participant/Print NameDateParent or Legal Guardian if Program Participant is under 18/Print NameDate
EXHIBIT BPROTECTED HEALTH INFORMATION, CONFIDENTIALITY, AND SECURITY AGREEMENT Protected Health Information (PHI) includes patient information based on examination, test results, diagnoses,response to treatment, observation, or conversation with the patient. This information is protected and the patient hasa right to the confidentiality of his or her patient care information whether this information is in written, electronic, orverbal format. PHI is individually-identifiable information that includes, but is not limited to, patient’s name, accountnumber, birthdate, admission and discharge dates, photographs, and health plan beneficiary number.Medical records, case histories, medical reports, images, raw test results, and medical dictations from healthcarefacilities are used for student learning activities. Although patient identification is removed, all healthcare informationmust be protected and treated as confidential.Students enrolled in school programs or courses and responsible faculty are given access to patient information.Students are exposed to PHI during their clinical rotations in healthcare facilities.Students and responsible faculty may be issued computer identifications (IDs) and passwords to access PHI.Initial each to accept the PolicyInitial Policy1. It is the policy of the school/institution to keep PHI confidential and secure.2. Any or all PHI, regardless of medium (paper, verbal, electronic, image or any other), is not tobe disclosed or discussed with anyone outside those supervising, sponsoring or directlyrelated to the learning activity.3. Whether at the school or at a clinical site, students are not to discuss PHI, in general or indetail, in public areas under any circumstances, including hallways, cafeterias, elevators, orany other area where unauthorized people or those who do not have a need-to-know mayoverhear.4. Unauthorized removal of any part of original medical records is prohibited. Students andfaculty may not release or display copies of PHI. Case presentation material will be used inaccordance with healthcare facility policies.5. Students and faculty shall not access data on patients for whom they have no responsibilitiesor a “need-to-know” the content of PHI concerning those patients.6. A computer ID and password are assigned to individual students and faculty. Students andfaculty are responsible and accountable for all work done under the associated access.7. Computer IDs or passwords may not be disclosed to anyone. Students and faculty areprohibited from attempting to learn or use another person’s computer ID or password.8. Students and faculty agree to follow Hospital’s privacy policies.9. Breach of patient confidentiality by disregarding the policies governing PHI is grounds fordismissal from the Hospital.I agree to abide by the above policies and other policies at the clinical site. I further agree to keep PHI confidential.I understand that failure to comply with these policies will result in disciplinary actions.I understand that Federal and State laws govern the confidentiality and security of PHI and that unauthorizeddisclosure of PHI is a violation of law and may result in civil and criminal penalties.Signature of Program Participant / Print NameDateParent or Legal Guardian if Program Participant is under 18 / Print NameDate
Confidentiality and Security AgreementI understand that the facility or business entity (the “Company”) for which I work, volunteer or provide services manages healthinformation as part of its mission to treat patients. Further, I understand that the Company has a legal and ethical responsibility tosafeguard the privacy of all patients and to protect the confidentiality of their patients’ health information. Additionally, the Companymust assure the confidentiality of its human resources, payroll, fiscal, research, internal reporting, strategic planning information, orany information that contains Social Security numbers, health insurance claim numbers, passwords, PINs, encryption keys, credit cardor other financial account numbers (collectively, with patient identifiable health information, “Confidential Information”).In the course of my employment/assignment at the Company, I understand that I may come into the possession of this type ofConfidential Information. I will access and use this information only when it is necessary to perform my job related duties inaccordance with the Company’s Privacy and Security Policies, which are available on the Company intranet (on the Security Page) andthe Internet (under Ethics & Compliance). I further understand that I must sign and comply with this Agreement in order to obtainauthorization for access to Confidential Information or Company systems. General Rules1.2.3.I will act in the best interest of the Company and in accordance with its Code of Conduct at all times during myrelationship with the Company.I understand that I should have no expectation of privacy when using Company information systems. The Companymay log, access, review, and otherwise utilize information stored on or passing through its systems, including email, inorder to manage systems and enforce security.I understand that violation of this Agreement may result in disciplinary action, up to and including termination ofemployment, suspension, and loss of privileges, and/or termination of authorization to work within the Company, inaccordance with the Company’s policies. Protecting Confidential Information1.2.3.4.5.6.I will not disclose or discuss any Confidential Information with others, including friends or family, who do not have aneed to know it. I will not take media or documents containing Confidential Information home with me unlessspecifically authorized to do so as part of my job.I will not publish or disclose any Confidential Information to others using personal email, or to any Internet sites, orthrough Internet blogs or sites such as Facebook or Twitter. I will only use such communication methods whenexplicitly authorized to do so in support of Company business and within the permitted uses of Confidential Informationas governed by regulations such as HIPAA.I will not in any way divulge, copy, release, sell, loan, alter, or destroy any Confidential Information except as properlyauthorized. I will only reuse or destroy media in accordance with Company Information Security Standards andCompany record retention policy.In the course of treating patients, I may need to orally communicate health information to or about patients. While Iunderstand that my first priority is treating patients, I will take reasonable safeguards to protect conversations fromunauthorized listeners. Such safeguards include, but are not limited to: lowering my voice or using private rooms orareas where available.I will not make any unauthorized transmissions, inquiries, modifications, or purgings of Confidential Information.I will not transmit Confidential Information outside the Company network unless I am specifically authorized to do soas part of my job responsibilities. If I do transmit Confidential Information outside of the Company using email orother electronic communication methods, I will ensure that the Information is encrypted according to CompanyInformation Security Standards. Following Appropriate Access1.2.I will only access or use systems or devices I am officially authorized to access, and will not demonstrate the operationor function of systems or devices to unauthorized individuals.I will only access software systems to review patient records or Company information when I have a business need toknow, as well as any necessary consent. By accessing a patient’s record or Company information, I am affirmativelyrepresenting to the Company at the time of each access that I have the requisite business need to know and appropriateconsent, and the Company may rely on that representation in granting such access to me.
Using Portable Devices and Removable Media1.2.I will not copy or store Confidential Information on removable media or portable devices such as laptops, personal digitalassistants (PDAs), cell phones, CDs, thumb drives, external hard drives, etc., unless specifically required to do so by myjob. If I do copy or store Confidential Information on removable media, I will encrypt the information while it is on themedia according to Company Information Security StandardsI understand that any mobile device (Smart phone, PDA, etc.) that synchronizes company data (e.g., Company email)may contain Confidential Information and as a result, must be protected. Because of this, I understand and agree thatthe Company has the right to:a. Require the use of only encryption capable devices.b. Prohibit data synchronization to devices that are not encryption capable or do not support the required securitycontrols.c. Implement encryption and apply other necessary security controls (such as an access PIN and automaticlocking) on any mobile device that synchronizes company data regardless of it being a Company or personallyowned device.d. Remotely "wipe" any synchronized device that: has been lost, stolen or belongs to a terminated employee oraffiliated partner.e. Restrict access to any mobile application that poses a security risk to the Company network. Doing My Part – Personal Security1.2.3.4.5.I understand that I will be assigned a unique identifier (e.g., 3-4 User ID) to track my access and use of ConfidentialInformation and that the identifier is associated with my personal data provided as part of the initial and/or periodiccredentialing and/or employment verification processes.I will:a. Use only my officially assigned User-ID and password (and/or token (e.g., SecurID card)).b. Use only approved licensed software.c. Use a device with virus protection software.I will never:a. Disclose passwords, PINs, or access codes.b. Use tools or techniques to break/exploit security measures.c. Connect unauthorized systems or devices to the Company network.I will practice good workstation security measures such as locking up diskettes when not in use, using screen saverswith activated passwords, positioning screens away from public view.I will immediately notify my manager, Facility Information Security Official (FISO), Director of Information SecurityOperations (DISO), or Facility or Corporate Client Support Services (CSS) help desk if:a. my password has been seen, disclosed, or otherwise compromised;b. media with Confidential Information stored on it has been lost or stolen;c. I suspect a virus infection on any system;d. I am aware of any activity that violates this agreement, privacy and security policies; ore. I am aware of any other incident that could possibly have any adverse impact on Confidential Information orCompany systems. Upon Termination1.I agree that my obligations under this Agreement will continue after termination of my employment, expiration of mycontract, or my relationship ceases with the Company.2. Upon termination, I will immediately return any documents or media containing Confidential Information to theCompany.3. I understand that I have no right to any ownership interest in any Confidential Information accessed or created by meduring and in the scope of my relationship with the Company.By signing this document, I acknowledge that I have read this Agreement and I agree to comply with all the terms and conditionsstated above.Employee/Consultant/Vendor/Office Staff SignatureEmployee/Consultant/Vendor/Office Staff Printed NameFacility Name and COIDPOP26536Business Entity NameHCADate
EXHIBIT CAttestation of Satisfactory Background Investigation and Drug and Alcohol ReportOn behalf of Galen College of Nursing, I acknowledge and attest to Palms of Pasadena Hospital that we own, andhave in our possession, a background investigation report on the individual identified below. Such backgroundinvestigation and drug and alcohol report is satisfactory in that it:Does not reveal any criminal activityDoes not reveal ineligibility for rehire with any former employer or otherwise indicate poor performanceConfirms the individual is not on either the GSA or OIG exclusion listsConfirms the individual is not listed as a violent sexual offenderConfirms this individual is not on the U.S. Treasury Department’s Office of Foreign Assets Control listof Specially Designation NationalsNo other aspect of the investigation required by Employer reveals information of concernDoes not reveal the inappropriate use of drugs or alcoholI further attest there are no prior or pending investigations, reviews,
Nursing, Tampa Campus at Hospital unless such injury or loss arises solely out of Hospital's gross negligence or willful misconduct. Signature of Program Participant/Print Name Date . Parent or Legal Guardian if Pro
