20210315 Exhibits Local Policies Procedures and Permits - 538-16-101.pdf

CHILLICOTHE VAMC, OHIO EXHIBITS - LOCAL POLICIES, PROCEDURES, AND PERMITS

LIST OF EXHIBITS

LOCAL POLICIES, PROCEDURES, AND PERMITS

1. VHA Directive 1085 SMOKE-FREE POLICY FOR PATIENTS, VISITORS, CONTRACTORS, VOLUNTEERS, AND VENDORS AT VA HEALTH CARE FACILITIES

2. Policy Memorandum (PM) No. 07-29 Parking and Motor Vehicle Operation

3. Designated Parking for Contractors and Contract Employees and VA Police Parking Map

4. Policy Memorandum (PM) No. 116-25 Management of Violence in the Workplace

5. Policy Memorandum (PM) No. 00-07 Prevention of Sexual Harassment

6. Exhibit 6 is not applicable to this project and not included.

7. Standard Operating Procedure (SOP) 11 Fall Protection

8. Standard Operating Procedure (SOP) 12 Construction Project Inspections

9. Standard Operating Procedure (SOP) 20 Confined Space Entry

10. Standard Operating Procedure (SOP) 30 Control of Hazardous Energy (Lockout/Tagout)

11. Standard Operating Procedure (SOP) 30 Control of Hazardous Energy (Lockout/Tagout) Appendix A Hazardous Energy Inventory

12. Standard Operating Procedure (SOP) 31 Hot Work Policy

13. Standard Operating Procedure (SOP) 32 Dig Permits

14. Standard Operating Procedure (SOP) 57 Coordinating Utility Outages

15. Standard Operating Procedure (SOP) 41 Contractor Key Control

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Department of Veterans Affairs VHA DIRECTIVE 1085 Veterans Health Administration Transmittal Sheet Washington, DC 20420 March 5, 2019

SMOKE-FREE POLICY FOR PATIENTS, VISITORS, CONTRACTORS,

VOLUNTEERS, AND VENDORS AT VA HEALTH CARE FACILITIES

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive provides a comprehensive smoke-free policy for patients, visitors, contractors, volunteers, and vendors, at the Department of Veterans Affairs (VA), Veterans Health Administration (VHA) health care facilities.

2. SUMMARY OF MAJOR CHANGES: This updated VHA directive implements a smoke-free policy for patients, visitors, contractors, volunteers, and vendors at VA health care facilities, as defined in this directive, based on scientific evidence regarding the adverse health effects of secondhand and thirdhand smoke exposures.

3. RELATED ISSUES: VHA Directive 1056 National Smoking and Tobacco Use Cessation Program, dated February 10, 2014.

4. RESPONSIBLE OFFICE: The Assistant Deputy Under Secretary for Health for Administrative Operations (10NA) and the Assistant Deputy Under Secretary for Health for Clinical Operations (10NC) are responsible for the contents of this directive. Questions may be referred to VHA Smoke Free: vhasmokefree@va.gov.

5. RESCISSIONS: VHA Directive 1085, Smoke-Free Policy for VA Health Care Facilities, dated February 8, 2017, is rescinded.

6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of March 2024. This VHA directive will continue to serve as national VHA policy until it is recertified or rescinded.

BY THE DIRECTION OF THE UNDER

SECRETARY FOR HEALTH:

/s/ Renee Oshinski Deputy Under Secretary for Health for Operations and Management

NOTE: All references herein to VA and VHA documents incorporate by reference subsequent VA and VHA documents on the same or similar subject matter.

DISTRIBUTION: Emailed to the VHA Publications Distribution List on March 5, 2019.

mailto:vhasmokefree@va.gov

March 5, 2019 VHA DIRECTIVE 1085 i

CONTENTS

SMOKE-FREE POLICY FOR PATIENTS, VISITORS, CONTRACTORS,

VOLUNTEERS, AND VENDORS AT VA HEALTH CARE FACILITIES

1. PURPOSE

2. BACKGROUND

3. DEFINITIONS

4. POLICY

5. RESPONSIBILITIES

6. TOBACCO USE AND SMOKE-FREE POLICY IMPLEMENTATION

7. TRAINING

8. RECORDS MANAGEMENT

9. REFERENCES

SMOKE-FREE POLICY FOR PATIENTS, VISITORS, CONTRACTORS, VOLUNTEERS,

AND VENDORS AT VA HEALTH CARE FACILITIES

1. PURPOSE

This Veterans Health Administration (VHA) directive provides a comprehensive smoke-free policy for patients, visitors, contractors, volunteers, and vendors on all property assigned to VHA that is under the charge and control of VA (and not under the charge and control of the General Services Administration (GSA)). AUTHORITY: Public Law (Pub.

L.) 102-585, Section 526; 38 U.S.C. 7301(b); and Title 38 Code of Federal Regulations (CFR) 1.218(a)(3), (a)(4), and (b)(6).

2. BACKGROUND

a. Smoke-Free Policy. All VA medical facilities have had a smoke-free policy since 1991, with smoking allowed only in designated areas.

(1) On November 4, 1992, Congress passed the Veterans Health Care Act of 1992, Pub. L. 102-585. Under section 526 of that law, Use of Tobacco Products in Department Facilities, each VA medical center, nursing home or domiciliary care facility is required, consistent with medical requirements and limitations, to establish and maintain a suitable indoor smoking area for patients or residents and provide access to such area for patients or residents of the facility who are receiving care or services and who desire to smoke tobacco products.

(2) On August 9, 1997, President Clinton signed Executive Order (EO) 13058 Protecting Federal Employees and the Public from Exposure to Tobacco Smoke in the Federal Workplace, which established a smoke-free environment for federal employees and members of the public visiting or using Federal facilities.

(3) On February 8, 2017, the Department of Veterans Affairs published VHA Directive 1085, Smoke-Free Policy for VA Health Care Facilities. In accordance with the requirements of Pub. L. 102-585 Section 526, VHA Directive 1085 restricted smoking to designated smoking areas.

b. Smoking Cessation Policy. In accordance with VHA Directive 1056, National Smoking and Tobacco Use Cessation Program, dated February 10, 2014, patients have access to treatment and consultation for tobacco use cessation in the clinical setting.

c. Reports of Fire and Safety Hazards. There are numerous reports in VA issue briefs and The Joint Commission citations of fire and safety hazards caused by smoking. VHA seeks to reduce all fire and safety hazards associated with smoking as documented in issue briefs and citations on fire and safety hazards related to smoking on VA property.

d. Scientific Evidence. The Surgeon General Reports of 2006, 2010, and 2014 concluded that cigarette smoking is the number one preventable cause of morbidity and premature mortality worldwide. Studies also have shown that the harmful effects of smoking are not confined solely to the smoker, but extend to co-workers and members of the public who are exposed to secondhand smoke as well. The scientific evidence in these reports indicate that there is no risk-free level of exposure to secondhand smoke.

There are also new studies that demonstrate risks to patients and anyone exposed to thirdhand smoke. NOTE: See paragraph 9, References, for details.

(1) As the nation’s largest integrated health care system, VHA has a strong commitment to protecting and ensuring the health and safety of patients, visitors, contractors, vendors, volunteers, and employees.

(2) VHA seeks to reduce all hazardous health exposures associated with smoking through the reduction of secondhand and thirdhand smoke exposures.

e. As there is currently overwhelming evidence that smoking and exposure to secondhand smoke creates significant medical risks, and a growing body of evidence that exposure to thirdhand smoke creates additional risks to safety and direct patient care, VHA is unable to establish suitable indoor smoking areas that are consistent with medical requirements and limitations as required by Pub L. 102-585 Section 526.

Accordingly, VHA must eliminate all designated smoking areas for patients at VHA health care facilities in order to be consistent with medical requirements and limitations, and to prevent the creation of hazards to persons on VA property, as required by 38 CFR 1.218(a)(3).

3. DEFINITIONS

a. Designated Smoking Area. For the purposes of this directive, a designated smoking area is a smoking area in a VHA Health Care Facility that is accessible to patients, visitors, contractors, volunteers, and vendors. This could be an indoor or outdoor smoking area and includes an area in a detached building that is accessible, heated and air-conditioned as appropriate, and meets The Joint Commission requirements for ventilation. NOTE: Such areas have in the past been referred to as “shelters” or “outdoor” smoking areas.

b. Smoking. For the purposes of this directive, the term smoking includes the smoking of cigarettes, cigars, pipes, any other combustion of tobacco and non-Federal Drug Administration (FDA) approved electronic nicotine delivery systems (ENDS), including but not limited to electronic or e-cigarettes, vape pens, or e-cigars.

c. Smoke-free. For the purposes of this directive, smoke-free means that smoking is prohibited for patients, visitors, contractors, volunteers, and vendors at all property assigned to VHA that is under the charge and control of VA (and not under the charge and control of GSA).

d. Thirdhand Smoke. For the purposes of this directive, thirdhand smoke is the particulate matter or residue left behind or carried around on materials with which smokers come into contact and can be deposited in areas where there is no smoking activity.

e. VHA Health Care Facility. For the purposes of this directive, a health care facility is any property assigned to VHA that is under the charge and control of VA (and not under the charge and control of GSA) and includes Veterans Integrated Service Networks (VISNs), VA medical facilities, VHA Health Care Systems, Community-Based Outpatient Clinics (CBOCs), Readjustment Counseling Centers (Vet Centers), and VHA Research Centers of Excellence.

f. Volunteer. For the purposes of this directive, the term volunteer is a person who has an agreement with VHA to provide services without payment pursuant to VA’s Voluntary Service program. These volunteers are described in detail in VHA Handbook 1620.01, Voluntary Services Procedures, dated February 12, 2010.

4. POLICY

Consistent with its core health mission, as authorized in 38 U.S.C. 7301(b), it is VHA policy that all VHA health care facilities will be smoke-free for patients, visitors, contractors, volunteers, and vendors effective October 1, 2019. Accordingly, at VHA health care facilities, by that date all designated smoking areas for patients, visitors, contractors, volunteers, and vendors must be eliminated.

5. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for:

(1) Establishing overall strategic priorities for VHA.

(2) Ensuring a safe and functional environment for patients, visitors, contractors, volunteers, and vendors.

b. Deputy Under Secretary for Health for Operations and Management. The Deputy Under Secretary for Health for Operations and Management is responsible for providing oversight of VISNs to assure compliance with this directive, relevant standards, and applicable regulations. NOTE: For more information, please see The Joint Commission, Environment of Care Standards EC.02.01.03 and EC.02.03.01.

c. Assistant Deputy Under Secretary for Health for Administrative Operations.

The Assistant Deputy Under Secretary for Health for Administrative Operations is responsible for providing technical assistance and support on questions related to the implementation of this directive, including the dismantling and phasing out of former designated smoking areas.

d. Assistant Deputy Under Secretary for Health for Clinical Operations. The Assistant Deputy Under Secretary for Health for Clinical Operations is responsible for:

(1) Providing ongoing clinical training to VA health care providers to inform them of the appropriate use of tobacco use screening and smoking cessation medications for outpatient and inpatient populations consistent with VHA Directive 1056.

(2) Providing consultation to VA medical facility Directors and health care providers on best practices to increase the use of smoking cessation medications to prevent withdrawal among patients who have been identified as tobacco users during inpatient admissions consistent with VHA Directive 1056.

e. Veterans Integrated Service Network Director. The VISN Director or designee is responsible for providing resources and oversight of VHA health care facilities to ensure compliance with this directive.

f. VA Medical Facility Director/Readjustment Counseling Center Director. The VA medical facility Director/Readjustment Counseling Center Director, or designee, is responsible for:

(1) Ensuring that designated smoking areas for patients, visitors, contractors, volunteers, and vendors at VHA health care facilities are eliminated. Examples include but are not limited to indoor areas with separate ventilation systems on an inpatient unit, lobby, or community living center.

(2) In accordance with 38 CFR 1.218(a)(4), developing appropriate signage for installation at each VHA health care facility indicating that the facility is smoke-free.

(3) Developing, publishing, communicating, and implementing a local smoke-free implementation plan that is consistent with this directive. The plan must be communicated, to patients, visitors, contractors, volunteers, and vendors.

(4) Assigning appropriate staff, such as Police Service, to verbally remind individuals who are not complying with the smoke-free signage; however, if verbal communication is ineffective in promoting compliance, a courtesy violation warning can be issued by VA Police. Ultimately, failure to comply with the signage can result in the issuance of a Federal citation in accordance with 38 CFR 1.218(b)(6).

6. TOBACCO USE AND SMOKE-FREE POLICY IMPLEMENTATION

a. VHA will implement this policy with guidance from a National VHA Smoke-Free Implementation Plan and Toolkit. For more information, see:

https://www.va.gov/health/smokefree.

b. 38 CFR 1.218(a)(3) prohibits the creation of any hazard to persons or things on property under the charge and control of VA (and not under the charge and control of the General Services Administration). VHA interprets the harmful effects of both secondhand and thirdhand smoke to constitute a hazard to persons. As such, the smoking of cigarettes, cigars, or any combustible tobacco products by any patient, visitor, contractor, volunteer, or vendor is prohibited at all VHA health care facilities. This prohibition includes the use of non-FDA approved ENDS, including but not limited to electronic or e-cigarettes, vape pens or e-cigars, as these products have not been proven to be safe to the user or others. Further, their use imposes greater enforcement issues as it is difficult to distinguish them from traditional cigarettes. The inclusion of ENDS is consistent with smoke-free policies of many hospital and university campus grounds, other Federal agencies, and U.S. military medical treatment facilities. NOTE: GSA Order ADM 5800.1C prohibits the smoking of tobacco products in all government-owned or -leased vehicles assigned to GSA, as well as GSA-occupied space.

c. Although permitted under 38 U.S.C. 1715, VHA will not participate in the sale of tobacco products because the sale or distribution of tobacco products is inconsistent https://www.va.gov/health/smokefree with VA’s mission as a national leader in disease prevention and health promotion. This includes ENDS or any other nicotine delivery device that has not been FDA-approved as a smoking cessation aid or medication. In addition, sales or distribution of free tobacco products, ENDS, or any non-FDA approved nicotine product by any groups will not be permitted in VHA health care facilities.

d. Many Department of Defense (DoD) Medical Treatment Facilities (MTF) have adopted smoke-free campus grounds, prohibiting the use of any tobacco products. In the instances of co-located VA-DoD facilities, the smoke-free policy of VA must be followed when the facility is on the grounds of a VA health care facility. If the co-located facility is on the grounds of a DoD MTF, then DoD policy must be followed.

e. All outpatients coming into the VHA health care facility must be notified prior to arrival that the VHA health care facility is smoke-free. NOTE: As a best practice Nicotine replacement therapy (NRT) can be used with outpatients identified as tobacco users to prevent nicotine withdrawal, unless otherwise medically contraindicated (please see the U.S. Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update). For details about NRT, refer to VHA Directive 1056.

f. In accordance with VHA Directive 1056, all inpatients must be routinely screened by the appropriate medical providers for current tobacco use status upon admission. NRT must be routinely prescribed for use for inpatients identified as current tobacco users to prevent nicotine withdrawal, unless otherwise medically contraindicated. NOTE: For more information, please see the U.S. Department of Health and Human Services.

Treating Tobacco Use and Dependence: 2008 Update.

7. TRAINING

There are no formal training requirements associated with this directive.

8. RECORDS MANAGEMENT

All records regardless of format (e.g., paper, electronic, electronic systems) created by this directive shall be managed per the National Archives and Records Administration (NARA) approved records schedules found in VA Records Control Schedule 10-1.

Questions regarding any aspect of records management should be addressed to the appropriate Records Manager or Records Liaison.

9. REFERENCES

a. Pub. L. 102-585, section 526.

b. 38 U.S.C. 1715 and 7301(b).

c. 38 CFR 1.218(a)(3), (a)(4), and (b)(6).

d. General Services Administration (GSA) Order ADM 5800.1C, dated August 20, 2009.

e. VHA Directive 1056, National Smoking and Tobacco Use Cessation Program, dated February 10, 2014.

f. VHA Handbook 1620.01, Voluntary Services Procedures, dated February 12, 2010.

g. VHA Smoke-Free Web site: https://www.va.gov/health/smokefree.

h. Adhami, N., Chen, Y., Martins-Green, M. Biomarkers of disease can be detected in mice as early as 4 weeks after initiation of exposure to third-hand smoke levels equivalent to those found in homes of smokers. Clin Sci (Lond).

2017 Sep 14;131(19): https://www.ncbi.nlm.nih.gov/pubmed/28912356.

i. Adhami, N., Starck, S.R., Flores, C., Martins-Green, M. A Health Threat to Bystanders Living in the Homes of Smokers: How Smoke Toxins Deposited on Surfaces Can Cause Insulin Resistance. PLoS One. 2016; 11(3):

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4774920/.

j. The Joint Commission, Environment of Care Standards EC.02.01.03 and

EC.02.03.01.

k. Martins-Green, M. Adhami, N., Frankos, M., Valdez, M., Goodwin, B., Lyubovitsky, J., Dhall, S., Garcia, M., Egiebor, I., Martinez, B., Green, H.W., Havel, C., Yu, L., Liles, S., Matt, G., Destaillats, H., Sleiman, M., Gundel, L.A., Benowitz, N., Jacob, P., Hovell, M., Winickoff, J.P., and Curras-Collazo, M. Cigarette smoke toxins deposited on surfaces: implications for human health”, PLoS One. 2014 Jan 29;9(1):

https://www.ncbi.nlm.nih.gov/pubmed/24489722.

l. Northrup, T.F., Khan, A.M., Peyton, J., Benowitz, N., Hoh, E., Hovell, M.F., Matt, G.E. and Stotts, A.L. Thirdhand smoke contamination in hospital settings: Assessing exposure risk for vulnerable pediatric patients. Tobacco Control. 2016 Nov; 25(6):

619–623. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893002/.

m. U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010:

https://www.hhs.gov/surgeongeneral/reports-and-publications/tobacco/index.html.

n. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006:

https://www.hhs.gov/surgeongeneral/reports-and-publications/tobacco/index.html.

o. U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: U.S.

Department of Health and Human Services, Centers for Disease Control and https://www.va.gov/health/smokefree https://www.ncbi.nlm.nih.gov/pubmed/28912356 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4774920/ https://www.ncbi.nlm.nih.gov/pubmed/24489722 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893002/ https://www.hhs.gov/surgeongeneral/reports-and-publications/tobacco/index.html

Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014: https://www.hhs.gov/surgeongeneral/reports-and-publications/tobacco/index.html.

p. U.S. Department of Health and Human Services. Treating Tobacco Use and Dependence: 2008 Update. Tobacco Use and Dependence Guidebook Panel.

Rockville, MD: U.S. Department of Health and Human Services, Public Health Services, 2008. (Accessed on December 14, 2018):

https://www.ncbi.nlm.nih.gov/books/NBK63952/.

https://www.hhs.gov/surgeongeneral/reports-and-publications/tobacco/index.html https://www.ncbi.nlm.nih.gov/books/NBK63952/

POLICY MEMORANDUM VA Medical Center NO. 07-29 Chillicothe, Ohio August 20, 2019

PARKING AND MOTOR VEHICLE OPERATION

1. PURPOSE: To establish regulations for operating privately owned motor vehicles on the medical center grounds.

2. POLICY: It is the policy of this medical center to promote safe vehicle control on the roadways, maximize the utilization and benefit of parking facilities, and provide for consistent enforcement of the regulations governing these areas.

3. DEFINITIONS: None

4. RESPONSIBILITIES:

a. VA Police: Ensures all new employees are issued parking registration cards and rearview mirror parking decals identified by sequential numbers to each vehicle operator. Takes enforcement actions when violations of this policy are identified or reported to include the issuance of citations, arrests or towing of vehicles.

b. Immediate Supervisors: Takes corrective action when notified that an employee has received enforcement action for any parking violation.

5. PROCEDURES:

a. Vehicle Registration: All employees parking a privately-owned vehicle on the medical center property are required to register that vehicle using VA Form 10- 6196, Privately Owned Motor Vehicle Registration. This includes contractors, volunteers, consultants, etc. These forms are completed at the Police Operations Center, Building 18 lower level, during the in-processing procedure.

A parking decal is issued for each vehicle and is displayed on the backside of the rearview mirror or attached to an index card placed on the driver’s side dashboard of the vehicle. Any changes in the vehicle such as color, plate number or new vehicle are reported to the Police Operations Center within five workdays. When a vehicle is traded or sold, the employee is responsible for the removal and destruction of the decal. Failure to register and display an identification sticker may result in a citation or restriction from the use of parking facilities.

b. Traffic Regulations:

(1) All motor vehicle laws of the State of Ohio are observed while operating a vehicle at this medical center.

(2) Parking is allowed in designated areas only. Cars are parked between the marked lines.

Policy Memorandum No. 07-29

(3) Vehicle ignition keys are removed, and the vehicle locked when left unattended in any parking area.

(4) The Department of Veterans Affairs assumes no responsibility for the safety of employees' cars, and any such parking is at the risk of the employee.

(5) In addition to the requirements of the Ohio State Motor Vehicle Code, a

PEDESTRIAN HAS THE RIGHT OF WAY when crossing a highway or street from any point within the geographical limits of the medical center grounds.

Vehicles stop for pedestrians in a crosswalk.

c. Parking Allocations:

(1) Reserved parking areas are designated for handicapped, outpatients, physicians, consultants, volunteers, American Federation of Government Employees (AFGE) Union, and Credit Union (short term). Personnel not designated to use these parking spaces use general parking lots.

(2) The ambulance ramp to Building 31 and the two adjacent spaces are reserved for emergency vehicles loading/unloading at Urgent Care.

d. Enforcement:

(1) Courtesy Violation Notice (CVN): This violation notice is merely a reminder to the offender that s/he is in violation of posted rules and regulations governing VA property and the offense is punishable under the law. The yellow copy of the notice is forwarded to the appropriate service chief/care line manager.

Service chiefs/care line managers are responsible for making sure their employees are familiar with and comply with parking and motor vehicle regulations, and for counseling employees upon receipt of the second CVN.

(2) Uniform Violation Notice (UVN): This notice is used by the medical center police officer to notify a violator, in writing, that s/he has violated the statutory authority contained in Title 38, United States Code, Section 218(b), 38 Code of Federal Regulations 1.218 and VA Regulations 1.218(b) for traffic, parking, and petty offenses. Any person receiving a UVN is required to comply with the instructions contained in the ticket at the time of issuance. This notice involves forfeiture of collateral and/or appearance before the District Court Magistrate.

(3) Arrest: The Rule of Court, Southern District of Ohio, dictates the amount of collateral to be posted for a specific offense and those offenses requiring a mandatory appearance before a U.S. Magistrate. However, the Rule of Court does not prohibit the officer from making an arrest and taking the offender directly before a U.S. Magistrate to answer the charge placed against the offender.

3 . Policy Memorandum No. 07-29

(4) Towing: A privately owned vehicle may and will be towed from the medical center grounds when immediate removal is necessary to ensure public safety, or after 96 hours when abandoned. Owners of towed vehicles are liable for charges for towing and storage before the vehicle is released by the towing company.

(5) Any vehicle improperly parked, unauthorized, abandoned, impeding or blocking traffic, or otherwise in violation of the law, is subject to ticketing and/or being towed away at the owner’s expense without notice, depending on the situation.

(6) All violators are subject to appropriate law enforcement action deemed necessary. A schedule of offenses and fines are posted at entrances of all main buildings at this medical center.

e. Traffic Accidents: The Chief, Protective Services, or designated Police Officer, investigates and prepares required reports for all motor vehicle accidents on medical center grounds, and may, when authorized, participate in investigations which involve government vehicles off medical center grounds. Neither the Department of Veterans Affairs nor the United States Government assumes responsibility for accidents occurring on the medical center grounds between privately owned motor vehicles. Such accidents are reported to the VA Police as required by law.

6. REFERENCES: U.S. District Court, Southern District Rule No. 5.

Title 38, U.S. Code, Section 218(b).

Title 38 Code of Federal Regulations, Section 1.218.

AFGE Master Agreement.

7. RESCISSION: Policy Memorandum No. 07-29, Parking and Motor Vehicle

Operation, dated May 31, 2016.

8. RESPONSIBLE OFFICE: Police Service (07P)

9. COLLABORATED WITH: VHACLL Tops, VHACLL AFGE Local 1631 Officers

10. RESCISSION DATE: August 20, 2022

Kathy W. Berger

Medical Center Director

Distribution: ALL

4 . Policy Memorandum No. 07-29

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DESIGNATED PARKING FOR CONTRACTORS AND CONTRACTORS'S EMPLOYEES

1. All contractors and/or all contractors' employees performing work at this facility are required to park their vehicles in the designated parking area(s) as shown on the attached drawing.

2. The parking requirements will be strictly adhered to by all contractors and their employees and will be strictly enforced by the VA Contracting Officer and/or the VA Contracting Officer's Representative and/or the VA Police.

3. Failure to observe the required parking, may result in actions such as, but not limited to, parking fines, removal from facility, etc.

4. Other parking may be available pending medical center usage. Contact your COR for requests for approval.

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POLICY MEMORANDUM VA Medical Center No. 116-25 Chillicothe, Ohio October 23, 2019

MANAGEMENT OF VIOLENCE IN THE WORKPLACE

1. PURPOSE: To establish a policy for the prevention of violence involving patients, staff, visitors, volunteers and contractors at this medical center. To establish a procedure for the management of disruptive, threatening, or violent behavior in order to maintain a safe environment for patients, staff, and visitors at this medical center and to describe the process for using patient record flags including flags for suicide risk.

2. POLICY: It is the policy of this medical center to promote a safe environment for employees, patients, visitors, and volunteers. The medical center is committed to maintaining an environment free from violence, threats of violence, harassment, intimidation, and other disruptive behavior.

a. Disruptive, threatening, or violent behaviors interfere with the capacity to provide safe and effective healthcare.

b. Violent behavior of patients, beneficiaries, visitors, volunteers, and/or employees at this medical center, and other locations where medical center employees are required to perform their duties, is an occupational hazard. Reports of incidents are taken seriously and are dealt with appropriately.

c. This medical center implements a broad-based program of violence prevention, including the use of patient record flags for those unusual clinical risks that threaten health care safety and quality, Employee Threat Assessment Team (ETAT), and the Prevention and Management of Disruptive Behavior (PMDB) program.

3. DEFINITIONS: As used in this policy, violence is defined as unwanted or hostile physical contact, threats, coercion, or harassment.

a. Physical attack is unwanted or hostile physical contact, such as hitting, fighting, pushing, shoving or the throwing of objects.

b. Threat is the expression of a present or future intent to cause physical or mental harm. An expression constitutes a threat without regard to whether the party communicating it has the present ability to do harm, and without regard to whether the expression is contingent, conditional, or future.

c. Harassment is behavior or communication designed or intended to intimidate, menace or frighten another person.

d. Property damage is behavior or acts that contribute to the destruction or damage of private or government property.

2. POLICY MEMORANDUM NO. 116-25

e. Employee Threat Assessment Team (ETAT) is a medical center-level interdisciplinary team composed of designated representatives from American Federation of Government Employees (AFGE), the Occupational Safety and Health Manager, Protective Services, Human Resources Management Service, Equal Employment Opportunity (EEO), Rehabilitation Medicine and Services Care Line, Psychologist and the Code Orange Team Coordinator. The team’s primary charge is using evidence-based and data-driven practices for addressing the risk of violence posed by generated behavior that is disruptive or that undermines a culture of safety.

f. Employee-generated disruptive behaviors which undermine a culture of safety can be committed by VHA employees, contractors, volunteers, academic affiliates, locum tenens and any other personnel whose responsibilities bring them into a VHA facility.

g. The Disruptive Behavior Committee (DBC) is a medical center-level committee operating under the authority of, and reporting to, the Medical Staff Executive Committee. The DBC is chaired by the Mental Health Care Line Manager, or designee.

h. The Crisis Intervention/Code Orange Response Team is a clinical team on the main campus of the Chillicothe VA Medical Center comprised of staff who respond to emergency requests for help and provide employees with assistance in managing disruptive behavior.

a. The Medical Center Director is responsible for:

(1) Providing and maintaining policy and procedures to ensure that patients, employees, visitors, volunteers and all other categories of personnel are provided a safe and healthful environment.

(2) Implementing a system to notify law enforcement agencies when violations of the policy are committed.

(3) Ensuring that employee-generated disruptive behavior is addressed through administrative processes.

(3) Ensuring that high-risk areas within the medical center are designated based upon the Workplace Behavioral Risk Assessment (WBRA) conducted by medical center staff.

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b. The Workplace Violence Prevention Program Coordinator is responsible for:

(1) Assisting with educational efforts to ensure that a procedure is in place to provide training to employees and volunteers on disruptive behavior prevention. The training includes customer service training that addresses methods to recognize potential disruptive behavior, appropriate responses, methods to obtain assistance, and procedures to summon VA Police.

Warning signs, response procedures, prevention techniques and defensive techniques are addressed in this training.

(2) Reviewing the medical center’s Workplace Violence Prevention Program annually to ensure that the program is current and addresses the medical center’s need.

(3) Reviewing incident investigation reports, conducting incident investigations, if deemed appropriate, and identifying corrective actions to preclude incidents of violence at the medical center.

(4) Ensuring that reported incidents of violence involving patients, employees, volunteers, or visitors (either as the victim or perpetrator) are appropriately referred.

(5) Developing recommendations and ensuring implementation of corrective action(s) intended to preclude recurrence of disruptive behavior incidents involving employees (in coordination with the requirements of this program).

(6) Identifying trends and developing strategies to reduce or eliminate risks associated with disruptive behavior at this medical center. This includes developing a standardized database for gathering and reporting data of disruptive incidents.

(7) Prevention of Violence in the Workplace briefing is provided to new employees. A yearly briefing to incumbent employees is recommended when requested by medical center service chiefs/care line managers and documented as continuing in-service training.

(8) Providing training on workplace violence prevention matters for supervisors and employees, when requested.

c. The Disruptive Behavior Committee (DBC) operates under the authority of, and reports to, the Medical Staff Executive Committee. The DBC is chaired by the Mental Health Care Line Manager, or designee.

d. The ETAT is responsible for:

(1) Acting in an advisory capacity to supervisors, assessing workplace violence complaints or other significant incidents.

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(2) Activating or notifying the ETAT when any member becomes aware of or receives reports of violence or threats of violence. An email group is organized and maintained by the chairperson under VHACLL ETAT.

(3) Identifying trends, developing strategies, and performing workplace analyses as defined by the Occupational Safety and Health Administration (OSHA) in order to review and eliminate risks associated with disruptive behavior at the medical center.

(4) Performing risk assessments and making recommendations to supervisory staff in reference to referred or reported incidents.

e. Supervisors are responsible for:

(1) Enforcing VA safety rules, regulations, and standards, including those concerning violent behavior.

(2) Investigating injuries or illnesses that occur to employees under their supervision and preclude recurrence of similar injuries. If a patient(s) is/are involved, an electronic Patient Event Report (ePER) the incident is completed. The ePER is available on the Chillicothe VAMC home page. If a visitor or volunteer is involved, notify the Occupational Safety and Health Manager.

(3) Ensuring that employees or volunteers who are verbally or physically assaulted, who witness disruptive behavior in the workplace, or who have demonstrated warning signs associated with potential disruptive behavior are offered employee assistance, counseling and professional support, as appropriate.

(4) Initiating administrative action, as appropriate, against employees or volunteers who assault patients, volunteers, visitors or other employees.

f. Employees and Volunteers are responsible for:

(1) Following safe work practices (those that minimize the potential for disruptive behavior).

(2) Immediately reporting work-related injuries as a result of workplace violence to supervisory personnel.

(3) Employees are responsible for reporting incidents of disruptive behavior through the Disruptive Behavior Reporting System (DBRS).

(4) Attend mandatory training related to disruptive behavior prevention.

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g. Human Resources Management Service responsibilities:

(1) Assisting, when appropriate, with investigations of claims of violence raised by employees and others.

(2) Advise managers on how to address and resolve concerns in their areas.

(3) Refer reported potential workplace violence situations to VA Police, appropriate level of supervision, and the Chairperson of the ETAT.

h. The Suicide Prevention Coordinator is responsible for:

(1) Managing the process of using Category I Patient Record Flags (PRFs) to identify patients at high risk for suicide.

(2) Exclusively controlling Category I suicide flags and limiting their use to patients who meet the criteria of being placed on the medical center high-risk suicide list.

(3) Coordinating with the DBC, to incorporate the use of Category I PRFs into the overall process of utilization of PRFs at the medical center.

(4) Working with clinicians, who refer potential high-risk patients for flagging, to determine the advisability of the flag.

(5) Maintaining communications with the DBC to keep it aware of flag placements and outcomes of reviews. The DBC assists the Suicide Prevention Coordinator (SPC) in making flag placement recommendations.

(6) Maintaining a list of patients who currently have a flag and establishing a system of reviewing these flags at least every 90 days.

i. The Crisis Intervention/Code Orange Response Team is responsible for:

(1) Responding to emergency requests for help and providing employees with assistance in managing disruptive behavior.

(2) Providing verbal and physical intervention, as needed, to ensure the safety of persons (patients, volunteers, visitors and employees). Community Based Outpatient Clinic (CBOC) staff contact appropriate community law enforcement agencies for emergency response.

j. The patient’s primary provider and treatment team are responsible for:

(1) The management of their assigned patients.

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(2) Controlling immediate, threatening situations before calling the Code Orange

(Crisis Intervention) Team.

(3) Ensuring that the roles and responsibilities of each team member during the management of an incident are well understood and communicated to all staff of the team.

(4) Documenting the management plan for the patient’s inappropriate behavior.

When needed, The DBC is available to assist the team in writing the plan.

The DBC is responsible for writing the necessary patient record flags.

k. Clinical staff are responsible for notifying the SPC of patients who may need PRF for suicide risk.

a. Acts of violence perpetrated by patients are referred to the attending provider, treatment team and VA Police for evaluation and appropriate action. The DBC will evaluate cases involving patients referred to the committee from facility staff.

While the patients may or may not be reported to law enforcement authorities, clinical personnel determine the reason(s) for the assault and implement corrective action.

b. Any employee who has concerns regarding personal situations that may affect his or her workplace safety (e.g., restraining orders, domestic violence, or stalking) may consult with the VA Police Operations Officer and/or the ETAT Chairperson.

c. Any supervisor or manager who receives a complaint of violence, threats or harassment, or who has reason to suspect that these acts or behaviors are occurring, involving employees, volunteers, and/or patients, investigates the complaint and contacts the VA Police and/or the ETAT for assistance.

d. Training and education are provided so staff members are aware of potential security hazards and how to protect themselves and co-workers through established policies and procedures. Employees receive general awareness training annually through PMDB. Awareness training is a mandatory segment of new employee orientation.

e. Patient Record Flags (PRFs):

(1) Category I Behavioral National PRFs are nationally approved and are shared by all VA facilities. Only the VA facility initiating a Category I PRF is permitted to modify its content. A Category I PRF requires a documented history of violence or disruptive and/or threatening behavior or the documented

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presence of other factors that indicate a significant risk of violence. An electronic progress note in the Computerized Patient Record System (CPRS) accompanies a Category I PRF. Category I PRFs also recommend specific behavioral limit-setting or treatment-planning actions designed to reduce risk.

Criteria for Category I PRFs may include, but are not limited to:

(a) A history of physical violence against patients or staff at a medical center or clinic.

(b) Documented acts of repeated violence against others.

(c) Credible verbal threats of harm against specific individuals, patients, staff or VA property.

(d) Possession of weapons or objects used as weapons in a health care facility.

(e) A history of suicidal or parasuicidal behavior within health care facilities.

(f) A history of repeated nuisance and disruptive or larcenous behavior that disrupts the environment of care.

(g) A history of sexual harassment toward patients or staff.

(2) Category II Local PRFs. Category II Local PRFs are locally established by the medical center. Examples of Category II PRFs are patients who are enrolled in a research project, patients with documented unsafe drug-related behavior, or patients with a pattern of non-compliance with treatment. The use of Category II PRFs is strictly limited to information that is essential for delivery of safe and appropriate health care. A text integrated utility (TIU) progress note in the computerized patient record system (CPRS) also accompanies all Category II PRFs.

(3) PRFs are not used to punish or to discriminate against a patient, nor are they constructed merely for staff convenience. They are limited to those unusual risks that threaten the safe delivery of health care.

(4) PRFs alert staff to a potential risk only. At each patient encounter, the examining clinician is responsible for making appropriate clinical decisions.

(5) Patients may request an amendment to the presence or content of a PRF advisory through the Chief, Health Information Management Section (161F).

(6) Only the nationally developed PRF software is utilized.

(7) PRFs are used to identify patients at high risk for suicide. Suicide Risk PRFs

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are evaluated at least every 90 days to ensure that they are removed promptly when the high-risk status is resolved.

f. Orders of Behavioral Compliance may restrict the services provided to patients who threaten staff/other patients, flagrantly violate hospital rules, and/or are non-compliant with treatment. They must be approved by the DBC and the Chief of Staff prior to implementation.

(1) Reasonable efforts are made to provide safe and appropriate medical care to veterans. Nevertheless, disruptive patients and patients making threats against staff have Orders of Behavioral Compliance restricting the services available to them in order to protect staff from potential harm.

(2) Corrective and administrative measures are selectively applied in keeping with the gravity and particular offense.

(3) Administrative action is not taken against patients who, because of mental status, are incapable of determining right from wrong.

(4) Ethical principles are involved in determining the best solution to the management of these patients:

(a) Legally and ethically, the medical center is bound to provide reasonable assessment and treatment services to eligible veterans.

(b) The assigned treatment team identifies the patient’s presenting problems and underlying needs and either provides treatment for the needs or makes referral to a source that can treat the needs.

(c) The patient has freedom to choose or reject treatment that is offered.

(d) The patient is required to cooperate and comply with treatment that he/she accepts. For example, if the patient seeks treatment for addiction, he/she is expected to attempt to remain free of substances.

(e) If no further viable treatment approach is known for the patient because of his/her refusal of treatment or non-compliance, the VA is misusing its resources by continuing to keep the patient in treatment.

(f) Part of the treatment process for a patient is understanding the consequences of non-compliance with needed treatment.

(g) Decisions about the best approach to a patient’s treatment reside with the patient’s treatment team.

(h) Each patient is unique. There is no one solution that fits all patients.

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(5) Examples of limits include, but are not limited to, the following:

(a) Restricting care at Community Based Outpatient Clinics (CBOCs) where a Code Orange Team and/or VA police are not on site.

(b) Limiting unsupervised on-site services where potential for disruptive or violent behavior can occur, e.g., medical center-based lodging.

(c) Limiting off-site services where actual or potential for disruptive or violent behavior can occur that puts the public at risk, e.g., contracted shuttle services.

(d) Limiting services of non-compliant and drug seeking patients to urgent services.

(e) When appropriate, the patient is required to check in with Protective Services when coming to the medical center and is escorted by Protective Services to all appointments.

(f) Case management may be considered to assure consistency in approach to the management of the patient.

(g) When appropriate, a contract is prepared outlining an agreement between the patient and this medical center for the continuation of services to the patient. The contract is signed by the patient's primary provider and the patient.

(6) Serious charges, such as endangering life or health of others, narcotics, and alcohol violations, possession of dangerous weapons, theft, etc., are reported and processed in accordance with DM&S Supplement, MP-1, Part 1, Chapter 2, and Policy Memorandum No.00-2, Patient Safety Improvement Program.

(7) Removal of PRFs other than those for suicide risk: The DBC removes the patient record flag when criteria are met that indicate it is no longer needed.

When the flag is removed, a new progress note is written stating the reason for the flag being discontinued. The DBC reviews each PRF at least every two years, when the risk factors change significantly, or when a patient with a PRF requests a review. To remove the warning note, all following criteria are met:

(a) Absence of behavior related to the warning and other behavioral management problems.

(b) Absence of inappropriate contacts with the medical center.

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(c) Compliance with the treatment plan and positive outcome.

(d) Decrease of inappropriate requests for admission.

(e) There is a treatment plan in place to address continued help for the patient with the specific problems that resulted in non-compliance once the warning note has been removed. The problem behavior has been placed on the problem list.

(f) The risk of the patient returning to his/her previous problem behaviors is minimal if the warning note is removed.

(g) Warning notes are also removed when the patient repeatedly presents such dangerous behaviors (e.g., severe suicidal or assaultive behaviors, life threatening health issues) that the patient and medical center are at risk if the warning note delays providing care for the patient.

(8) Removal of PRFs for suicide risk: The SPC removes the patient record flag when the suicide risk has sufficiently decreased, and removal of the flag is clinically indicated. When the flag is removed, a new progress note is written stating the reason for the flag being discontinued. The SPC reviews each PRF at least every 90 days, when the risk factors change significantly, or when a patient with a PRF requests a review.

(a) Suicidal and assaultive behavior is monitored and reported through ongoing quality management activities.

(9) The nurse in charge of the area requesting the Code Orange Team records on the 24-hour Report of Patient's Condition, a description of the incident, the…