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Security Management Plan 

I. PURPOSE:
Manage security risks of all persons, environment, equipment and supplies on or in Sandhills Regional Medical Center’s property, grounds or facilities.
 
II. SCOPE:
This policy applies to all persons on the property of Sandhills Regional Medical Center. Protected health information, privacy act information and electronic information shall be in accordance with policy established by the Health Information Management, Employee Health, Risk Management and Human Resources Departments.

III. OBJECTIVE:
Develop and implement processes to effectively manage the physical security of personnel on hospital property. 

IV. DEFINITIONS:

A. Physical Security: issues regarding physical harm, property damage or theft.
B. Electronic Security: issues regarding the unauthorized access of any electronically stored or transmitted information, media or data.
C. Information Security: issues regarding the access of any protected health or privacy act information.
D. Security Manager: the person designated by the Chief Executive Officer in cooperation with the Medical Executive Committee to manage the security of persons on the campus of Sandhills Regional Medical Center.
E. MIS Manager: Person designated by the Chief Executive Officer in cooperation with the Medical Executive Committee to manage the electronic security of protected information in the custody of Sandhills Regional Medical Center.
F. Privacy Officer: Person designated by the Chief Executive Officer in cooperation with the Medical Executive Committee to manage the distribution of protected information in the custody of Sandhills Regional Medical Center.
G. Security Officer:  the person(s) regardless of job title designated to respond to security situations or emergencies.
H. Staff: those people employed by the hospital, employed by a contracted service provider; belong to a charitable organization; are a clergyman; or students participating in authorized training, that have been processed through the Human Resources Department.
I. Patients: those persons who have gone through the admitting and/or the registration processes and are under the care of hospital staff.
J. Guests: those persons who have come to Sandhills Regional Medical Center to be with a patient, participate in public service program, attend a social function or take advantage of the gift shop or cafeteria.
K. Visitor: officials of Federal, State or Local agencies or others by virtue of ability or position having importance to the hospital.
L. Vendors: representatives of companies providing goods or services of interest to the hospital.
M. Contractors: trades or craftsmen constructing, installing or otherwise providing products or equipment to the hospital.
N. Forensic Staff: those persons performing in an official capacity as a representative of government, emergency or public service.
O. Undesirable Patient/Visitor: is any person who by their actions or behavior intimidates or otherwise communicates a threat to patients, visitors or hospital staff.
P. High Risk Patient/Visitor:

1. Any person under legal or correctional restriction including patients in custody local, county, state or federal law enforcement agency, victims of domestic violence and victims of violent crimes.
2. Any VIP admitted or registered through the hospital.
3. Any patient for which there exist a reasonable risk for abduction. 

J. VIP (Very Important Person): Person(s) who by their prominence in public attention and the ensuing media attention, or position in political or industrial institutions would necessitate variations in manning for traffic and crowd control, physical security or access/egress to the hospital.
K. High Risk Situation:

1. Any time a “High Risk Patient/Visitor” is within the hospital. (i.e. Gang Member)
2. Any time there exist or the threat exists of a civil disturbance on the property of Sandhills Regional Medical Center. (i.e. Riot)
3. Any time there exist or the threat exists of physical harm or property damage to those exiting or seeking access to the property of Sandhills Regional Medical Center. (i.e. Labor Action or Public Protest)

L. Weapon: any machine, device or contrivance that causes another to be in fear of losing their life or receiving bodily injury.
M. Normal Working Hours: Monday through Friday (except Holidays), between the hours of 8:00 am (0800 hrs.) and 4:30 pm (1630 hrs.)
N. Prohibited Areas: those areas that store; controlled substances, infectious, inherently dangerous or toxic materials, or desirable items, and not used for the treatment of patients. They include but are not limited to:

1) Pharmacy
2) Warehouse
3) Mechanical Rooms
4) Clean Utility Rooms
5) Soiled Utility Rooms
6) Bio-hazardous Material Storage
7) Staff Locker Rooms
8) Janitorial Closets
9) Central Energy Plant
10) Clean Linen Storage
11) Soiled Linen Storage
12) Med Prep Rooms
13) Kitchen 
14) Central Sterile Supply
15) Clinical Laboratory

O. Restricted Areas: those areas that store; controlled substances, inherently dangerous or toxic materials, or desirable items and are used for treatment of patients. They include but are not limited to:

1) Operating Rooms
2) Post Anesthesia Recovery Unit
3) Outpatient Recovery
4) Intensive Care Unit 
5) Outpatient Laboratory
6) Emergency Department
7) Physical Therapy
8) Mental Health Unit
9) Radiology
10) Cardiopulmonary

P. Limited Areas: those areas that provide accommodation for patients prior to or after treatment. These areas include but are not limited to:

1) Telemetry Unit
2) Acute Care Unit

Q. Private Areas: those administrative spaces that store confidential information cash or are private offices. These areas include but are not limited to:

1) Administration
2) Medical Records
3) Business Office
4) Admitting
5) Mail Room
6) Human Resources & Marketing 
7) Education
8) Employee Health/Risk Management
9) Utilization Review
10) Data Processing
11) Materials Management
12) Doctor’s Library
13) Dictation Rooms
14) Consult Rooms
15) Offices

R. Public Areas: those areas within the hospital that are open to the public. These areas include but are not limited to:
1) Cafeteria
2) Gift Shop
3) Waiting Areas
4) Chapel
5) Reception Area

V. RESPONSIBILITY:
A. Chief Executive Officer will ensure that the Security Plan meets the needs of the facility.
B. Chief Operating Officer will assist the Chief Executive Officer to ensure compliance with the Security Plan.
C. Security Manager will advise the Chief Executive Officer to ensure the Security Plan meets the needs of the facility, and is implemented in an effective and efficient manner.
D. MIS Manager: will advise the Chief Executive Officer to ensure the electronic security measures are in compliance with all applicable requirements.
E. Privacy Officer: will advise the Chief Executive Officer to ensure the distribution security measures of all protected information are in compliance with all applicable requirements.
F. Environment of Care Committee:

1. Conducts a proactive risk assessment to evaluate potential undesirable effects of buildings, grounds occupants and physical systems upon the security of persons utilizing hospital facilities.
2. Uses identified risk to develop and implement administrative and physical controls to minimize potential undesirable effects upon the security of persons utilizing hospital facilities.
3. Identify as appropriate all persons utilizing hospital facilities.
4. Identifies security sensitive areas and establishes access controls.
5. Identify and implement security incident procedures.
6. Identify and implement infant or pediatric abduction procedures.
7. Identify and implement V.I.P. and/or media procedures.
8. Identify and implement Emergency Department vehicular access procedures

E. Director of Marketing and Public Relations shall represent the hospital as Official Spokesperson when directed by, or in the absence of, the Chief Executive Officer.
F. Human Resources Department shall provide appropriate identification badges for employees, vendors, and contractors.
G. All Employees will comply with the policy and procedures of the Security Plan.

VI. ELEMENTS:

A. Policy:

1. There shall be a person appointed by the Chief Executive Officer and the Medical Executive Committee to coordinate the development, implementation and monitoring of all physical security activities designated the Security Manager.
2. There shall be a person appointed by the Chief Executive Officer and the Medical Executive Committee to develop and coordinate the electronic security of all protected information designated the Electronic Security Manager.
3. There shall be a person appointed by the Chief Executive Officer and the Medical Executive Committee to develop and coordinate policies and procedure to secure the distribution of all protected information designated the Privacy Officer. 
4. There shall be a proactive risk assessment performed annually on the external environment and services provided to evaluate their potential adverse affects the security of personnel.
5. The risks identified by the above assessment shall be utilized to select and implement procedures and controls to obtain the least potential for adverse impact on security. 
6. All persons entering the hospital shall be identified as to purpose upon entering.
7. Any available staff member shall provide escort, whenever such escort is required.
8. During the hours of darkness, travel in remote or isolated areas only in a group (two or more).
9. Refrain from engaging in acts of physical violence, intimidation, coercion, or harassment.
10. Staff members finding themselves or observing another person in a hostage situation shall, if possible dial 61 and say “CODE WHITE”, followed by the location three times, via the overhead page.
11. Staff members finding themselves or observing another person needing physical assistance, dial 61 and say “CODE BLACK”, followed by the location three times, via the overhead page. If this is not possible for any reason and you feel your life, safety or the life or safety of another person is at jeopardy:

a. Dial 911 and follow instructions or have another staff member do it, or;
b. Pull the nearest fire alarm pull station.

12. All able bodied employees shall respond to the Security needs until relieved by local law enforcement personnel.
13. Anyone, (other than those here for medical necessity) on Sandhills Regional Medical Center property, is here at the discretion of the hospital administration. The hospital reserves the right to take all appropriate action to ensure the safety and security of the staff, patients, guests, and visitors of the hospital.
14. Staff member shall be responsible for security of the personal items they bring to work.
15. Secure storage of staff personal items will be made available upon request.
16. Secure storage of patient items shall be performed in accordance with policies and procedures described in the Administrative policy manual.
17. Security incidents shall be reported to the Risk Manager in accordance with Risk Management Policy.
18. Sandhills Regional Medical Center requires that all persons detained or under administrative restraint by law enforcement agencies shall be guarded by a responsible law enforcement agency at all times.
19. All employees will be observant of unidentified or suspicious persons within the hospital and either politely challenge them or notify Facilities Services (if present) or the Charge Nurse to establish their need or authority to be in the hospital.
20. Every reasonable effort to expedite the processing and treatment of “Undesirable” patients shall be made with the intent of removing those patients from the general hospital population (i.e. waiting rooms) and placing them in more isolated environment (i.e. treatment or patient room).
21. “Undesirable” visitors may be asked to leave voluntarily; if these visitors refuse the local law enforcement agency will be called to enforce removal.

B. Physical Security:

1. Access:

a. Exterior and interior doors shall be equipped with appropriate hardware and locked according to the door schedule (Enclosure 18).
b. Keys will be issued by the Security Manager and returned to Human Resources when no longer required for performance of assigned hospital duties.

2. Identification:

a. Identification badges shall be provided by the Human Resources Department for staff, volunteers, on site contract employees, privileged physicians and select others providing services to the hospital.
b. Badges shall be of laminated construction, contain the hospital logo, a photograph of the individual, their name and reporting department.
c. Vendors entering the hospital shall be directed to Materials Management offices for issuance of temporary identification badges, which shall be similar to staff badges except they will have no picture or name and will bear the legend “VENDOR”.
d. Contractors entering the hospital shall be directed to Materials Management offices for issuance of temporary identification badges, which shall be similar to staff badges except they will have no picture or name and will bear the legend “CONTRACTOR”.
e. Forensic staff shall be identified by their uniforms, agency issued identification and/or badges and require no further identification.
f. Guests and visitors will be identified by the fact that they have no unique identification.
g. Identification badges shall be displayed prominently between the shoulder and the waist on their outermost garment with the picture (if applicable showing).

3. Weapons

a. Policy:

1. Signs will be posted at public entrances identifying the hospital as a being a firearms free facility.
2. The Safety Officer must be notified of any incident involving a firearm or deadly weapon. If not on campus, the Safety Officer must be telephoned or paged.
3. The home phone number and pager number for the Safety Officer will be kept current and placed on the Emergency Phone Numbers List (Enclosure 9). This list will be prominently displayed at the PBX.
4. With the exception of sworn officers of the City, County, State or Federal Government weapons may not be brought onto Sandhills Regional Medical Center property.
5. Sworn Officers of the City, County, State or Federal Government will be allowed to bring weapons on to the premises, provided they are transported according to their department policies.
6. No person may enter the Mental Health Unit with a firearm or deadly weapon.
a. Staff members will be educated during orientation and annual refresher training.
b. Forensic staff will be asked to secure their firearms in their vehicles or surrender them to the Safety Officer.
7. Patients and visitors that are "Licensed to Carry Concealed Weapons" are requested to surrender all weapons to the Safety Officer upon entering the building.
8. Patients, who enter for admission with a weapon, will be asked to send the weapon home with a family member if possible.
9. Patients being admitted through the Emergency Department or arriving at Sandhills Regional Medical Center without a family member will be requested to surrender their weapon.
10. Visitors not complying with this regulation will be denied access to Sandhills Regional Medical Center. Local law enforcement will be called if the visitor becomes disruptive.

b. Procedure:

1. If a patient or visitor volunteers that he/she is in possession of a weapon, call Safety Officer to check weapon.
2. If a patient or visitor is found to have a weapon but is unwilling to surrender it, Safety Officer shall be called.
3. Do not attempt to confront the patient/visitor.
4. Weapons surrendered or confiscated must be checked clear by the Safety Officer.
5. Cleared weapons shall be locked secure storage in the hospital safe, in accordance with the “Securing of Patient Valuables” policy in the Administrative Policy and Procedure Manual.

4. Vehicular Traffic and Parking:

a. All staff, patients, guest and visitors will park only in the designated areas.
b. Staff will park on the North side of the building.
c. Vehicles must be parked only on paved areas, fully within the painted lines and not in reserved spaces unless authorized by Administration.
d. Staff overflow and after hours parking will be the last two rows of the South, West Parking lot
e. Americans with Disabilities and physicians have reserved parking identified by appropriate markings on the pavement.
f. All persons on hospital property will obey the directions of traffic control personnel and all posted parking signs.
g. Sandhills Regional Medical Center reserves the right to take appropriate action to ensure the timely delivery or removal of any equipment or person for medical or operational necessity.

5. Security Incidents:

a. Code Black – Staff needs assistance. Assume staff member needs assistance that may or may not require specialized training, may or may not involve physical threat or restraint.
 
1. Upon notification, the PBX operator will announce “Code Black” over the overhead paging system three times in succession.
2. As long as patient care is not compromised all able bodied personnel are to report to the scene to render assistance. 
3. Observe all appropriate Universal precautions.
4. Where the threat of physical force is eminent, only those persons having current P.R.I.D.E. certification will normally be required to participate.
5. Secure from Code Black by instruction of the originating person(s). 

b. Code White – Hostage Situation. Assume a weapon is involved and person(s) are in immediate danger.

1. Upon notification, the PBX operator will announce “Code White” over the overhead paging system three times in succession.
2. Staff should report to respective work centers for instructions.
3. Activate the Incident Command Center (ICC) in accordance with the Emergency Management Plant.
4. Call 911 and inform the dispatcher of the situation.
5. Security officers should keep the area clear until relieved by local authority.
6. Secure from Code White upon instruction from the ICC.

c. Code Green – Building Lock Down. Assume that an event has transpired or is eminent where person(s) involved may be wanted for interrogation and/or special protection, or a threat to health or safety exists or the building is to be made as secure as possible from encroachment.

1. Upon notification, the PBX operator will announce “Code Green” over the overhead paging system three times in succession.
2. Staff should report to respective work centers for instructions.
3. Activate the Incident Command Center (ICC) in accordance with the Emergency Management Plant.
4. Department managers assign personnel to exterior doors in accordance with enclosure 19.
5. Secure from Code Green upon instruction from the ICC.

6. Code Pink - Infant/Pediatric Abduction. Assume infant/pediatric patient is being or has been abducted by unauthorized person(s) either with or without consent. 

a. Upon notification from the patient’s room dial *24 and announce “Code Pink” over the overhead paging system three times in succession.
b. Staff should report to respective work centers for instructions.
c. Activate the Incident Command Center (ICC) in accordance with the Emergency Management Plant. Dial 911 and report the situation.
d. Department managers assign personnel to exterior doors in accordance with enclosure 19.
e. Secure from Code Green upon instruction from the ICC.

7. VIPs and Media: 

a. Upon notification of the imminent arrival of a VIP as a patient, the following persons shall be notified:
1. Chief Executive Officer/Administrator on Call.
2. Medical Director
3. Chief Nursing Officer
4. Emergency Department Physician
5. Other specialist as required.

b. If necessary the Chief Executive Officer shall call a “Director’s Meeting” (Threat Condition Charlie) in the Education Conference Room and institute the following items deemed necessary:

1. Call a “Code Green”. (If interference is anticipated from the local community or media)
2. Commence a “Phased Recall”. (If additional staff is required)
3. Activate the Command Center. (If necessary for private or government security)

c. Trauma/ER Nurses and/or Physicians shall make ready a receiving area and discharge or transfer patients who may be in that area.
d. Department managers remain in or report to their respective departments and stand by if needed.
e. The Chief Executive Officer or person(s) designated by the Chief Executive Officer shall communicate with the news media as necessary.
f. If necessary VIP patients shall be admitted to the ICU.
g. Patient shall be admitted as "Secured Patient". Patient's name will not appear on computer or unsecured reports to prevent unauthorized viewing.
h. The patient must be registered under correct name for Lab work and blood transfusions for risk prevention.
i. If allowed to enter, media personnel shall be directed to the Dining Room.
j. Authority and responsibility for internal security will be turned over to local, state, or federal law enforcement when requested for Governmental VIP(s).
k. In all other instances, security requirements will be met utilizing available hospital staff, external security services or local law enforcement agencies at the discretion of administration.

8. Emergency Room Access:

a. Only Ambulances and authorized ground transport will be authorized access to the Emergency Department access road.
b. All reasonable means to discover and advise the operators of Vehicles discovered to be in the Emergency Department access will be attempted as time and circumstance permits.
c. If operators are unable or unwilling to remove delinquent vehicles the vehicles will be removed by the least destructive method available as time and circumstance permits.
d. Upon receiving notification of a “Code D”, Security Officers will report to the Emergency Department to enforce this policy.