Q:
Can we place the room/bed number for a semi-private room on the Enhanced Barrier Precaution sign located outside the resident’s room to notify staff which resident requires PPE for high contact activities or is this a HIPAA violation?
A:
CMS addresses the signage in Frequently Asked Questions (FAQ) listed below. The signage indicates what Personal Protective Equipment (PPE) and precautions are necessary for staff to properly care for the resident. The signage should not include why the precautions are being used, for example a device or MDRO as that would be a violation. However, identifying which bed on the sign would not be a HIPAA violation, just as placing the sign on a private room would not be a violation.
The QSO 24-08 was issued by CMS on March 20, 2024. The QSO refers to the following CDC link for nursing homes which has another link to the frequently asked questions (FAQ).
Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes | LTCFs | CDC
CMS FAQ Question #28. Does posting signs specifying the type of Precautions and recommended PPE outside the resident room violate Health Insurance Portability and Accountability Act (HIPAA) and resident dignity?
No. Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of Precautions and the recommended PPE to be worn when caring for the resident. Generic signs that instruct individuals to speak to the nurse are not adequate to ensure Precautions are followed. Signs should not include information about the resident’s diagnosis or the reason for the Precautions (e.g., presence of a resistant pathogen); inclusion of that information would violate HIPAA and resident dignity.
CDC has created examples of signs that can be used by facilities to communicate information about Transmission-Based and Enhanced Barrier Precautions. Facilities can use these signs or modify them to create signs that work for their facility.
Contact Proactive for IPC Program supporting including Infection Preventionist training and coaching info@proactiveltcexperts.com
Written by:
Melissa Brandenburg, RN
Clinical Consultant
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