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Signs & Postings in Hospitals
Manual2013
Published by Wisconsin Hospital Association, Inc.
www.wha.org
Copyright © 2013 Wisconsin Hospital Association, Inc.
All rights reserved.
1 © 2013 Wisconsin Hospital Association, Inc.
WHA Signs & Postings in Hospitals Manual
The following manual was drafted in October 2012 and is based on the laws or the proposed
laws in effect at that time. This manual does not reflect changes to the law since October 2012.
Users should determine whether the laws or proposed laws discussed in this manual have been
updated. A non-exhaustive list of areas of the law that have been updated or had proposed
updates released since October 2012 appears at the end of this manual.
Table of Contents
I. Scope ........................................................................................................................................... 5
II. Emergency Treatment & Active Labor Act ............................................................................... 5
a. EMTALA Rights ..................................................................................................................... 5
i. Location ............................................................................................................................... 5
ii. Wording .............................................................................................................................. 5
iii. Sample language ................................................................................................................ 6
b. Medicaid ................................................................................................................................. 6
c. No Physician Presence Twenty-Four Hours per Day, Seven Days per Week ........................ 7
i. In General ............................................................................................................................ 7
ii. Content ................................................................................................................................ 7
iii. Location ............................................................................................................................. 7
III. Pricing & Payment .................................................................................................................... 7
a. Signs Pertaining to Financial Assistance (Proposed IRS Rules) ............................................ 7
i. Conspicuous Public Displays & Other Measures ................................................................ 7
1. Content & Wording......................................................................................................... 8
2. Examples ......................................................................................................................... 8
ii. Internet ................................................................................................................................ 9
b. Signs Pertaining to Hospital Charges ..................................................................................... 9
i. Display & Signage Requirements ...................................................................................... 10
ii. Hospital Disclosure of Charges ........................................................................................ 10
iii. Hospital Quality Information........................................................................................... 10
iv. Health Care Provider Charge Information ....................................................................... 10
v. Health Care Provider Quality Information ....................................................................... 11
vi. Good-Faith Estimate of Out-of-Pocket Costs from Insurer ............................................. 11
2 © 2013 Wisconsin Hospital Association, Inc.
IV. Confidentiality ........................................................................................................................ 11
a. Header ................................................................................................................................... 12
b. Uses & Disclosures ............................................................................................................... 12
c. Individual Rights ................................................................................................................... 13
d. Covered Entity’s Duties ........................................................................................................ 13
e. Complaints ............................................................................................................................ 13
f. Contact ................................................................................................................................... 13
g. Effective Date ....................................................................................................................... 13
h. Optional Elements ................................................................................................................. 14
V. Rights of Patients Receiving Treatment for Mental Illness, Developmental Disabilities,
Alcoholism, or Drug Dependency ................................................................................................ 14
a. Notice Regarding Confidentiality of Treatment Records ..................................................... 14
b. Rights of Patients in a Treatment Facility or Unit ................................................................ 14
VI. Employment-Related Signs .................................................................................................... 15
a. Employment Related Signs Unique to Hospitals & Health Care Providers ......................... 15
i. Whistleblower Protection .................................................................................................. 15
1. Protected Reporting ...................................................................................................... 15
2. Approved Form ............................................................................................................. 15
b. Employment Related Signs—Wisconsin Law ...................................................................... 16
i. Wisconsin Business Closing & Mass Layoff .................................................................... 16
ii. Honesty Testing Devices .................................................................................................. 16
iii. Fair Employment Law ..................................................................................................... 16
iv. Family & Medical Leave Law ......................................................................................... 16
v. Minimum Wage Rates ...................................................................................................... 17
vi. Minimum Wage for Workers with Disabilities ............................................................... 17
vii. Hours of Work for Minors .............................................................................................. 17
viii. Cessation of Health Care Benefits ................................................................................. 17
ix. Unemployment Benefits .................................................................................................. 17
x. Hazardous Chemicals, Toxic Substances, Infectious Agents & Pesticides ...................... 18
c. Signs Applicable to Employers—Federal Law ..................................................................... 18
i. Employee Polygraph Protection Act.................................................................................. 18
ii. Federal Minimum Wage/Fair Labor Standard Act of 1938.............................................. 19
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iii. Occupational Safety & Health Act .................................................................................. 19
iv. Uniformed Services Employment & Reemployment Rights Act .................................... 19
v. Family & Medical Leave Act ........................................................................................... 20
vi. Workers with Disabilities Paid at Special Minimum Wages ........................................... 20
vii. Equal Employment Opportunity ..................................................................................... 20
viii. Genetic Information Non-Discrimination Act (GINA) ................................................. 21
ix. Employee Rights Under the National Labor Relations Act ............................................. 21
1. Employers ..................................................................................................................... 21
2. Federal Government Contractors & Subcontractors ..................................................... 22
VII. Signs Regarding Independent Contractors ............................................................................ 23
a. In General .............................................................................................................................. 23
b. Emergency Room.................................................................................................................. 23
i. Beyond the Emergency Room ........................................................................................... 24
VIII. Radiation Areas .................................................................................................................... 24
a. In General .............................................................................................................................. 24
b. Posting of Radiation Caution Signs ...................................................................................... 24
c. Radiation Symbol .................................................................................................................. 25
d. Exceptions ............................................................................................................................. 25
e. Posting of Notices to Workers .............................................................................................. 26
IX. Other Health Care-Related Signs & Postings ......................................................................... 27
a. Operating Rooms .................................................................................................................. 27
b. Pharmacy Licenses—Display ............................................................................................... 27
c. Physician & Physician Assistants—Display of Registrations .............................................. 27
d. Nursing Homes ..................................................................................................................... 27
e. Respiratory Care.................................................................................................................... 27
f. Medicare Provider-Based Departments ................................................................................. 27
X. Other Non-Health Care Related Signs & Postings .................................................................. 28
a. Food-Related Signs ............................................................................................................... 28
i. Posting Menus in Kitchen—Medicare Conditions of Participation/Interpretive Guidance
............................................................................................................................................... 28
ii. Food Permits ..................................................................................................................... 28
b. No Smoking Signs ................................................................................................................ 28
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i. In General .......................................................................................................................... 28
ii. Sign ................................................................................................................................... 28
iii. Content............................................................................................................................. 29
c. Weapon on Premises ............................................................................................................. 29
d. Fire-Related Signage. ............................................................................................................ 29
i. Direction for Escape; Exit Lights & Signs ........................................................................ 29
1. Direction for Escape ..................................................................................................... 29
2. Alternative Exits ........................................................................................................... 30
3. Exit Doors & Signs ....................................................................................................... 30
4. Stairs ............................................................................................................................. 30
ii. Firewall Signs ................................................................................................................... 30
e. Conveyances ......................................................................................................................... 30
XI. Federal & State Contractors and Other Entities Receiving Federal or State Financial
Assistance ..................................................................................................................................... 31
XII. Manual Updates ..................................................................................................................... 31
5 © 2013 Wisconsin Hospital Association, Inc.
I. Scope
This Manual provides a broad overview of requirements for posting notices and signage in
hospitals, including requirements in federal law and state law. The scope of this Manual includes
signage and notices addressed to patients as well as signage and notices addressed to employees.
There may be additional signage-related requirements depending on each hospital’s particular
facts and circumstances. This Manual discusses the requirements as of the date of publication.
Changes to signage requirements may occur from time to time.
II. Emergency Treatment & Active Labor Act
As described more fully in the WHA Patient Discharge & Transfer Manual, the Emergency
Medical Treatment and Active Labor Act (EMTALA) and its implementing regulations protect
persons who come to the hospital’s emergency department requesting examination or treatment
for a medical condition. In addition to screening, stabilizing, and transfer requirements,
EMTALA includes signage requirements as discussed in this section.
a. EMTALA Rights
EMTALA requires Medicare-participating hospitals to post signs conspicuously in emergency
departments and other various locations specifying the rights of individuals (including those who
are not Medicare beneficiaries) under EMTALA to examination and treatment for an emergency
medical condition and women in labor. See 42 C.F.R. § 489.20(q)(1).
i. Location
Hospitals must post the signs in the following places: (1) emergency departments; (2) places
likely to be noticed by all individuals entering the emergency department; and (3) places likely to
be noticed by individuals waiting for examinations and treatment in areas other than traditional
emergency departments (e.g., entrance, admitting areas, waiting rooms, and treatment areas). See
42 C.F.R. § 489.20(q)(1).
ii. Wording
The wording on the sign must be clear and in simple terms and language, understandable to the
population served by the hospital. See State Operations Manual, Appendix V—Interpretive
Guidelines—Responsibilities of Medicare Participating Hospitals in Emergency Cases, Tag A-
2402/C-2402 (Rev. 46, 05/29/09). Additionally, the sign must satisfy the following criteria: (1) it
must specify the rights of individuals with emergency conditions and women in labor who come
to the emergency department for health care services; (2) it must indicate whether the facility
participates in the Medicaid program; (3) it must be printed in English and other languages that
are common to the population of the area served; and (4) the letters within the signs must be
6 © 2013 Wisconsin Hospital Association, Inc.
clearly readable at a distance of at least twenty feet or the expected vantage point of the
emergency department patients. See Medicare General Information, Eligibility, and Entitlement,
Chapter 5, Section 10.1.10—Posting of Signs in Hospital Emergency Departments.
iii. Sample language
CMS provides the following language below as a sample, but it may be adapted. A best practice
would be to use CMS’s sample language, which is presented below. See id.
IT’S THE LAW
IF YOU HAVE A MEDICAL EMERGENCY OR ARE IN LABOR
YOU HAVE THE RIGHT TO RECEIVE, WITHIN THE CAPABILITIES OF THIS
HOSPITAL’S STAFF AND FACLITIES:
An appropriate medical SCREENING EXAMINATION
Necessary STABILIZING TREATMENT (including treatment for an unborn child)
And if necessary
An appropriate TRANSFER to another facility
Even if
YOU CANNOT PAY OR DO NOT HAVE MEDICAL INSURANCE
OR
YOU ARE NOT ENTITLED TO MEDICARE OR MEDICAID
This hospital (does/does not) participate in the Medicaid program
b. Medicaid
Hospitals must also post conspicuously, in a form specified by the Secretary of U.S. Department
of Health and Human Services (DHHS), information indicating whether the hospital participates
in the Medicaid Program. See 42 C.F.R. § 489.20(q)(2). The wording must be clear and in simple
terms and language understandable to the population served by the hospital. See State Operations
Manual, Appendix V—Interpretive Guidelines—Responsibilities of Medicare Participating
Hospitals in Emergency Cases, Tag A-2402/C-2402 (Rev. 46, 05/29/09). The sample language
from CMS above also satisfies the Medicaid notice requirement.
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c. No Physician Presence Twenty-Four Hours per Day, Seven Days per
Week
i. In General
Hospitals with a dedicated emergency department must post a notice if a doctor of medicine or
doctor of osteopathy is not present twenty-four hours per day, seven days per week. See 42
C.F.R. § 489.20(w)(5). A “dedicated emergency department” means any department or facility
of the hospital (on campus or off campus) that satisfies one of the following requirements: (1) it
is licensed by the State under applicable law as an emergency room or emergency department;
(2) it is held out to the public (by name, signs, advertising, or other means) as a place that
provides care for emergency medical conditions on an urgent basis without requiring a scheduled
appointment; or (3) during the immediately preceding calendar year, based on a sample of
patient visits, it provides at least one third of all of its outpatient visits for the treatment of
emergency medical conditions on an urgent basis without requiring a previously scheduled
appointment. See 42 C.F.R. § 489.24(5).
ii. Content
The notice must state that the hospital does not have a doctor of medicine or osteopathy present
in the hospital twenty-four hours per day, seven days per week. The notice must also indicate
how the hospital will satisfy the needs of any patient with an emergency medical condition at a
time when there is no doctor in the hospital. See 42 C.F.R. § 489.20(w)(5).
iii. Location
The hospital must post the notice conspicuously in a place or places likely to be noticed by all
individuals entering the dedicated emergency department. See id.
III. Pricing & Payment
a. Signs Pertaining to Financial Assistance (Proposed IRS Rules)
As described in the WHA Special Issues Facing Tax-Exempts Manual, I.R.C. § 501(r)(4)
requires hospital organizations to establish a written financial assistance policy (FAP). Among
other requirements, the FAP must include measures to widely publicize the FAP within the
community served by the hospital organization. See I.R.C. § 501(r)(4). Proposed regulations
issued by the IRS would require hospitals to address four types of measures that they will take to
widely publicize the FAP. See 77 Fed. Reg. 38,148, 38,152, 38,161 (June 26, 2012) (proposed
rules). Two of the proposed measures require posting of the FAP as described below.
i. Conspicuous Public Displays & Other Measures
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First, under the proposed regulations, the hospital organization’s FAP must include measures that
the hospital organization will take to inform and notify visitors about the FAP through
conspicuous public displays or other measures “reasonably calculated” to attract the attention of
visitors to the hospital. See 77 Fed. Reg. at 38,163. Whether a measure is “reasonably calculated”
to attract attention would depend on all facts and circumstances, including the primary languages
spoken by residents of the community served by the hospital, along with other attributes of the
community and the facility. See id.
1. Content & Wording
At a minimum, the measures have to notify the reader that the hospital offers financial assistance
under a FAP and inform the reader about how or where to obtain more information. See 77 Fed.
Reg. at 38,163. Thus, a display would not have to provide visitors with the FAP itself or all of
the information in it but could instead provide a summary of the FAP or notify visitors of its
existence and provide instructions on how to obtain more information. See 77 Fed. Reg. at
38,152.
2. Examples
To notify visitors of the FAP, the IRS suggests conspicuously posting signs and displaying
brochures in public locations of the hospital. See 77 Fed. Reg. at 38,152. The IRS provides the
following as an illustration of an appropriate public display under the proposed rules:
The hospital “conspicuously displays a sign in large font regarding the FAP in its
billing office, admission and registration areas, and emergency room. The sign
says: “Uninsured? Having trouble paying your hospital bill? You may be eligible
for financial assistance.” The sign also provides the URL of the Web page where
[the facility’s] FAP and FAP application form can be accessed. In addition, the
sign provides a telephone number and room number of [the facility] that
individuals can call or visit with questions about the FAP or the FAP application
process. Underneath each sign, [the facility] conspicuously displays copies of a
brochure that contains all of the information required to be included in a plain
language summary of the FAP [as described in the proposed regulations].
See 77 Fed. Reg. at 38,163. As a second example, for a community in which 11 percent of the
community speaks Spanish, the IRS provides that the hospital also displays Spanish versions of
the documents.
Based on the foregoing, a publicly displayed sign could look as follows:
Uninsured?
9 © 2013 Wisconsin Hospital Association, Inc.
Having Trouble Paying Your Hospital Bill?
You may be eligible for financial assistance.
Our facility has in place a financial assistance policy.
You may access our financial assistance policy and application forms at [web page]. You may
also call [phone number] or stop by _______________ with any questions on our financial
assistance policy or the application process.
Please take a brochure below for additional information.
The hospital organization could also provide the same language and information in alternative
languages at the bottom of the sign.
ii. Internet
Second, the proposed regulations require the hospital to make the FAP, application form, and a
plain language summary of the FAP widely available on the hospital’s web site or the web site of
the hospital organization that operates the hospital if it does not have its own web site. See 77
Fed. Reg. at 38,152-53, 38,163. The hospital would have to conspicuously post complete and
current versions of the documents in English and in the primary language of any populations
with limited English proficiency that comprise more than 10 percent of residents of the
community served by the facility. See id. The hospital could also post the documents on another
entity’s web site, as long as the web site of the hospital or hospital organization provides a
conspicuously displayed link to the web page on which the document is posted, along with clear
instructions for accessing the document on the web site. See 77 Fed. Reg. at 38,163. Under the
proposed rules, any individual with access to the internet would have to be able to access,
download, view, and print a hard copy of the documents without requiring special computer
hardware or software and without paying a fee to the hospital, hospital organization, or other
entity. See id.
b. Signs Pertaining to Hospital Charges
In January 2011, a price and quality transparency law became effective for health care providers
and hospitals in Wisconsin, requiring them to disclose certain charge and quality information.
See 2009 Wis. Act 146. A summary of the law and its signage requirements are discussed in this
section. For purposes of the law, “health care provider” means a nurse, chiropractor, dentist,
physician, physician assistant, physical therapist, podiatrist, athletic trainer, optometrist,
pharmacist, psychologist, speech language pathologist or audiologist, a partnership, corporation
or limited liability company of such providers, a hospice, a clinic, and an ambulatory surgery
center, among other providers. See Wis. Stat. §§ 146.81(1)(a)-(L), 146.903(c). Wisconsin’s price
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and quality disclosure requirements do not apply to providers that: (1) practice individually or in
association with not more than two other individual providers or (2) are an association of three or
fewer individual providers. See Wis. Stat. § 146.903(3)(g).
i. Display & Signage Requirements
Each hospital and health care provider must prominently display a statement informing
consumers that they have the right to (1) the information on charges as described below; (2) the
information on quality as described below, if applicable; and (3) in certain circumstances, a
good-faith estimate from their insurers of their out-of-pocket costs for a specified service
according to the individual’s benefit terms and the geographic region in which the service will be
performed. See Wis. Stat. § 146.903(3)(f), (4)(e). The hospital or health care provider must
display the statement in an area of the hospital or health care provider’s practice or facility that is
most commonly frequented by consumers. See id.
ii. Hospital Disclosure of Charges
For hospitals, the sign must notify consumers that the following charge information is available
at no cost upon the request of the consumer (but need not provide the underlying charge
information): (1) the hospital’s median billed charges, (2) the average allowable payment under
Medicare, (3) and the average allowable payment from private third-party payers for seventy-
five diagnosis related groups (DRGs) and seventy-five outpatient surgical procedures. The
seventy-five inpatient DRGs must consist of the seventy-five DRGs for which hospitals in
Wisconsin most frequently provide inpatient care, as identified by the Wisconsin Hospital
Association, Inc. (WHA). See Wis. Stat. §§ 146.903(4)(a),(e), 153.21(3). Likewise, the seventy-
five outpatient surgical procedures must consist of the seventy-five outpatient surgical
procedures most frequently performed by hospitals in the state, as determined by WHA. See id.
iii. Hospital Quality Information
If a hospital submits data to a “health care information organization,” the display for such
hospital must also notify consumers that the following quality information is available at no cost
to consumers upon request (but need not provide the underlying quality information): any public
information reported by a health care information organization regarding the hospital’s quality
relating to the seventy-five DRGs or seventy-five outpatient surgical procedures for which the
hospital must provide its charge data, compared to the quality of such health care services
provided by other hospitals. See Wis. Stat. § 146.903(4)(am),(e). A “health care information
organization” is an organization that gathers data from health care providers or hospitals
regarding utilization and the quality of health care services and produces reports on the
comparative quality of services. Wis. Stat. § 146.903(1)(br).
iv. Health Care Provider Charge Information
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For health care providers, the display must notify consumers that the following charge
information is available at no cost upon request (but need not provide the underlying charge
data):
- The provider’s median billed charge (assuming no complications) for a health care
service, diagnostic test, or procedure that is specified by the consumer and furnished by
the provider. See Wis. Stat. § 146.903(3)(a),(f); and
- The provider’s (1) median billed charge, (2) Medicare payment to the provider (if
Medicare-certified), and (3) average allowable payment from private third-party payors
for twenty-five conditions identified by Wisconsin Department of Health Services
(DHS). See Wis. Stat. § 146.903(3)(b),(f).
v. Health Care Provider Quality Information
If the health care provider submits data to a health care information organization, the display
must also notify consumers that the following quality information is available at no cost upon
request (but need not provide the underlying quality information): public information reported by
the health care information organization regarding the provider’s quality of care relevant to the
service, test, or procedure identified by the consumer or to the twenty-five presenting conditions
identified by DHS, compared to the quality of health care services furnished by other providers.
See Wis. Stat. § 146.903(3)(am),(bm).
vi. Good-Faith Estimate of Out-of-Pocket Costs from Insurer
The display for hospitals and health care providers must also inform consumers that, in certain
circumstances, they may receive a good-faith estimate from their insurers of their out-of-pocket
costs for a specified service. See Wis. Stat. § 146.903(3)(f), (4)(e). The sign itself does not have
to provide the estimate, but must inform consumers that the estimate may be available. To
provide some background, an insurer or self-insured plan must provide the estimate as of the date
of the request, assuming no medication complications or modifications to the insured’s treatment
plan. See id. Before providing the information, the insurer or self-insured plan may require the
insured to provide in writing: (1) the name of the provider performing the service, (2) the facility
at which the service will be performed, (3) the date the service will be performed, (4) the health
care provider’s estimate of the charge for the service, and (5) the CPT codes for the service. See
Wis. Stat. § 632.798(2)(d).
IV. Confidentiality
The WHA Managing Health Information Manual discusses confidentiality of patient health
information (PHI), including requirements for providing a Notice of Privacy Practices and
posting such notice on the covered entity’s website. Because hospitals are covered entities under
the Health Insurance Portability and Accountability Act (HIPAA) with direct treatment
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relationships with individuals and maintain physical service delivery sites, they must post a
Notices of Privacy Practices. See 45 C.F.R. § 164.520(c)(2)(iii)(B). (Section V.a below discusses
confidentiality of records created in the course of providing services for mental illness,
developmental disabilities, alcoholism, or drug dependency.)
The covered entity must post the Notice of Privacy Practices at the service delivery site, in a
clear and prominent location where it is reasonable to expect individuals seeking service from
the covered entity to be able to read the Notice of Privacy Practices. Id. The Notice of Privacy
Practices must be written in plain language and include the following information.
a. Header
The Notice must include the following language as a header or otherwise prominently displayed:
“THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.”
b. Uses & Disclosures
The Notice must include:
- A description, including at least one example, of the types of uses and disclosures that the
covered entity is permitted under the HIPAA Privacy Rule to make for each of the
following purposes: (1) treatment, (2) payment, and (3) health care operations. If a use or
disclosure is prohibited or materially limited by other applicable law, the description of
such use or disclosure must reflect the more stringent law. The description must be of
sufficient detail to place the individual on notice of the uses and disclosures that are
permitted or required by the Privacy Rule or other applicable law;
- A description of each of the other purposes for which the covered entity is permitted or
required under the Privacy Rule to use or disclose PHI without the individual’s written
authorization. If a use or disclosure is prohibited or materially limited by other applicable
law, the description of such use or disclosure must reflect the more stringent law. The
description must be of sufficient detail to place the individual on notice of the uses and
disclosures that are permitted or required by the Privacy Rule or other applicable law;
- A statement that the covered entity will make other uses and disclosures only with the
individual’s written authorization and that the individual may revoke such authorization;
- If the covered entity intends to engage in any of the following activities, the description
of the uses and disclosures must include a separate statement that:
o The covered entity may contact the individual to provide appointment reminders
or information about treatment alternatives or other health-related benefits and
services that may be of interest to the individual;
o The covered entity may contact the individual to raise funds for the covered
entity; or
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o A group health plan, or a health insurance issuer or HMO with respect to a group
health plan, may disclose PHI to the sponsor of the plan.
c. Individual Rights
The Notice must include a statement of the individual’s rights with respect to PHI and a brief
description of how the individual may exercise such rights, as follows:
- The right to request restrictions on certain uses and disclosures of PHI, including a
statement that the covered entity is not required to agree to a requested restriction;
- The right to receive confidential communications of PHI, as applicable;
- The right to inspect and copy PHI;
- The right to amend PHI;
- The right to receive an accounting of disclosures of PHI; and
- The right of an individual, including an individual who has agreed to receive the Notice
electronically, to obtain a paper copy of the Notice from the covered entity upon request.
d. Covered Entity’s Duties
The Notice must contain:
- A statement that the covered entity is required by law to maintain the privacy of PHI and
to provide individuals with notice of its legal duties and privacy practices with respect to
PHI;
- A statement that the covered entity is required to abide by the terms of the Notice
currently in effect; and
- For the covered entity to apply a change in privacy practice that is described in the Notice
that the covered entity created or received prior to issuing a revised Notice, a statement
that it reserves the right to change the terms of its Notice and to make the new Notice
provisions effective for all PHI that it maintains. The statement must also describe how
the covered entity will provide individuals with a revised notice.
e. Complaints
The Notice must contain: (1) a statement that the individual may complain to the covered entity
and to the Secretary of DHHS if the individual believes his or her privacy rights have been
violated, (2) a brief description of how the individual may file a complaint with the covered
entity, and (3) a statement that the individual will not be retaliated against for filing a complaint.
f. Contact
The Notice must contain the name, or title, and telephone number of a person or office to contact
for further information. The contact typically will be the hospital’s privacy officer.
g. Effective Date
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The Notice must contain the date on which the Notice is first in effect, which may not be earlier
than the date on which the Notice is printed or otherwise published.
h. Optional Elements
If a covered entity elects to limit a use or disclosure that it is permitted to make under the Privacy
Rule, the covered entity may describe its more limited uses or disclosures in its Notice. However,
the covered entity may not include in its Notice a limitation affecting its rights to make a use or
disclosure that is: (1) required by law or (2) necessary to prevent or lessen a serious and
imminent threat to the health and safety of a person or the public and made to a person or
persons reasonably able to prevent or lessen the threat, including the target. See 45 C.F.R.
§ 164.520.
V. Rights of Patients Receiving Treatment for Mental Illness,
Developmental Disabilities, Alcoholism, or Drug Dependency
a. Notice Regarding Confidentiality of Treatment Records
As described in the WHA Mental Health Issues Manual, Wisconsin law addresses the
confidentiality of treatment records created in the course of providing services to individuals
with a mental illness, developmental disability, alcoholism, or drug dependency and maintained
by treatment facilities. Treatment facilities and service providers must prominently display and
make available for inspection and copying a notice describing their treatment record access
procedures. See Wis. Admin. Code § DHS 92.03(1)(d). A “treatment facility” is “any publicly or
privately operated facility or unit thereof providing treatment of alcoholic, drug dependent,
mentally ill, or developmentally disabled persons” including inpatient and outpatient treatment
programs. See Wis. Stat. § 51.01(19). Where both federal and state laws protect the
confidentiality of patient medical records, disclosure can only be made where the requirements
of both laws are satisfied.
b. Rights of Patients in a Treatment Facility or Unit
As discussed in the WHA Mental Health Issues Manual, treatment facilities must post copies of
section 51.61 of the Wisconsin Statutes, which addresses patient rights for individuals receiving
services for mental illness, developmental disabilities, alcoholism, or drug dependency. See Wis.
Stat. § 51.61(1)(a). Treatment facilities must post the copies conspicuously in each patient area
and make copies available to the patient’s guardian and immediate family. See id. The posting
requirement regarding patient rights is generally not necessary for hospital emergency rooms or
hospital outpatient departments, unless such department is otherwise a “treatment facility.” This
is because the term “patient” as used in the statute generally does not include any individual who
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receives treatment in a hospital emergency room or on an outpatient basis at a private hospital or
public general hospital. See Wis. Stat. § 51.61(1).
VI. Employment-Related Signs
Various signage requirements exist for hospitals in their capacity as employers. This section
provides a broad overview of employment-related signage requirements. Failure to post required
notices may result in fines or cause claims not to be barred by the relevant statute of limitations.
Additional requirements may exist, particularly for federal and/or state contractors.
a. Employment Related Signs Unique to Hospitals & Health Care
Providers
i. Whistleblower Protection
Wisconsin law requires all health care providers and health care facilities, including hospitals, to
post a notice setting forth employees’ rights under section 146.997 of the Wisconsin Statutes.
The health care facility must post the notice in one or more conspicuous places where notices to
employees are customarily posted.
1. Protected Reporting
Section 146.997 protects employees of a facility or health care provider who in good faith report
the following information, unless prohibited by law:
- Potential violations of any state or federal law by the provider or an employee of the
provider; or
- Any situation in which the quality of health care services furnished by the provider or any
employee of the provider violates any standard established by state or federal law or any
clinical or ethical standard established by a professionally recognized accrediting body or
standard-setting body and poses a potential risk to public health and safety.
See Wis. Stat. § 146.997. The law protects reporting to the following persons and entities:
- A professionally recognized accrediting or standard-setting body that accredited,
certified, or otherwise approved the provider;
- Any officer or director of the facility; or
- Another employee of the provider who is in a supervisory capacity or a position to take
corrective action.
See id. The provider may not take or threaten disciplinary action against any person who reports
the information in good faith. See id.
2. Approved Form
16 © 2013 Wisconsin Hospital Association, Inc.
The facility or provider must post the notice in a form approved by the DHS. Wisconsin’s
Department of Workforce Development (DWD) provides the poster that health care facilities and
providers may use at: http://dwd.wisconsin.gov/dwd/posters.htm.
b. Employment Related Signs—Wisconsin Law
i. Wisconsin Business Closing & Mass Layoff
Employers with fifty or more employees in Wisconsin must post, in one or more conspicuous
places where notices to employees are customarily posted, a notice in a form approved by the
DWD setting forth employees’ rights with respect to business closings and mass layoffs. Wis.
Stat. § 109.07(7); Wis. Admin. Code § DWD 279.07. Notably, the term “employer” for purposes
of this law does not include any charitable or tax-exempt institutions. See Wis. Admin. Code §
DWD 279.01(d). The approved form is available at: http://dwd.wisconsin.gov/dwd/posters.htm.
ii. Honesty Testing Devices
Employers who administer lie detector tests, or have a lie detector test administered, must post a
notice prepared by DWD. See Wis. Stat. § 111.37(3). “Lie detector” includes a polygraph,
deceptograph, voice stress analyzer, psychological stress evaluator, or other similar device,
whether mechanical or electrical, that is used to render a diagnostic opinion about the honesty or
dishonesty of the individual. See Wis. Stat. § 111.37(1). The employer must post the notice in
conspicuous places on its premises where notices to employees and applicants for employment
are customarily posted. See Wis. Stat. § 111.37(3). Because of Wisconsin’s stringent laws
concerning honesty testing devices, many employers choose not to use such testing. DWD’s
prepared notice is available at: http://dwd.wisconsin.gov/dwd/posters.htm.
iii. Fair Employment Law
Every employer, employment agency, and licensing agency must post in conspicuous places on
its premises a poster prepared by DWD relating to Wisconsin’s fair employment law. See Wis.
Admin. Code § DWD 218.23. DWD’s prepared poster is available at:
http://dwd.wisconsin.gov/dwd/posters.htm.
iv. Family & Medical Leave Law
Employers with at least fifty employees must post, in one or more conspicuous places where
notices to employees are customarily posted, a notice approved by DWD setting forth
employees’ rights under Wisconsin law relating to family and medical leave. See Wis. Stat.
§ 103.10(1)(c), (14). DWD’s approved form is available at:
http://dwd.wisconsin.gov/dwd/posters.htm.
17 © 2013 Wisconsin Hospital Association, Inc.
Additionally, persons employing at least twenty-five individuals must post, in one or more
conspicuous places where notices to employees are customarily posted, a notice describing its
policy with respect to family and medical leave. Wis. Stat. § 103.10(1)(c), (14).
v. Minimum Wage Rates
DWD provides an informational poster relating to minimum wage rates at:
http://dwd.wisconsin.gov/dwd/posters.htm. Posting of this poster is optional.
vi. Minimum Wage for Workers with Disabilities
An employer operating under a special minimum wage license must display at all times and
make available to employees a poster required by DWD. See Wis. Admin. Code § DWD
272.09(10). The poster must explain, in general terms, the conditions under which special
minimum wages may be paid. See id. The employer must post the poster in a conspicuous place
on the employer’s premises where it may be readily observed by workers with disabilities, the
parents and guardians of workers, and other employees. See id. Alternatively, the employer may
provide a copy of the poster directly to each applicable employee who is subject to the poster’s
terms. See id. DWD provides the required poster at: http://dwd.wisconsin.gov/dwd/posters.htm.
vii. Hours of Work for Minors
Employers must post a summary of Wisconsin’s rules on hours and days of labor for minors in a
form required by DWD. See Wis. Admin. Code § DWD 270.03. The employer must post the
notice in a conspicuous place in all places of employment where minors are employed or
permitted to work. See id. DWD provides the required poster at:
http://dwd.wisconsin.gov/dwd/posters.htm.
viii. Cessation of Health Care Benefits
Each employer that employs fifty or more persons in Wisconsin must post a notice in a form
approved by DWD setting forth the rights of employees, retirees, and dependents under
Wisconsin law regarding notices of cessation of health care benefits. See Wis. Stat. § 109.075.
The employer must post the notice in one or more conspicuous places where notices to
employees are customarily posted. See id. DWD’s provides the poster at:
http://dwd.wisconsin.gov/dwd/posters.htm.
ix. Unemployment Benefits
Employers must inform employees about Wisconsin’s unemployment benefits by posting notices
supplied by DWD. See Wis. Admin. Code § DWD 120.01. The employer must permanently post
the notices at suitable points in each of the employer’s work places and establishments in
Wisconsin. See id. Suitable points for posting the required posters include bulletin boards, near
18 © 2013 Wisconsin Hospital Association, Inc.
time clocks, and other places where employees will readily see the posters. See id. DWD
provides the poster at: http://dwd.wisconsin.gov/dwd/posters.htm.
x. Hazardous Chemicals, Toxic Substances, Infectious Agents &
Pesticides
Employers who use, study, or produce a toxic substance, infectious agent, or pesticide must post
a sign. See Wis. Stat. § 101.581(1). The sign must inform employees that the employer must,
upon request, provide an employee or employee representative with the following:
- The identity of any toxic substance or infectious agent which an employee works with or
is likely to be exposed to;
- A description of any hazardous effect of the toxic substance or infectious agent;
- Information regarding precautions to be taken when handling the toxic substance or
infectious agent;
- Information regarding procedures for emergency treatment in the event of overexposure
to the toxic substance or infectious agent; and
- Access to the information contained on the label of any pesticide with which the
employee works or is likely to be exposed.
See id. The employer must post the notice in every workplace at the location where notices to
employees are usually posted. See id. A poster from the Wisconsin Department of Safety and
Professional Services is available at: http://dsps.wi.gov/sb/sb-divforms.html.
c. Signs Applicable to Employers—Federal Law
i. Employee Polygraph Protection Act
Employers must post on their premises (in every establishment of the employer) a notice
explaining the Employee Polygraph Protection Act, which includes prohibitions on lie-detector
use with respect to employees or prospective employees. See 29 C.F.R. § 801.4. The law applies
to employers engaged in or affecting commerce or in the production of goods for commerce. See
29 C.F.R. § 801.3. Commerce means trade, transportation, transmission, or communication
among the states or between any state and any place outside of the state. See 29 C.F.R. § 801.2.
“Lie detector test” includes a polygraph, deceptograph, voice stress analyzer, psychological
stress evaluator, or any other similar device that is used, or the results of which are used, for the
purpose of rendering a diagnostic opinion regarding the honesty or dishonesty of an individual.
“Lie detector test” does not include medical tests used to determine the presence of controlled
substances or alcohol in bodily fluids, written or oral tests commonly referred to as “honesty” or
“paper and pencil” tests, or handwriting tests. See id.
Employers must post the notice in a prominent and conspicuous place where it can be readily
observed by employees and applicants. See 29 C.F.R. § 801.6. The Wage and Hour Division
19 © 2013 Wisconsin Hospital Association, Inc.
(WHD) of the Department of Labor (DOL) provides the poster at:
http://www.dol.gov/whd/regs/compliance/posters/eppa.htm.
ii. Federal Minimum Wage/Fair Labor Standard Act of 1938
Employers subject to the Fair Labor Standard Act of 1938’s minimum wage requirements must
post a notice explaining the Act in conspicuous places where employees can readily observe it.
See 29 C.F.R. § 516.4. The Act requires employers to pay a minimum wage to employees who in
any work week are engaged in commerce or in the production of goods for commerce or are
employed in an enterprise engaged in commerce or in the production of goods for commerce. See
29 U.S.C. §§ 203, 206. DOL provides the poster at: http://www.dol.gov/whd/regs/
compliance/posters/flsa.htm.
iii. Occupational Safety & Health Act
Employers engaged in a business affecting interstate commerce must post a notice informing
employees of the protections and obligations provided for in the Occupational Safety and Health
Act and that the employee may contact the employer or DOL for assistance and information. See
29 C.F.R. § 1903.2. The employer must post the notice in a conspicuous place or places where
notices to employees are customarily posted and take steps to ensure that the notices are not
altered, defaced, or covered by other material. See id. The notice is required in each
establishment of the employer, which means a physical location where business is conducted or
where services are performed. See id. The Occupational Safety and Health Administration
provides the required poster. Reproductions of the poster must be at least eight and one-half
inches by fourteen inches, and the font size must be at least ten. See id. If the poster size
increases, the print size must also increase. See id. The caption or heading must be in large type
and generally not less than a thirty-six font size. See id. The required poster is available at DOL’s
website: http://www.osha.gov/Publications/poster.html.
iv. Uniformed Services Employment & Reemployment Rights Act
Employers must provide a notice to persons entitled to rights and benefits under the Uniformed
Services Employment and Reemployment Rights Act. See 38 U.S.C. § 4334. The notice must
address the rights, benefits, and obligations of such persons and employers under the Act. See id.
Employers may satisfy the notice requirement by posting the notice where employers
customarily place notices for employees. See id. DOL furnishes the text for the notice. See
Appendix to 20 C.F.R. § 1002. However, posting one of the notices in 70 Fed. Reg. 75316 (Dec.
19, 2005) is also sufficient. See id. Additionally, DOL indicates that employers may provide the
notice in alternative ways that will minimize costs while ensuring that the full text is provided.
See http://www.dol.gov/oasam/boc/osdbu/sbrefa/poster/matrix.htm. Examples include
distributing the notice by mailing or electronic mail. See id. DOL provides the poster at:
http://www.dol.gov/compliance/topics/posters.htm.
20 © 2013 Wisconsin Hospital Association, Inc.
v. Family & Medical Leave Act
Covered employers must post a notice explaining the Family & Medical Leave Act’s (FMLA)
provisions and providing information on filing complaints for violations of the Act. See 29
C.F.R. § 825.300(a). Covered employers include persons who employ fifty or more employees
for each working day during twenty or more weeks in the current or proceeding calendar year.
See 29 C.F.R. § 825.104(a).
The employer must post the notice in conspicuous places where employees are employed and
prominently where employees and applicants for employment can readily see it. See 29 C.F.R.
§ 825.300(a). The poster and text must be large enough to be easily read, and the text must be
fully legible. See id. Electronic posting of the notice may be sufficient (all employees should
have access to a computer to view the poster and must be informed that it is available for review
on the Intranet). Covered employers must post the notice even if no employees are eligible for
FMLA leave. See id. If the workforce includes a significant portion of workers who are not
proficient in English, the employer must provide the notice in a language in which the employees
are literate. See id. DOL provides the notice. See 29 C.F.R. Pt. 825, App. C;
http://www.dol.gov/whd/regs/compliance/posters/fmla.htm.
vi. Workers with Disabilities Paid at Special Minimum Wages
Every employer with workers employed under special minimum wage certificates must at all
times display and make available to employees a poster required by DOL. See 29 C.F.R.
§ 525.14. The poster explains the conditions under which special minimum wages may be paid.
See id. The employer must post the poster in a conspicuous place on the employer’s premises
where the workers with disabilities, the parents and guardians of such workers and other workers
may readily observe it. See id. If the employer finds that it is inappropriate to post the notice, the
employer may provide the notice directly to all employees who are subject to the notice’s terms.
See id. DOL provides the notice at: http://www.dol.gov/whd/regs/compliance/posters/disab.htm.
vii. Equal Employment Opportunity
Employers and federal contractors covered by various non-discrimination and equal employment
opportunity laws must post the Equal Employment Opportunity Commission’s (EEOC) “Equal
Employment Opportunity is the Law” poster on their premises. See
http://www.dol.gov/ofccp/regs/compliance/posters/ofccpost.htm; see also Executive Order
11246; Title VII of the Civil Rights Act of 1964; Age Discrimination in Employment Act of
1967; Americans with Disabilities Act of 1990; 29 C.F.R. § 1627.10; 41 C.F.R. §§ 60-1.4, -1.42;
41 C.F.R. § 60-250.5; 41 C.F.R. § 60-300.5; 41 C.F.R. § 60-741.5. Employers and applicable
contractors must post the notice prominently where employees (and potentially applicants) can
readily see it. See id.; see also http://www.dol.gov/oasam/boc/osdbu/sbrefa/poster/matrix.htm.
21 © 2013 Wisconsin Hospital Association, Inc.
The required “Equal Employment Opportunity is the Law” poster is available from EEOC at:
http://www.dol.gov/ofccp/regs/compliance/posters/ofccpost.htm.
viii. Genetic Information Non-Discrimination Act (GINA)
Employers must post and keep posted a notice prepared or approved by EEOC that sets forth
excerpts or summaries of regulatory provisions relating to GINA and information for filing a
complaint. See 29 C.F.R. § 1635.10(c). The employer must post the notice in conspicuous places
upon its premises where notices to employees and applicants for employment are customarily
posted. See id. GINA protects employees and employment applicants from discrimination based
on genetic information, restricts an employer’s ability to acquire genetic information, and limits
disclosure of genetic information. See 29 C.F.R. §§ 1635.1-1635.12. GINA is addressed in
EEOC’s “Equal Employment Opportunity is the Law” poster.
ix. Employee Rights Under the National Labor Relations Act
Federal law requires most employers and federal contractors and subcontractors to post a notice
relating to employee rights under the National Labor Relations Act (NLRA), as described below.
The notice requirements applicable to most employers are temporarily on hold as of the date this
section was drafted (October 3, 2012).
1. Employers
The National Labor Relations Board (NLRB) has issued a Final Rule with notice requirements
for many private sector employers. The Final Rule requires employers subject to the NLRA to
post notices informing employees of their rights under the NLRA, NLRB contact information,
and information concerning enforcement procedures. See 76 Fed. Reg. 54,006, 54,046-48
(August 30, 2011). Hospitals, blood banks, physician offices, dentist offices, and other health
care facilities with a gross annual volume of at least $250,000 are subject to the NLRB’s
jurisdiction and must post the notice. See id. Nursing homes with a gross annual volume of at
least $100,000 are subject to the NLRB’s jurisdiction and must post the notice. See id.
Applicable employers must post the notice in conspicuous places where employees can readily
see it, including all places where notices to employees concerning personnel rules or policies are
customarily posted by the employer. See id. The notices must be at least eleven inches by
seventeen inches in size and in a format, type size, and style required by NLRB. See id. If 20
percent or more of the employer’s workforce does not speak English, the employer must post the
notice in the language employees speak. See id. However, if an employer requests a notice from
NLRB, but it is not available in the applicable language, the employer is not responsible for
compliance until the notice is available from NLRB in the requested language. See id. NLRB
provides an FAQ on the notice rule at https://www.nlrb.gov/faq/poster.
22 © 2013 Wisconsin Hospital Association, Inc.
NLRB provides the poster at: http://nlrb.gov/poster. Employers may use commercial services to
consolidate the notice into a poster with other federally mandated labor and employment notices,
as long as the consolidation does not alter the size, content, or format of the poster or the size and
style of the type.
Employers who customarily communicate with employees via an internet or intranet about
personnel rules or policies must also post the notice on such site. 76 Fed. Reg. at 54,046-48. The
employer would satisfy the electronic posting requirement by prominently displaying (no less
prominent than other notices) on the site an exact copy of the poster or a link to NLRB’s website
that contains the poster. See id. The link to NLRB’s website must state “Employer Rights under
the National Labor Relations Act.” See id.
NRLB’s Final Rule was originally scheduled to take effect November 14, 2011, but the D.C.
Circuit Court of Appeals has temporarily enjoined the Final Rule. See http://nlrb.gov/poster. As
of October 3, 2012, NRLB’s website indicates that the notice requirement is still on hold until
legal issues are resolved. See id.
2. Federal Government Contractors & Subcontractors
Additionally, federal government contracting departments and agencies must include a provision
in the contract requiring the contractor to post a notice relating to employee rights under federal
labor laws. See Executive Order 13496; 29 C.F.R. § 471.2. The notice addresses rights of
employees of federal contractors and subcontractors under the NLRA, including rights to
organize and bargain collectively with employers. See id. Contractors or subcontractors who post
notices to employees physically must post the notice physically. See 29 C.F.R. § 471.2(d). The
contractor must place the notice in conspicuous places in plants and offices so that it is
prominent and employees can readily see it. See id. The contractor must place the notice in areas
where employees covered by the Act engage in activities relating to the contract. See id. The
contractor or subcontractor must also provide the notice in languages that employees speak if a
significant portion of the contractor’s workforce is not proficient in English. See id.
Contractors or subcontractors that customarily post notices to employees electronically must also
post the required notice electronically. See 29 C.F.R. § 471.2(f). The contractor or subcontractor
would satisfy the electronic posting requirement by displaying prominently a link to DOL’s
website containing the poster on any website maintained by the contractor or subcontractor and
customarily used for notices to employees regarding terms and conditions of employment. See
id. The link to DOL’s website must read “Important Notice about Employee Rights to Organize
and Bargain Collectively with Their Employers.” See id. DOL provides the posters at:
http://www.dol.gov/olms/regs/compliance/EO13496.htm.
23 © 2013 Wisconsin Hospital Association, Inc.
VII. Signs Regarding Independent Contractors
a. In General
When independent contractor physicians provide care in a hospital, the hospital should provide
notice of this practice to patients. Hospitals could provide notice, in part, by posting signs (e.g.,
in the emergency department). Such notice could help reduce the risk that the hospital could be
held liable for the negligent acts of independent contractor physicians under the doctrine of
apparent authority. Under the doctrine of apparent authority, hospitals may be liable for the
malpractice of independent physicians in certain circumstances, even if such physician does not
provide direct care (e.g., radiologists). See Pamperin v. Trinity Mem’l Hosp., 144 Wis.2d 188,
423 N.W.2d 188 (Wis. 1988). However, a sign alone may not be sufficient because patients may
not see it. A best practice could include notifying patients during the admissions process that the
physicians providing care at the hospital are not hospital employees. For example, the
admissions form could include a checkbox that staff could mark to document that the patient was
provided with verbal or written notice that physicians providing services are not employees of
the hospital, but rather independent contractors of the hospital.
Ultimately, few cases involving apparent authority for independent physicians exist because
physicians in Wisconsin must have insurance up to $1,000,000, and the balance is covered by the
Wisconsin Injured Patients and Families Compensation Fund. Apparent authority is likely to be
an issue only in cases where the allegedly negligent physician was not named as a defendant and
the statute of limitations has run, so that the physician cannot be added to the case. The
Wisconsin Supreme Court first applied the apparent authority doctrine in the emergency room
context, but later extended the doctrine beyond the emergency
b. Emergency Room
The Wisconsin Supreme Court applied the doctrine of apparent authority in the emergency room
context in Pamperin v. Trinity Memorial Hospital. The case involved a patient who was taken to
the emergency room after falling and injuring his leg. Both the treating physician and a
radiologist allegedly failed to identify a fracture of the patient’s proximal tibia on an x-ray. The
radiologist was not an employee of the hospital but of a radiology group that contracted with the
hospital to provide diagnostic radiology for the hospital. In the ensuing litigation, the patient
sought a ruling from the court that the hospital was responsible for the radiologist’s alleged
negligence under the doctrine of apparent authority.
The Wisconsin Supreme Court concluded that a hospital holding itself out as providing complete
medical care and services to a patient may be held liable under the doctrine of apparent authority
for the negligence of an independent physician retained by the hospital to provide emergency
room care, unless the patient knows or should know that the physician is an independent
contractor. See Pamperin v. Trinity Mem’l Hosp., 144 Wis.2d 188, 423 N.W.2d 188 (Wis. 1988).
24 © 2013 Wisconsin Hospital Association, Inc.
Apparent authority in the hospital context requires the plaintiff to show that (1) the hospital, or
its agent, acted in a manner that would lead a reasonable person to conclude that the allegedly
negligent individual was a hospital employee or agent, and (2) the plaintiff acted in reliance upon
the conduct of the hospital or its agent, consistent with ordinary care and prudence. See id.
Additionally, if the acts of the agent created the appearance of authority, the plaintiff must show
that the hospital had knowledge of such acts and acquiesced in them. See id. at 208.
In discussing the elements of apparent authority, the Wisconsin Supreme Court noted that the
plaintiff could satisfy the first element if the plaintiff could prove that the hospital held itself out
as a provider of emergency room care without informing the patient that the care was provided
by independent contractors. See id. at 210. With respect to the plaintiff’s reliance, the court noted
that there is a distinction when patients are seeking care from the hospital or merely looking to
the hospital as a place for his or her personal physician to provide care. See id. at 211.
Accordingly, the court held that the plaintiff could satisfy the reasonable reliance element by
proving that he relied upon the hospital to provide complete medical care rather than upon a
specific physician. See id. The court in Pamperin suggested that a hospital would not be liable
for an independent physician’s malpractice under the doctrine of apparent authority if the
hospital informs the patient that the care is provided by an independent physician. See id at 210.
i. Beyond the Emergency Room
The Wisconsin Supreme Court expanded the doctrine of apparent authority beyond the
emergency room context in Kashishian v. Port. See Kashishian v. Port, 167 Wis.2d 24, 481
N.W.2d 277 (Wis. 1992). In Kashishian, the patient received care outside of the emergency room
from a physician who was an independent contractor. The court determined that the hospital
could be liable for the malpractice of independent contractors under any factual situation (e.g.,
settings outside of the emergency room) if all elements necessary to prove apparent authority
were satisfied. See id. at 47.
VIII. Radiation Areas
a. In General
Wisconsin law requires persons licensed or registered by DHS to receive, possess, use, transfer,
or dispose of sources of radiation, including hospitals, to comply with signage requirements for
radioactive areas. See Wis. Admin Code § DHS 157.29. Federal law provides similar
requirements. See 10 C.F.R. §§ 20.1901-1903. Some exceptions exist for hospitals, as explained
in further detail below.
b. Posting of Radiation Caution Signs
25 © 2013 Wisconsin Hospital Association, Inc.
The signage requirements include postings of radiation caution signs, which vary based on the
particular radiation area as follows:
- Radiation Areas: The licensee must post a conspicuous sign bearing the radiation symbol
(see below) and the words “CAUTION, RADIATION AREA” in each radioactive area.
- High Radiation Areas: The licensee must post a conspicuous sign bearing the radiation
symbol and the words “CAUTION, HIGH RADIATION AREA” or “DANGER, HIGH
RADIATION AREA” in each high radiation area.
- Very High Radiation Area: The licensee must post a conspicuous sign bearing the
radiation symbol and the words “EXTREME DANGER, VERY HIGH RADIATION
AREA” or “GRAVE DANGER, VERY HIGH RADIATION AREA” in each very high
radiation area.
- Airborne Radiation Areas: The licensee must post a conspicuous sign bearing the
radiation symbol and the words “CAUTION, AIRBORNE RADIOACTIVITY” in each
airborne radiation area.
- Areas or Rooms in which Material is Used or Stored: The licensee must post a
conspicuous sign bearing the radiation symbol and the words “CAUTION,
RADIOACTIVE MATERIAL(S)” or “DANGER, RADIATIVE MATERIAL(S)” in each
room in which there is used or stored an amount of material exceeding ten times the
quantity of material specified in Appendix F of DHS 157. (Appendix F may be accessed
at
https://docs.legis.wisconsin.gov/document/administrativecode/DHS%20157%20Appendi
x%20F.pdf.
c. Radiation Symbol
The radiation symbol that the licensee must use is specifically identified in section DHS 157.29
of the Wisconsin Administrative Code. Federal law requires the same symbol, which is available
at http://ecfr.gpoaccess.gov/graphics/pdfs/ec02oc91.000.pdf. The cross-hatched area must be
magenta, purple, or black, and the background must be yellow. See Wis. Admin. Code § DHS
157.29; 10 C.F.R. § 20.1901. A licensee or registrant may also provide, on or near the required
signs, additional information, as appropriate, to make individuals aware of potential radiation
exposures and to minimize exposures. See id.
d. Exceptions
Both state and federal rules include the following exceptions:
- A licensee or registrant is not required to post caution signs in areas or rooms containing
sources of radiation for periods of less than eight hours if all of the following conditions
are satisfied: (1) the sources of radiation are constantly attended during these periods by
an individual who takes precautions necessary to prevent exposure of individuals to
sources of radiation in excess of limits specified in Wisconsin and federal law; and
(2) the area or room is subject to the licensee’s or registrant’s control; and
26 © 2013 Wisconsin Hospital Association, Inc.
- A room or area does not require a caution sign because of the presence of a sealed source
provided the radiation level at thirty centimeters from the surface of the sealed source
container or housing does not exceed 0.05 mSv (500 mrem) per hour.
See Wis. Admin. Code § DHS 157.29(3); 10 C.F.R. § 20.1903.
Wisconsin also provides the following exceptions:
- Rooms or other areas in hospitals that are occupied by patients do not require caution
signs provided that no member of the public could receive a deep dose equivalent in
excess of 5 mSv (500 mrem) from entering the room during the patient’s stay;
- A room or area does not require a caution sign because of the presence of radiation
machines used solely for diagnosis in the healing arts; and
- Rooms or other areas in hospitals that are occupied by patients do not require caution
signs provided that safety instruction requirements in section DHS 157.64(2)(a) of the
Wisconsin Administration Code (unsealed radioactive materials) or section DHS
157.65(4)(a) of the Wisconsin Administrative Code (manual brachytherapy) are satisfied.
See Wis. Admin. Code § DHS 157.29(3).
e. Posting of Notices to Workers
In addition to the posting requirements above for radiation areas, a licensee or registrant must
post current copies of all of the following documents in a conspicuous location accessible to all
workers on the way to or from the worker’s station or job:
- (1) Subchapters III and X of Chapter DHS 157 of the Wisconsin Administrative Code;
- (2) The license, conditions, or documents incorporated into the license by reference and
license amendments;
- (3) The operating procedures applicable to activities under the license or registration;
- (4) Any notice of violation, forfeiture assessment, or order and any response from the
licensee or registrant until removal is authorized by DHS;
- (5) The certificate of registration;
- (6) Emergency procedures that apply to activities conducted under the license or
registration; and
- (7) A “Notice to Employees” form that details the types of information that employers
must give to their employees and related DHS contact information.
See Wis. Admin. Code § DHS 157.88(1). The Notice to Employees is available at:
http://www.dhs.wisconsin.gov/publications/p4/P45027.pdf.
If posting the documents in (1) through (3) is not physically practical, the licensee or registrant
may post a summary of the documents that states where the full documents may be examined.
See id. The documents in (4) through (7) must be posted by the licensee in their entirety. See id.
The licensee must also replace within ten days the documents, notices and forms if they are
27 © 2013 Wisconsin Hospital Association, Inc.
defaced or altered. See id. Finally, the documents in (4) must be posted within two working days
after receipt of the document from DHS, the licensee’s response, if any, must be posted within
two working days after submitting the document to DHS, and the documents must remain posted
for a minimum of five working days or until the violation is corrected, whichever is later. See id.
IX. Other Health Care-Related Signs & Postings
a. Operating Rooms
Wisconsin law requires hospitals to make available and post rules and policies relating to
operating rooms in appropriate locations inside and outside of the operating rooms. See Wis.
Admin. Code § DHS 124.20(2)(a)6.
b. Pharmacy Licenses—Display
Every original license issued by the Pharmacy Examining Board and any current renewal license
in force must be displayed in the place of practice. See Wis. Stat. § 450.09(5).
c. Physician & Physician Assistants—Display of Registrations
Every person licensed or certified under Subchapter II of Chapter 448 of the Wisconsin Statutes
(e.g., physicians and physician assistants) must display the registration certificate conspicuously
in the office at all times. See Wis. Stat. § 448.07(1)(a).
d. Nursing Homes
Various posting requirements exist for nursing homes, community-based residential facilities,
and residential care apartment complexes. For example, Chapter 50 of the Wisconsin Statutes
includes posting requirements for such facilities.
e. Respiratory Care
CMS Interpretive Guidelines regarding respiratory care indicate that written policies developed
and approved by the medical staff should address safety practices, including posting signs. See
State Operations Manual, Appendix A—Interpretive Guidelines—Hospitals, Tag A-1160 (Rev.
37, 10/17/2008).
f. Medicare Provider-Based Departments
Hospitals with provider-based departments must hold such departments out to the public and
other payers as part of the main hospital. See 42 C.F.R. § 413.65(d)(4). Patients entering the
provider-based department must be aware that they are entering the hospital. See id. Hospitals
should post signs to ensure that patients know that they are entering the hospital. Signage is
28 © 2013 Wisconsin Hospital Association, Inc.
particularly important for off-campus departments or in other circumstances where there is likely
to be uncertainty or confusion for patients as to whether the location is actually part of the
hospital.
X. Other Non-Health Care Related Signs & Postings
a. Food-Related Signs
i. Posting Menus in Kitchen—Medicare Conditions of
Participation/Interpretive Guidance
Current patient menus should be posted in the hospital kitchen, according to CMS Interpretive
Guidelines. See State Operations Manual, Appendix V—Interpretive Guidelines—
Responsibilities of Medicare Participating Hospitals in Emergency Cases, Tag A-0628/C-2402
(Rev. 37, 10/17/08).
ii. Food Permits
Restaurants (i.e., any building, room, or place where meals are prepared, served, or sold to
transients or the general public) must post a current permit issued by DHS in a place visible to
the public. See Wis. Admin. Code §§ DHS 196.03(5), 196.04(7). The permit may not be altered
or defaced. See id.
b. No Smoking Signs
i. In General
Wisconsin law prohibits smoking in various enclosed places, including inpatient health care
facilities, assisted living facilities (with some exceptions), enclosed places of employment, and
enclosed public places. See Wis. Stat. § 101.123. “Inpatient health care facilities” includes
hospitals, nursing homes, hospices, and treatment facilities (i.e., an inpatient facility that
provides treatment of alcoholic, drug dependent, mentally ill, or developmentally disabled
persons), among other facilities. See Wis. Stat. § 101.123(1). “Places of employment” is defined
broadly and includes enclosed places that employees normally frequent during employment,
including an office, work area, elevator, lounge, restroom, conference room, meeting room,
classroom, hallway, stairway, lobby, common area, vehicle, or cafeteria. See id. A “public place”
is also defined broadly and includes enclosed places that are open to the public (regardless of
whether a fee is charged) or places to which the public has lawful access or may be invited. See
id. Consequently, the smoking ban covers many places and buildings.
ii. Sign
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The person in charge of the location must make reasonable efforts to prohibit smoking, including
posting signs setting forth the prohibition and providing other appropriate notification and
information. See Wis. Stat. § 101.123(2m)(c).
iii. Content
The Department of Safety and Professional Services (DSPS) is required to specify uniform
dimensions and other characteristics for the required signs. See Wis. Stat. § 101.123(6). As of
September 28, 2012, DSPS requires only that signs include the international “No Smoking”
symbol consisting of a pictorial cigarette enclosed in a red circle with a red bar across the
cigarette. See Wis. Admin. Code § SPS 362.0400(5). A sample sign is available at:
http://www.wibettersmokefree.com/resources/workplace/employers/window_sign_post-july5.pdf
c. Weapon on Premises
A hospital may choose to prohibit weapons in the building and on the grounds. To do so, the
hospital must post signs prohibiting weapons. Different signage requirements apply to different
locations or venues, as follows:
- Building. The sign must be five inches by seven inches and located in a prominent place
near all of the entrances to the part of the building in which the restriction applies. Any
individual entering the building must be reasonably able to see the sign. See Wis. Stat.
§ 943.13(2)(bm);
- Grounds/Land. The sign must be five inches by seven inches and located in a prominent
place near all probable access points to the grounds/land to which the restriction applies.
Any individual entering the grounds or land must reasonably be able to see the sign. See
id.; and
- Parking Lot. The signs may not prohibit firearms located in vehicles driven or parked in
any part of the building, grounds, or land used as a parking facility. See Wis. Stat.
§ 943.13(1m)(c)2.
d. Fire-Related Signage.
This section provides a broad overview of fire-related signage requirements. Additional
requirements may also exist.
i. Direction for Escape; Exit Lights & Signs
1. Direction for Escape
Hospitals must post a notice conspicuously in every room occupied by “transients” giving
complete and plain direction for reaching at least two exits. See Wis. Admin. Code § SPS
379.19.
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2. Alternative Exits
The Joint Commission (TJC) requires hospitals to post signage identifying the location of
alternative exits to everyone affected. See The Joint Commission, LS.01.02.01 EP 2.
3. Exit Doors & Signs
Wisconsin rules require lights at exit doors to be accompanied by a sign with the word “Exit” or
“Out” in plain letters not less than five inches in height. See Wis. Admin. Code § SPS 379.08.
Exit signs must be illuminated, transparent, and operated over all exit doors. See Wis. Admin.
Code § SPS 375.24(4). TJC requires signs reading “No Exit” on any door, passage, or stairway
that is not an exit or an access to an exit, but that may be mistaken for an exit. See The Joint
Commission, LS.02.01.20 EP 30. Additionally, TJC requires exist signs to: (1) be visible when
the path to the exit is not readily apparent, (2) adequately lit, and (3) have letters that are four or
more inches high (or six inches if externally lit). See The Joint Commission, LS.02.01.20 EP 31;
LS.03.01.20 EP 19.
4. Stairs
TJC requires a sign in stairwells serving five or more stories. A sign must be located on each
floor landing in the stairwell to identify the story, the stairwell, the top and bottom, and the
direction to and story of exit. See The Joint Commission, LS.02.01.20 EP 29. The sign must be
placed five feet above the floor landing in a position that is easily visible when the door is open
or closed. See id. Additionally, TJC requires signs reading “No Exit” to be posted on doors to
stairs in areas that are not conforming exits and that may be mistaken for exits. See The Joint
Commission, LS.03.01.20 EP 19.
ii. Firewall Signs
Wisconsin law provides that a city, village, or town may (by ordinance) require owners to
identify the location of a fire wall at the exterior of the building. See Wis. Stat. § 101.135. Such
ordinances must comply with Wisconsin rules that specify uniform dimensions and
characteristics for firewall signs. See id.
e. Conveyances
The owner of a conveyance (e.g., elevators, escalators, and moving walkways) must display the
permit to operate on or in the conveyance. See Wis. Admin. Code § SPS 318.1014(2). The rule
applies to conveyances operated in places of employment and public buildings. See Wis. Stat.
§ 101.01(10); Wis. Admin. Code § SPS 318.1002. “Public buildings” include structures used in
whole or in part for lodging, occupancy, or use by the public or by three or more tenants. See
Wis. Stat. § 101.01(12).
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XI. Federal & State Contractors and Other Entities Receiving Federal
or State Financial Assistance
Additional requirements may exist for federal and/or state contractors and other entities receiving
federal and/or state financial assistance (including Medicaid or Medicare Part A payments).
Among other requirements, such additional requirements may include signage relating to
affirmative action for veterans, signage covering all protected classes in Wisconsin, and signage
regarding the availability of language assistance. For example, some providers may have to post
signs to notify patients that language assistance may be available at no cost to the patient.
XII. Manual Updates
This manual was drafted in October 2012 and is based on the laws or the proposed laws in effect
at that time. This manual does not reflect changes to the law since October 2012. Users should
determine whether the laws or proposed laws discussed in this manual have been updated. A
non-exhaustive list of areas of the law that have been updated or have had proposed updates
released since October 2012 appears below.
Users of this manual may wish to consider, among other things, the following:
1. Release of additional proposed rules and IRS guidance regarding 501(r) requirements;
2. Changes to HIPAA related to Notice of Privacy Practices;
3. New case law regarding NLRB employee rights poster.
In addition, users may visit von Briesen & Roper’s health law blog at
http://www.vonbriesenhealth.com/ for recent legal updates.