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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


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


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


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


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


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.


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


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?


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


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


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


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


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


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


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


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:



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:


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:


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


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


(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.


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.


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.


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.


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).


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


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


- 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


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


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


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.


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).


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.

http://www.vonbriesenhealth.com/

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