DRUG, ALCOHOL, AND SUBSTANCE ABUSE POLICY AND PROGRAM

Transcription

1 I. Purpose DRUG, ALCOHOL, AND SUBSTANCE ABUSE POLICY AND PROGRAM In compliance with the Drug-Free Workplace Act of 1988, Acadiana Management Group, LLC (AMG Corporate) and all Affiliated Hospital Companies have a longstanding commitment to provide a safe, quality-oriented and productive work environment consistent with the standards of the health care industry and communities we serve. Drug, alcohol and substance abuse poses a threat to the health and safety of the abusing employee, patients, employees, staff, guests, the public, and to the security of the company s equipment and facilities. Our Company values its patients, employees and guests, and recognizes the problem of drug, alcohol, and substance abuse in society. For these reasons, the Company is committed to the elimination of drug, alcohol and substance use and abuse in the workplace. This policy provides Company employees with guidelines pertaining to drug, alcohol and substance abuse during the normal course of employment. II. Scope This policy applies to all employees of all AMG Affiliated Companies. III. Policy It is the policy of AMG to maintain a workplace and workforce free of drugs, alcohol or other substances; and a workplace free of drug diversion. The presence of illegal drugs, alcohol, or other such substances in one s system, on one s person, on facility premises, while conducting business, or while operating vehicles, machinery or equipment is prohibited by this policy. Drug diversion of any kind is considered theft and prohibited in the workplace. Compliance with the policies and guidelines set forth herein below is a condition of beginning and continued employment with this Company. It supersedes any other Company/hospital policy or practice on this subject. At any time, the Company may, at its sole discretion, amend, supplement, modify, or change any part of this policy without prior notice. Employees must be physically and mentally able to perform their assigned duties and carry out their responsibilities optimally in a safe and efficient manner when they report to work, and must maintain that ability throughout their shift or working schedule. Employees in violation of this policy are subject to disciplinary action up to and including termination, under applicable the Company policies. This policy does not represent or express an implied contract, and it does not affect employee s status as an at-will employee under Louisiana law. If you have any questions about this policy, please immediately direct them to the CEO of this facility and/or Human Resources. IV. Definitions For the purpose of the Company Drug, Alcohol and Substance Abuse Policy and guidelines (hereinafter referred to as the Program ), the following definitions shall be applicable: 1 of 15 Revised

2 1. Facility premises: encompasses AMG Hospital Facility affiliates and subsidiaries and all of their properties, offices, parking lots, facilities, lands, platforms, buildings, structures, fixtures, installations, automobiles, trucks and all other vehicles, boats, aircrafts, machinery and other equipment, whether owned, leased, or used. 2. Facility Business: encompasses employees whenever on duty and under Facility control, whether at facility work sites or during transit to and from work sites or while in the course and scope of the Facility s employment or pay status. 3. Employees: includes all Full-time, Part-time, PRN, student, volunteer, casual or contract employees who have received employment or an appointment with the Company, and all employment applicants and candidates as well. 4. Prescription medication: a medication that according to federal law requires a prescription of a licensed physician or another licensed provider prior to dispensing. Synonym: legend medication. 5. Illegal Drugs, Alcohol, or Other Such Substances: includes illegal drugs, unauthorized controlled substances, look-a-likes, inhalants of abuse, designer and synthetic drugs and shall include any drug which is not legally obtainable; or which is legally obtainable but has not been legally obtained or used. The term includes prescribed drugs not being used for prescribed purposes, or in excessive dosages. The term includes, but is not limited to: Marijuana/Hashish/Hash Oil (Cannabis),Cocaine, Heroin, Opiates, Amphetamines, Phencyclidine, Barbituates, Benzodiazepines, Methadone, Propoxyphene, Methampetamines, Hallucinogens, Inhalants from volatile Solvents like glue, paint or gasoline or from aerosols like hairsprays, deoderants, insecticide or from anesthetic gases like Ether, Choloroform, Amyl Nitrate. 6. Controlled Substances: includes medication classified as Schedule I through V by the Federal Drug Enforcement Adminstration and/or applicable state law. 7. Drug Diversion: includes intentionally and without proper authorization, using or taking possession of a prescription medication or medical gas from Company supplies, patients, or through the use of Company related prescription, ordering, or dispensing systems. Drug diversion of any kind is considered theft. Examples of drug diversion include, but are not limited to, the following: Medication theft; Using or taking possession of a medication without a valid order or prescription; Forging or inappropriately modifying a prescription; and/or Using or taking possession of medication waste, i.e., left over medication. Refer to Policy B.2.11.A for Drug Diversion in the Workplace - Reporting and Response. Refer to Policy B.2.11.B for Behavioral Observation Checklist. V. Prohibition of Illegal Drugs, Alcohol or Other Such Substances 1. The use of or abuse of any Illegal Drug or Other Such Substances; 2. The possession, transport, transfers of purchase of Illegal Drugs or Other Such Substances; 3. The presence in the body, presence on one s person or reporting to work under the influence of Illegal Drugs, Alcohol or Other Such Substances; 2 of 15 Revised

3 4. The sale or marketing of Illegal Drugs, Alcohol or Other Such Substances or other drug related paraphernalia; 5. The use abuse, presence in one s system or possession of Illegal Drugs, Alcohol or Other Such Substances while utilizing, operating, or in control or possession of facility property, including facility owned, leased, or rented equipment and/or vehicles; 6. Unlawful using, consuming, transporting, distributing or attempting to distribute, manufacture, or dispense Illegal Drugs or Other Such Substances; 7. Drug diversion in the workplace. Any employee involved in any of the foregoing prohibited activities at any time during a work shift or while working for, on behalf of or while representing AMG Facilities, whether or not on this facility s premises or property, is in violation of the Program and the Employee is subject to disciplinary action, including, but not limited to, immediate termination. Depending on the circumstances, other action, including, without limitation, (1) notification of the appropriate law enforcement, regulatory or licensing agencies and (2) denial, suspension or termination of workers compensation benefits and unemployment compensation benefits may be taken against any employee who violates these policies, mandates and prohibitions. The Program equally applies to all Employees. Compliance with this policy, mandates, and prohibitions will be required as a condition of employment for all Employees. There shall be no exceptions. VI. Unauthorized Use of Alcohol or Intoxicating Beverages Working or reporting to work under the influence of alcohol is prohibited. The personal possession, distribution, dispensation, sale or use of alcohol on Facility Premises or while on duty is prohibited. An employee whose blood level is 0.04% (40 MG/DL blood) or over while on Facility Premises, during work hours, or while conducting any Company Business is in violation of AMG Facilities policy and subject to immediate discharge or termination. VII. Prescription Drugs (Legally Controlled Substances and All Off-the-Shelf or Over the- Counter Medicines) All employees must report to the use of medically prescribed or authorized drugs or substances (including over-the-counter or off-the-shelf medication) which can impair or lessen job performance or adversely influence behavior (whether allowed to be dispensed with or without prescription) to their Department Manager or CCO; and upon the request by the Employee s Supervisor or Human Resources, must provide proper written medical authorization to Human Resources from a physician. This includes, without limitation, drugs such as tranquilizers, muscle relaxers, pain medication and anti-depressants. It is the Employee s responsibility to determine from a physician(s) whether prescribed, off-the-shelf or over-the-counter drugs, medicines or other such substances may impair job performance, compromise safety or adversely influence behavior. Failure to report to the usage of such drugs, medicines, or other substances, failure to provide proper evidence of medical authorization or the use (as evidence by presence in an Employee s body fluids or otherwise) of such drugs, medicines or other substances in amounts in excess of the amounts prescribed by the physician or excess of the label recommendations for over-the-counter or off-the-shelf drugs, medicines of other such substances may result in disciplinary actions, up to, and including, immediate termination. 3 of 15 Revised

4 Any employees who use authorized (prescription) drugs and/or narcotics, or over-the-counter, or offthe-shelf medication during work and have any reason to expect such use may impair, compromise safety, or affect their ability to perform their work must report this information to the Department Manager or CCO. A determination will then be made as to whether the employee will be able to perform the essential functions of the job safely and properly. Employees must not consume prescribed drugs or off-the-shelf or over-the-counter drugs; medicines or other such substances more often than prescribed by their doctor or as directed on the off-theshelf or over-the-counter medication label(s). All prescribed, off the-counter, over-the-counter medication must be in its original container with the Employee s name, the doctor s name and prescription number on the label and each prescription must not be older than one year of the date issued. However, the Facility, at any time reserves the right to have a licensed physician determine whether the prescription drug use increases the risk of injury to the Employee, the Facility s patients or guests while the Employee is working. If such a finding is made, the Facility may limit, suspend or terminate the Employee s work activities during the period job safety may be adversely affected by the consumption of such medication. Any Employee refusing to cooperate with submitting to questioning, medical or physical testing or examination, when requested by the Facility or its designee, is in violation of AMG Facility policy and subject to disciplinary action, including, but not limited to, immediate termination. VIII. Drug and Alcohol Testing Procedure In order to achieve the objectives of this policy, this Facility asserts and reserves its legal right to test any and all Employees for the presence of Illegal Drugs, Alcohol or Other Such Substances. Employees may be asked to submit to a medical examination and/or to submit urine, saliva, hair, breath and blood samples for testing for the presence of: Cocaine, Barbiturates, Marijuana, Phencyclidine, Methadone, Amphetamines, Benzodiazepines, Opiates and other Opiate Synthetics and Propoxyphene. Any information obtained through such examinations and/or testing may be retained by the Facility and is the property of the Facility s. All AMG Facilities reserve the right, in its discretion and within the limits of federal and state laws, to examine, screen and /or test for the presence of Illegal Drugs, Alcohol or Other Such Substances as stated herein in the following: 1. Pre-Hire Employment Testing. A pre-employment drug test will be conducted to undergo screening for the presence of the Illegal Drugs or Other Such Substances after any applicants have been job-offered, as a condition of beginning employment with this Company; and when a former employee is re-hired after being termed from the company for longer than 30 days. This also applies to employees returning from a leave of absence greater than 30 days who have not been participating in the Company s drug program and subsequently subject to the random selection process. Applicants will be required to voluntarily submit to a urinalysis test conducted by a laboratory designated by the Facility Human Resources, and by signing a Consent Agreement in connection with such testing will release the Facility and said laboratory from liability in `connection therewith. Any Applicant with a positive test result may be denied employment with this Facility. AMG Facilities will not tolerate the current abuse of Illegal Drugs or Other Such Substances. 2. Post-Accident or Incident Testing. If an accident or incident occurs involving an Employee while on Facility Business or on Facility Premises, no matter how minor or insignificant, the Facility may require a drug and/or alcohol 4 of 15 Revised

5 test. A drug and/or alcohol test may also be required after any situation where there has been a near miss incident or accident, even though no injury or property damage occurs. When there is reasonable cause to suspect that an Employee s behavior, performance, error in judgment, or unsafe actions are related to the use or abuse of Illegal Drugs, Alcohol or Other Such Substances, this Facility may require the Employee submit to a drug and/or alcohol test. Failure by an Employee and/or his/her Supervisor to report any accident or incident, which meets the post-accident or postincident testing criteria, is in violation of the Company policy and subject to disciplinary action, which includes without limitation, immediate termination. An Employee s testing positive may make him or her ineligible for worker s compensation benefits. 3. Random Testing. All Employees and/or specified Employees are subject to routine random drug and/or alcohol testing in order to detect the use, abuse, or presence in an Employee s system of Illegal Drugs, Alcohol or Other Such Substances without any advance notice or prior warning. Upon notification of a drug and/or alcohol test, company employee must report to the designated collection site within 2 hours (120 minutes) plus travel time. Failure to report to the collection site, refusal to test, or adulterating a specimen is considered the same as a positive test and is in violation of AMG Facilities policy and subject to immediate discharge or termination. 4. Post-Treatment Counseling, Rehabilitation, or Return to Work Testing. Employees who return to work following a (1) medical leave of absence, (2) a work related injury, (3) drug, alcohol or substance abuse counseling or (4) rehabilitation may be subject to drug and/or alcohol testing upon return to work and for up to one year following the Employee s return to work. A positive test result will constitute grounds for immediate termination. It is a condition of reinstatement of employment with the Facility for an Employee upon completion of a drug and/or alcohol counseling program or any other return-to-work established procedure to submit to a drug and/or alcohol-screening test. 5. Reasonable Suspicion Testing. If a clear, expressed belief, based on (but not limited to) specific and contemporaneous facts, observations and reasonable inferences from those facts, that an employee is using drugs/alcohol, or is impaired by the use of illegal drugs or alcohol while on Facility Business or on Facility Premises, no matter how minor or insignificant, the Facility may require drug and/or alcohol testing in order to detect the use, abuse, or presence in an Employee s system of Illegal Drugs, Alcohol or Other Such Substances without any advance notice or prior warning. Reasonable suspicion must be based on specific, contemporaneous observations and facts concerning the appearance, behavior, speech, or body odors of the employee, and may include symptoms of chronic use or withdrawal effects of controlled substance or alcohol. A company Behavioral Observation Checklist may be used to document specific witnessed observations, behaviors, facts and/or safety concerns that create a Reasonable Suspicion that the employee is under the influence of unauthorized or illegal drugs, or alcohol. Refer to Policy B.2.11.B for Behavioral Observation Checklist. IX. Searches and Surveillance In order to achieve the objective of this Policy, the Company reserves the right at all times to perform search and surveillance of Employees who are entering and departing Facility Premises, conducting Facility Business, or when circumstances warrant, or when reasonable suspicion or cause exists to have properly authorized supervisors or search personnel (including drug detection dogs) conduct 5 of 15 Revised

6 unannounced reasonable searches and inspections. These searches and surveillance may extend to other Facility Premises as described above as well as to the Employee s personal effects. Employee personal property subject to inspection includes, but is not limited to, lockers, baggage, briefcases, boxes, bags, parcels, lunch-boxes or bags, food/beverage containers, desks, tools, clothing and vehicles. The purpose of said search is to determine if Employees or others on Facility Premises or conducting Facility Business are in possession of, using, abusing, transporting, or concealing any Illegal Drugs, Alcohol and Other Such Substances or other items prohibited by this policy. Searches and surveillance may be initiated without prior notice or advanced warning and conducted at times and locations as deemed appropriate by the Facility. Any Employee found to have Illegal Drugs, Alcohol or Other Such Substances in their possession, on their person, or in their personal area (desks, vehicle, lunch containers) will be subject to immediate disciplinary action, up to and including immediate termination. AMG Facilities reserve the right to conduct any search and/or surveillance it deems appropriate as set forth in this policy. X. Drug Testing Procedures Drug testing under AMG Facilities Policy will be performed by SAMHSA federally licensed, certified, professional laboratories that will collect urine, blood, hair, breath and/or skin specimens at a qualified collection site. All testing will be conducted in a professional and sanitary manner with due regard to the Employee s privacy, dignity, and confidentiality. A secure written chain of custody process is or secured in frozen long-term storage. All Employee specimens will be analyzed by such SAMHSA federally licensed, certified, professional laboratories the presence of Illegal Drugs and Other Such Substances. All specimens will undergo an initial screening test. Any positive test result will be confirmed through a Gas Chromatography with Mass Spectrometry (GC/MS) test. Any positive result from this latter test will be reviewed by a centralized Medical Review Officer (MRO) as defined by Louisiana Law and the Medical Review Officer must provide an opportunity for an interview with the Employee as part of the verification process prior to the positive test result being communicated back to the Facility. This will ensure that positive test results are not due to authorized prescription, off-the-shelf or over-thecounter medications appropriately used or other factors, which the Medical Review Officer feels justify the presence of such illegal drugs or other such substances. An Employee who is suspected of being under the influence of Illegal Drugs, Alcohol, or Other Such Substances may, at the option of this Facility, be suspended from work until the results of the drug and/or alcohol test are received and reviewed by Human Resources and Facility CEO. Employees who are tested under this AMG Facility Policy will have the right upon request, to receive the results of his/her test. Employee s whose tests are verified positive by the Medical Review Officer, will be notified by either the Facility, the third party administrator (AHS), and/or the Medical Review Officer. XI. Alcohol Testing Testing Employees for the purposes of alcohol will initially be performed through the use of breath, saliva, skin, and/or other alcohol detector tests. If an Employee tests positive for alcohol in such a test, such positive result may, if challenged by the Employee, be confirmed through the use of a breath analyzer or blood alcohol test. A breath analyzer, or blood alcohol test result (or breath scan/comparable alcohol detector test which is not challenged) showing a concentration of 0.04% or greater shall be grounds for appropriate disciplinary action, including, without limitation, immediate discharge and/or termination. XII. Consequences of a Positive Drug or Alcohol Test 6 of 15 Revised

7 1. In the event of a confirmed positive test result for the presence, use or abuse of Illegal Drugs and Other Such Substances during pre-employment drug testing, the applicant will not be hired. 2. In the event of a confirmed positive test result for the presence, use or abuse of Illegal Drugs, Alcohol and Other Such Substances for current Employees during a drug and/or alcohol test provided for in this AMG Facility Policy, the Employee (1) may be immediately terminated and discharged, for cause, (2) may be reported to state and federal authorities and licensing or certification agencies and (3) may be denied workers compensation benefits or unemployment benefits. XIII. Employee Assistance In some circumstances such as self-reporting, an employee who is abusing drugs may be granted a leave of absence to undertake rehabilitation treatment. The employee will not be permitted to return to work until certification is presented to the CEO that the employee is capable of performing his/her job. Failure to cooperate with an agreed upon treatment plan will result in discipline, up to and including termination. Participation in a treatment program does not insulate an employee from discipline for violations of this or other company policies. CIGNA s Life Assistance Program is available for employee s who feel they need to speak to someone. Contact by calling or online at DRUG, ALCOHOL, AND SUBSTANCE ABUSE POLICY AND PROGRAM ACKNOWLEDGEMENT 1. I expressly confirm that I have read and understand Acadiana Management Group and Affiliated Companies DRUG, ALCOHOL, AND SUBSTANCE ABUSE POLICY AND PROGRAM; 2. I understand participation in the DRUG, ALCOHOL, AND SUBSTANCE ABUSE POLICY AND PROGRAM is a mandatory condition of my employment; and 3. I further agree and expressly consent to all terms, conditions, mandates, and prohibitions set forth in the DRUG, ALCOHOL, AND SUBSTANCE ABUSE POLICY AND PROGRAM. Applicant or Employee Name (Print): Employee s Last Four of Social Security Number: Applicant or Employee Signature: Date: Supervisor Name (Print): Supervisor Signature: Date: Human Resources Name (Print): Human Resources Signature: Date: 7 of 15 Revised

8 DRUG DIVERSION IN THE WORKPLACE REPORTING AND RESPONSE This policy is to provide guidelines for the identification, reporting, and investigation of suspected drug diversion by employees. KEY DEFINITION OF TERMS FOR POLICY PURPOSE: Drug Diversion: Intentionally and without proper authorization, using or taking possession of a prescription medication or medical gas from Company supplies, patients, or through the use of Company related prescription, ordering, or dispensing systems. Drug diversion of any kind is considered theft. Examples of drug diversion include, but are not limited to, the following: Medication theft; Using or taking possession of a medication without a valid order or prescription; Forging or inappropriately modifying a prescription; and/or Using or taking possession of medication waste, i.e., left over medication Prescription medication: A medication that according to federal law requires a prescription of a licensed physician or other licensed provider prior to dispensing. Synonym: legend medication. Reasonable Suspicion: A clear, expressed belief, based on (but not limited to) specific and contemporaneous facts, observations and reasonable inferences from those facts, that an employee is using drugs/alcohol, or is impaired by the use of illegal or legal drugs or alcohol. Reasonable suspicion must be based on specific, contemporaneous observations and facts concerning the appearance, behavior, speech, or body odors of the employee, and may include symptoms of chronic use or withdrawal effects of controlled substance or alcohol. (see Behavioral Observation Checklist attached) Employee: Any consulting staff, administrative staff, employee, student, volunteer, contract worker, or any other individual who has received employment or an appointment at the Company. Controlled substance: Medications classified as Schedule I through V by the Federal Drug Enforcement Administration and/or applicable state law. Licensed or Registered health care provider: Health care provider whose license or registration allows him/her to provide care and services within the scope of their respective practices and as authorized from respective regulatory agencies and Company departmental policies. Administrative Team: Team which includes facility CEO, CCO/ACCO, HR AA, AOC and supervisor(s) for handling of confidential matter. POLICY STATEMENTS: 8 of 15 Revised

9 1. Employees are prohibited from diverting drugs from the Company. 2. The prevention of drug diversion is essential to the safety of Company patients and employees, and is the individual responsibility of every Company employee. 3. Employees are required to report known or suspected incidents of drug diversion by employees, patients, and visitors. 4. All suspected incidents of drug diversion will be thoroughly investigated. 5. Suspicion of drug diversion may arise from a variety of circumstances, including, but not limited to, the following: A witnessed incident of probable drug diversion; Behaviors that may indicate an impaired individual (see Behavioral Observation Checklist attached); Suspicious activity identified during routine monitoring and/or proactive surveillance; Self-disclosure of drug diversion by an individual; and/or Notification of suspected drug diversion from an external source, such as local law enforcement or a family member of a suspected drug diverter. 6. Any employee who reports suspected drug diversion honestly and in good faith will be protected from retaliation. 7. Any employees who use authorized (prescription) drugs and/or narcotics during work and have any reason to expect such use may affect their ability to perform their work must report this information to the Department Manager or CCO. A determination will then be made as to whether the employee will be able to perform the essential functions of the job safely and properly. 7. Employees must be physically and mentally able to perform their assigned duties in a safe and efficient manner when they report to work and must maintain that ability throughout their shift. 8. Employees, their possessions, and their property on company premises are subject to search and surveillance at all times while on company premises, or while conducting company business off-site. 9. The Administrative Team will handle and manage the investigation of reports of suspected drug diversion. 10. Facility CEO, CCO, and HR AA will be notified immediately of incidents concerning reasonable suspicion and/or probable drug diversion. 11. Whenever possible, HRAA should contact Corporate Human Resources Director (CHRD), Corporate Chief Nursing Officer (CCNO) and/or Corporate Director of Pharmacy (CDP) for assistance in applying these rules, and whenever you feel that a reasonable suspicion drug and/or alcohol test may be warranted. If you are unable to reach CHRD, CCNO, and/or CDP, then the facility CEO is contacted for oversight and direction. 12. Diversion of any drug by an employee is grounds for immediate termination of employment. 13. In some circumstances such as self-reporting, an employee who is abusing drugs may be granted a leave of absence to undertake rehabilitation treatment. The employee will not be permitted to return to work until certification is presented to the CEO that the employee is capable of performing his/her job. Failure to cooperate with an agreed upon treatment plan will result in discipline, up to and including termination. Participation in a treatment program does not insulate an employee from discipline for violations of this or other company policies. 14.Drug diversion by any employee is considered theft and will be reported to all appropriate government, licensing, regulatory, and law enforcement agencies. 15. Employees may be required to take a blood, urine or hair test at any time to determine the presence of unauthorized drugs, controlled substances, or alcohol. Testing positive 9 of 15 Revised

10 for unauthorized drugs, controlled substances or alcohol will result in termination of employment, unless there is a qualifying disability protected by law. 16. If the employee under suspicion is Chief Executive Officer, Chief Clinical Officer, or Assistant Chief Clinical Officer then the Corporate Chief Operating Officer and CDHR will be advised of the situation and are included in the oversight and decision process. 17. Please remember that information regarding an employee s suspected alcohol and/or drug use or diversion is to be treated as confidential and shared only with management and HR on a need-to-know basis. Similarly, information you obtain about an employee s use of medication or medical condition is to be kept confidential and disseminated only on a need-to-know basis only with HR, CCO, and/or CEO. All testing results are to be kept in an employee s health file. PROCEDURE: The company performs reasonable suspicion drug screens if there is evidence or suspicion that an employee is or may be under the influence of an unauthorized drug, controlled substance or alcohol; or when there are controlled substances missing that cannot be accounted for. Initial Report and Investigation 1. Any employee who suspects that drug diversion has occurred should notify his or her immediate supervisor. 2. If there is no immediate risk to patient safety and an employee is not comfortable notifying his or her supervisor, the employee should contact the Facility CEO immediately to make a confidential report. If an employee is not comfortable notifying Facility CEO, they should immediately call the Compliance Hotline to make a confidential report at Upon notification of suspected drug diversion, the supervisor will immediately perform an initial safety assessment using the Behavioral Observation Checklist. All observations, determinations and documentation concerning reasonable suspicion need to be made by at least one supervisor, preferably two. If only one supervisor is on duty, then another witness is required. Contact the Administrator on Call or HRAA if necessary to witness employee behaviors. 4. Promptly call the HR AA, CCO and CEO if Reasonable Suspicion is identified. 5. The supervisor's initial safety assessment will include the following steps: I. Determine whether any patient has been harmed or placed at risk of harm, and take appropriate action to treat the patient or remove the risk of harm. If a patient has been harmed or placed at risk of harm, the supervisor will notify the patient's primary staff physician, CCO and CEO. II. If the supervisor answers Yes to 3 or more observations on the Behavioral Observation Checklist, then the employee will be sent for a Reasonable Suspicion drug and alcohol testing screen at the company designated collection facility. At that point: a. Remove the employee from the work area to a private location. Do not leave employee unattended. b. Have a witness, preferably HRAA present, for your conversation with the employee. c. Do not accuse the employee of being on drugs or drunk. d. Inform and describe for the employee of your observations of his/her appearance and behaviors of concern. e. Allow the employee an opportunity to explain behavior and appearance from his/her perspective. f. If reasonable suspicion still exists after explanation, then inform employee that you are sending him/her for reasonable suspicion drug 10 of 15 Revised

11 and alcohol screening test per Company policy and that refusal to take the test will result in disciplinary action up to and including termination. g. Refusal to submit to a drug and alcohol screening test means: (1) Failure to show up for any test within a reasonable time of one hour after being directed to do so by the employer, or to remain at the testing site until the screening process for the test is complete. (2) Failure to provide a specimen for any drug or alcohol screening test required by this policy. (3) Failure to permit the observation or monitoring of the provision of a specimen in the case of a directly observed or monitored collection in any drug and/or screening test. (4) Failure to provide a sufficient amount of a specimen when directed unless it has been determined through a medical evaluation that there was an adequate medical explanation. (5) Failure or declines to take a second test the employer has directed following a negative dilute result. (6) Failure to undergo an additional medical examination as directed by the Medical Review Officer (MRO). (7) Failure to cooperate with any part of the testing process. h. Make arrangements to transport the employee to the Company s designated collection facility. DO NOT ALLOW EMPLOYEE TO DRIVE HIM/HERSELF. ALSO, MAKE ARRANGEMENTS TO TRANSPORT EMPLOYEE HOME AFTER TESTING COLLECTION IS COMPLETED. If employee refuses transportation, inform him/her you will notify local authorities. Follow through if necessary by obtaining employees license plate number and contacting local authorities. Do not attempt to restrain employee at any time. i. Inform employee that you are placing them on administrative work suspension until the results of the testing are completed and that we will contact them. j. If test results are reported NEGATIVE, contact employee and advise them of results. Make arrangements for employee to return to work and inform him/her that he/she will be paid for any scheduled work hours missed during administrative work suspension. k. If test results are POSITIVE then notify CHRD of test results and discuss decision regarding disciplinary action. HRAA, CEO and CHRD are included in this discussion and decision. Employees who have tested positive, or otherwise violated this policy, are subject to discipline, up to and including termination. l. If results are POSITIVE, scheduled work hours missed during administrative work suspension time will not be paid. m. Document the facts of the investigation and disciplinary action, and give to the HRAA for placement in employee s HR file. All screening test results are to be kept in employee s health file. 6. In the event there is evidence of suspected Drug Diversion, the supervisor will take steps that are immediately necessary to preserve any readily apparent evidence, such as medication vials or syringes. If evidence involves an infusion pump, the medication will be removed from the pump and placed in a sealed plastic bag. The pump should not be cleared and should be sequestered. The supervisor should not engage in any additional evidence collection or investigation without consulting with the CCO and CEO. 11 of 15 Revised

12 7. In the event that Drug Diversion is suspected, the Pharmacist in Charge (PIC), CCO, and HRAA will be notified. If after hours, the Charge Nurse will notify the Administrator On-Call. If possible, the CHRD, Corporate Pharmacy Director (CPD) and CCNO will be consulted regarding the incident. A confidential investigation will be conducted by the PIC and CCO using activity reports from the automatic dispensing machine (by patient and nurse), patient MAR s/records, and employee/patient witness statements if given. 8. Suspicion of diversion may arise from a variety of circumstances including but not limited to: Witnessed incident of possible drug diversion; Un-reconciled narcotic/medication counts; Inconsistent medication records for patient(s) between clinicians from different shifts; Behaviors that may indicate impairment; Suspicious activity identified during routine monitoring or proactive surveillance; Self-disclosure of drug diversion by individual; and/or Notification of suspected diversion from an external source such as local law enforcement or family member. 9. If drug diversion is still substantiated through the investigation, call the employee in to meet with the HRAA and CCO. Inform the employee of your findings, including the suspicion of drug diversion. Do not accuse the employee of taking drugs or stealing drugs. Give the employee the opportunity to offer explanations of any findings and to account for any missing drugs. 10. If the suspicion of diversion remains substantiated after meeting with the employee, if possible contact the CDHR and CCNO and to discuss Reasonable Suspicion drug screen testing; and course of action regarding disciplinary action, termination of employment, and reporting responsibilities to appropriate government licensing agencies, regulatory agencies and law enforcement agencies. If corporate support listed above is not available, then the facility CEO, CCO and HR Assistant will make a decision regarding reasonable suspicion drug testing (follow 5., II., a. i. procedure as outlined above under Initial report and Investigation) and suspend employee until testing and investigation is complete. 11. If diversion is confirmed, contact CHRD regarding course of disciplinary action. 12 of 15 Revised

13 Behavioral Observation Checklist Instructions: Department Manager or Supervisor on Duty is to complete the Behavioral Observation Checklist to document specific witnessed observations, behaviors, facts and/or safety concerns that create a Reasonable Suspicion that the employee is under the influence of unauthorized or illegal drugs, or alcohol. If the results of the Behavioral Observation Checklist indicate further action is justified (3 or more Yes checks), the Department Manager or Supervisor should immediately contact facility HR AA, CCO/ACCO and CEO. The HR AA then contacts Corporate Director of HR, Corporate Chief Nursing Officer, and/or Corporate Director of Pharmacy. (See Drugs, Narcotics, Alcohol and Substance Abuse Policy, OR Drug Diversion in the Workplace Reporting and Response Policy, both listed under Human Resources). Employee Name: Department Manager/Supervisor Name: Witness Name: Date/Time: Date/Time: Date/Time: OBSERVATIONS Smell of Alcohol on breath or person Speech Slurred Confused Fragmented Slow Unusually soft or loud Distracted mid-thought Unable to verbalize thoughts Disoriented: Is employee confused about Where he/she is? What day it is? What time it is? Apparent inability to concentrate/focus on work Unusual or unexplained resistance to authority or refusal to follow reasonable directions Lack of motor coordination (unsteady/staggering/stumbling/change in handwriting) Mood Belligerent Agitated Argumentative Moody Ecstatic Yes No 13 of 15 Revised

14 More nervous than usual Giddy Talkative Drowsy Skin Color Pale Flushed Excessive perspiration Excessive trips to restroom Bloodshot eyes Dilated pupils Pinpoint pupils Traces of alcohol in any containers Confession of employee that he/she was consuming alcohol or ingesting drugs Traces of suspected drugs Evidence of suspected drug paraphernalia Smell of marijuana Weariness, fatigue or exhaustion Sleeping while on duty Deteriorating physical appearance Yawning excessively Blank stare or expression Sudden and/or unpredictable change in energy level Unusually energetic Shaking, trembling of hands Sunglasses worn at inappropriate time/environment Changes in appearance/behavior after breaks Prolonged breaks Withdrawing or avoiding peers Breathing or swallowing difficulties Unusual sneezing/nasal congestion Needle marks on arms Tardiness Unexplained departures from work or disappearance from work area Careless or unsafe operation of equipment (including accident) Careless job performance Using or taking possession of medication waste (left over medication) Forging or inappropriately modifying a prescription Witnessed medication theft Facility Administration Team Members Reported To: Date/Time: Reported By: Corporate Members Reported To: Date/Time: 14 of 15 Revised

15 DRUG DIVERSION IN THE WORKPLACE REPORTING AND RESPONSE I expressly confirm that I have read and understand the Company s DRUG DIVERSION INTHE WORKPLACE REPORTING AND RESPONSE POLICY. Applicant or Employee Name (Print): Applicant or Employee Signature: Date: HR/Supervisor Signature: Date: 15 of 15 Revised