ORANGE REGIONAL MEDICAL CENTER ARDEN HILL CAMPUS HORTON CAMPUS AND ALL OUTPATIENT FACILITIES Policy/Procedure

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1 ORANGE REGIONAL MEDICAL CENTER ARDEN HILL CAMPUS HORTON CAMPUS AND ALL OUTPATIENT FACILITIES Policy/Procedure MANUAL: Hospital Wide SUBJECT: Drug and Alcohol Free Work place Implementation : 10/02 Reviews: Concurrences: V.P. Human Resources Medical Review Officer Employee Health Medical Director Revisions: 12/04, 2/06, 2/07, 11/10 INITIATOR: Approval: Director, Human Resources Director, Employee Health President/CEO POLICY: Orange Regional Medical Center is committed to maintaining a drug and alcohol free workplace and expects all staff to arrive and remain free of the influence of alcohol and drugs while they are on the job. Staff is specifically prohibited from working while under the influence or from the use, purchase, possession, sale, theft, distribution, diversion or transfer of alcohol or illegal drugs or the unauthorized dispensing of legal drugs on Medical Center grounds or property or in any vehicles or equipment owned or operated by the Medical Center. Testing for drug and/or alcohol impairment will be initiated when reasonable suspicion is present. Postprobationary staff members may be offered the opportunity for rehabilitation except in the case of the sale theft, distribution, diversion or transfer of illegal drugs or the unauthorized dispensing of legal drugs. All ORMC employees tested will be immediately referred to the Employee Assistance Program (EAP) for further intervention, regardless of the disposition of the results. It is the responsibility of each staff member to promptly report any of the following: a. knowledge of another staff member in a condition which impairs them and potentially risks the welfare of others b. suspects the use, purchase, possession, sale, theft, distribution, diversion or transfer of alcohol or illegal drugs or the unauthorized dispensing of legal drugs by a staff member. DEFINITIONS Staff: All Medical Center employees, physicians, volunteers and all other persons doing business on the grounds of the Medical Center or any affiliated off site campuses or in any vehicles or equipment owned or operated by the Medical Center. Reasonable Suspicion : a. Appearance of impairments of physical or mental ability including but not limited to erratic, confused or inappropriate behavior, impaired judgment, clarity of thought, balance, gait, demeanor, observable changes in pupils or speech, a smell of alcohol or admission of drug use by a staff member. b. evidence or reasonable belief that the use, purchase, possession, sale, theft, distribution, diversion or transfer of alcohol or illegal drugs or the unauthorized dispensing of legal drugs has occurred.

2 Under the Influence : To be affected by a drug or alcohol or combination of such in any detectable quantity which may affect the safety of co-workers, patients, impact job performance or the safe, efficient operation of the Medical Center. Symptoms may be, but are not limited to impairment of physical or mental abilities. This includes the use of: a. alcohol b. illegal drugs c. a legal drug but not legally obtained d. a legal drug prescribed but not being used for the purpose intended or exceeding the dose prescribed. e. a legal drug being used as prescribed which nonetheless renders a person physically or mentally impaired. Legal drugs : Legally prescribed and/or over-the-counter medications used consistent with an appropriate medical treatment plan. This type of medication should be carried in its original container with label intact. When a staff person states they are using a legal drug according to prescribed instructions, but they demonstrate behavior that interferes with their ability to perform safely and efficiently, reasonable suspicion testing is still indicated. The drug screening results will be evaluated by the Medical Review Officer who will determine if the results indicate use consistent with the prescription. Referral to EAP will assist in further evaluation in determining if impairment or abuse has occurred. VIOLATION OF POLICY Staff are prohibited from: 1. Working under the influence of drugs or alcohol. 2. The use, purchase, possession, sale, theft, distribution, diversion or transfer of alcohol or illegal drugs or the unauthorized dispensing of legal drugs. TESTING PROCEDURE: 1. The supervisor or manager who observes the staff member, or to whom it is reported that a staff member appears to be under the influence of drugs or alcohol should corroborate the observation with another member of the management team when a management team member is available. When the second manager is not available, another non-management staff member, preferably one familiar with the suspected staff member, may be used. Management must utilize the Medical Center s Drug and Alcohol Free Workplace procedural checklists and forms. It is suggested that the forms be reviewed by the management team members before the suspected staff member is approached. (See Attachments A-E). These checklists and attachments must be submitted with an incident report to Human Resources at the conclusion of the process. If it is believed the Drug and Alcohol Free Workplace policy is to be implemented, call Employee Health to notify of the possibility of impending collection. (Outside regular Employee Health hours, phone numbers for Employee Health staff can be obtained from the clinical nursing supervisor or security. Call them as soon as you believe you will be implementing the policy to allow timely arrival.) The Medical Center may require a medical assessment, urine drug and/or blood alcohol screening of those staff members suspected of using or being under the influence following the completion of the procedural checklist. The supervisor or manager must have reasonable suspicion to test as defined in this policy. 2. A split specimen will be collected on all urine drug tests and sent to a NIDA certified laboratory. Specimens are obtained and processed following DOT Chain of Custody and Protection of Privacy Guidelines. The results are received by Employee Health and are sent to the Medical Review Officer. All test results must be evaluated by the Medical Review Officer who may choose to interview the subject prior to releasing to the Director of Employee Health or designee and / or to the Director of Human Resources or designee. Results will be reported as follows with explanation of each result:

3 Negative- NO alcohol or drugs tested for were present. Positive- Alcohol and / or one or more drug tested for was found in any reportable quantity and was not legally explained. Verified Negative- One or more drug tested for was found to be present, although a valid prescription was presented. Refusal- If the donor does not cooperate in following the collection process or if the laboratory determines that a substitution or adulteration of any kind has occurred. This includes failure to provide a specimen within 3hrs. Information regarding the presence and level of alcohol and / or the presence and level of drugs found in testing, as well as all prescriptions presented to Employee Health and any other pertinent information will be reported to the Director of Human Resources or designee and forwarded to the Employee Assistance Program Designee. Staff are given the opportunity to rebut or explain the test results in writing within 48 hours of being advised of the test results. If the results are positive, the staff member may request the testing of the second (split) sample taken at the time of the original collection. This split sample would be sent to another NIDA certified lab. This request must be done within 72 hours of being notified of the result. The staff member is responsible for expenses of the split test unless the second result is negative. The Hospital/Medical Center is responsible for the cost of handling and processing a specimen and for laboratory charges in testing the first specimen. 3. Written results will be secured in a locked location in Employee Health on behalf of the MRO and a copy will be provided to Human Resources who will automatically forward the results to the Employee Assistance Program. Further sharing of the test results will occur on a need to know basis only. 4. All persons participating in the evaluation, screening, investigation, or disciplinary action related to this policy are to hold such information in a confidential manner and share with other participants in the process on a need to know basis. All documentation related to a violation of this policy must be filed with the Director of Human Resources and are property of the Human Resources Department. 5. Post-probationary staff members may be offered the opportunity for rehabilitation except in the case of the sale, theft, distribution, diversion or transfer of illegal drugs or the unauthorized dispensing of legal drugs. The rehabilitation process will be managed by the Substance Abuse Professional (SAP) through the Employee Assistance program. Staff members who accept treatment and successfully complete the process as defined by the Employee Assistance Program and the Medical Center may be conditionally reinstated to a job provided they: Request and are approved for a leave of absence. Successfully complete an approved substance abuse or alcohol treatment program. Fully cooperate and complete the aftercare plan developed by the EAP and Director of Human Resources in conjunction with the treatment agency as outlined in the return-to-work agreement. 6. Employees will be permitted to return to work only after clearance from the Employee Assistance Program and Human Resources. 7. Professional staff, as defined and licensed by the NY State Education Department or NYS Department of Health, may or may not be reported to their respective licensing agency for further discipline and/or monitoring as specified by licensing regulation, depending on the nature and extent of the violation. In all cases of felony or misdemeanor theft or possession on property of illegal or illegally obtained substances, reporting to the appropriate agency of licensure will be mandatory. The Medical Center will make all necessary reports required by law. 8. The use, purchase, possession, sale, theft, distribution, diversion or transfer or manufacture of an illegal drug is a violation of the law. The Medical Center will report such illegal drug activities to the appropriate enforcement agency, after Executive Management has been notified and approves such notification to outside sources.

4 9. A member of the medical staff demonstrating behavior indicative of impairment should be escorted to a private room or office by members of the management team. If the managers believe there is reasonable suspicion as defined in this policy, the appropriate Medical Staff Chairperson should be contacted. The Medical Staff Chairperson will contact the Vice President of Medical Affairs. If neither is available, the manager will notify the administrator on-call to proceed. If the representative contacted concurs the interview indicates reasonable suspicion, the Chairman, V.P., and/or Administrator will escort the medical staff member to Employee Health and obtain specimens for drug and/or alcohol screening as required by this policy. References: Cross References: Employee Health Drug and Alcohol Free Workplace Collection Protocol Housewide- Pre-Employment Drug Testing Policy Attachments A- Drug and Alcohol Free Work Place Procedure Checklist B- Observation Checklist C- Agreement to Submit to Screening/Authorization for Release D- Refusal to Submit to Screening E- Return to Work Agreement F Employee Assistance Program Referral

5 ORANGE REGIONAL MEDICAL CENTER DRUG AND ALCOHOL FREE WORKPLACE PROCEDURE CHECKLIST ATTACHMENT A Utilizing the following Checklist will assist you in completing this process effectively. 1. Personally observe the staff member at their worksite. Request, whenever possible, that another supervisor or management representative assist you. 2. Personally escort the staff member to a private office. 3. Once the drug and alcohol free workplace process is initiated, DO NOT leave the staff member unattended, allow the staff member to use the bathroom or wash their hands, or to eat or drink anything or put anything in their mouth. You or another staff member must remain in attendance with the staff member until the completion of the entire process including collection. 4. Offer Union Representation to the suspected staff member to participate in the process and notify them that you will begin this process within ½ hour. Allow the staff member to contact this representative and wait with the staff member for the representative s arrival. If the representative or designee is not available, declines to come or does not arrive within ½ hour, do not postpone the interview. 5. If a staff member flatly refuses to cooperate, ask them to sign the refusal and suspend them at that time and follow personnel policy for suspending an employee unfit or insubordinate. Remind them that refusal to cooperate may result in disciplinary action up to and including termination. Make sure to have another supervisor or member of management present to witness the staff member s refusal to cooperate and the subsequent suspension. Write down the names of all persons present at the time of the refusal and suspension including any union representative. 6. If the staff member cooperates and you conclude they do not appear to be under the influence of a covered substance and is able to perform the work duties, then have them return to the work station if appropriate. 7. If you have reasonable suspicion to believe that a staff member is under the influence of alcohol, drugs, or both: - tell them you believe they are under the influence - remind them of the Medical Center s Drug and Alcohol Free Workplace policy - tell them that there is reasonable suspicion for testing - request the staff member submit to an assessment and drug/alcohol screening

6 ATTACHMENT A Page 2 Drug and Alcohol Free Workplace a. If the STAFF agrees: - have them sign the consent for collection - Call Employee Health and escort them to Employee Health for the collection process. (Outside regular Employee Health hours, phone numbers for the Director of Employee Health and other available staff can be obtained from the clinical nursing supervisor or security. Call them as soon as you believe you will be implementing the policy to allow timely arrival.) - Management staff must remain with the employee in Employee Health during the collection process and is responsible for their transportation home. - Inform the staff member that they will be referred to the Employee Assistance Program and must follow up with that referral, regardless of the results of the testing. Provide the EAP Referral form to the staff member. - Inform the staff member that they are temporarily suspended pending results of the testing and a full investigation and clearance from EAP and Human Resources. b. If the STAFF does not agree, advise them: - you believe they are under the influence - that there is reasonable suspicion for testing - that failure to comply to Medical Center s policy will result in disciplinary action, up to and including termination of employment. - they are suspended until the investigation is completed - ask them for a signature for refusal to consent During this process, make notes of your own observations as well as the checklist provided. COMPLETE ALL APPROPRIATE ATTACHMENTS. 8. Do not attempt to use force in seeking compliance with your requests. Screening and signing of documents are voluntary. 9. If a staff member should become abusive, violent, or threatening, CALL SECURITY and a Code Gray. 10. REGARDLESS OF STAFF S CONSENT TO TESTING, DO NOT PERMIT THE STAFF MEMBER SUSPECTED OF BEING UNDER THE INFLUENCE TO DRIVE A VEHICLE. Offer for them to contact someone to drive them home. If they cannot, offer a taxi at the expense of the Medical Center. IF THE STAFF MEMBER ADAMANTLY REFUSES ALTERNATE TRANSPORTATION AND INSISTS ON DRIVING, TELL THEM YOU WILL CONTACT THE POLICE AND THEN DO SO. Provide a vehicle description and license number if possible.

7 Drug and Alcohol Free Workplace ATTACHMENT B ORANGE REGIONAL MEDICAL CENTER DRUG AND ALCOHOL FREE WORKPLACE OBSERVATION CHECKLIST Questions for Suspected Substance/Alcohol Abuse Section 1 With another supervisor or management representative present, please ask the staff member who is suspected of substance abuse the following questions in the order listed below. 1. Are you feeling ill? [ ]Yes [ ]No If yes, what are your symptoms? 2. Can you explain why you are having so much trouble doing your job today? Comments: 3. Are you taking any type of medication? [ ] Yes [ ] No If yes, what kind, for what purpose, how much, when taken? (Add other comments) 4. Are you using any type of illegal drug? [ ]Yes [ ]No If yes, what kind of drug, how much, when taken? (Add other comments) 5. Did you drink alcohol or an alcoholic beverage today? [ ]Yes [ ]No Yesterday? [ ]Yes [ ]No If yes, what did you drink? Comments: (When? Where? With Whom? How Much?)

8 ATTACHMENT B Page 2 Section 2 DIRECTIONS: Check pertinent items based on your visual observation of the staff member. This section must be completed regardless of the outcome of the interview conducted to Section Walking/Standing: [ ] Normal [ ] Falling [ ] Stumbling [ ] Staggering [ ] Unsteady [ ] Holding on [ ] Swaying 2. Speech: [ ] Normal [ ] Whispering [ ] Slurred [ ] Silent [ ] Slow [ ] Slobbering [ ] Shouting [ ] Rambling/Incoherent 3. Demeanor: [ ] Normal [ ] Sleepy [ ] Silent [ ] Talkative [ ] Excited [ ] Crying [ ] Fighting 4. Actions: [ ] Normal [ ] Drowsy [ ] Hostile [ ] Hyperactive [ ] Erratic [ ] Profane [ ] Threatening [ ] Fighting [ ] Resisting Communications 5. Eyes: [ ] Normal [ ] Bloodshot [ ] Watery [ ] Glassy [ ] Closed [ ] Droopy Pupils: [ ] Dilated [ ] Constricted 6. Face: [ ] Flushed [ ] Pale [ ] Sweaty 7. Appearance: [ ] Normal [ ] Messy [ ] Dirty [ ] Unruly [ ] Partially dressed 8. Breath: [ ] Alcoholic odor [ ] Faint alcoholic odor [ ] No alcoholic odor [ ] Other detectible odor unable to clearly identify. 9. Movements: [ ] Normal [ ] Slow [ ] Fumbling [ ] Jerky [ ] Nervous [ ] Hyperactive 10. Eating/Chewing: [ ] Gum [ ] Candy [ ] Mints [ ] Other Identify, if possible:

9 ATTACHMENT C Drug and Alcohol Free Workplace ORANGE REGIONAL MEDICAL CENTER DRUG AND ALCOHOL FREE WORKPLACE CONSENT TO DRUG AND ALCOHOL TESTING & AUTHORIZATION FOR THE RELEASE OF DRUG AND ALCOHOL TESTING RESULTS AND OTHER PERTINENT INFORMATION BY ORMC S EMPLOYEE HEALTH AND MEDICAL REVIEW OFFICER. I have been informed that Orange Regional Medical Center, based on reasonable suspicion, is concerned that I may be under the influence of drugs or alcohol, or may otherwise have violated the Medical Center s rules against drug and alcohol use. My ability to perform my job duties, therefore, is in question, and as a result, I have been requested to submit to a drug and/or alcohol screen by blood and/or urine tests and medical assessment. This testing is to be administered by Employee Health. I have been informed and I understand, that my agreement to submit to the requested alcohol and/or drug screen by blood and/or urine tests is completely voluntary. I hereby authorize that the results of this urine drug and blood alcohol screen and/or medical assessment will be released to the Medical Review Officer who will evaluate the test results and disclose their interpretation of the results to the Director of Human Resources and/or Employee Health or designee as well as to the Employee Assistance Program Designee. I also authorize Employee Health to release other pertinent information to the Director of Human Resources and EAP or their designees. These results and pertinent information will be shared with necessary management personnel to assist in a complete investigation of the incident and help determine whether I was fit to perform my job duties, and/or whether I had violated the Medical Center s Drug and Alcohol Free Workplace rules concerning drug and alcohol use. I understand that the results of such tests may form the basis for disciplinary action against me, up to and including termination. With full knowledge of the previously described information, I have decided to voluntarily submit to the requested drug and alcohol screen by Employee Health and the release of the results and other pertinent data as described above and in recognition of this agreement, willingly sign this consent form. I also understand that any disclosure / release is bound by Title 42 of the Code of Federal Regulations governing the confidentiality of alcohol and drug abuse patient records, as well as the Health Insurance Portability and Accountability Act of 1996 ( HIPPA) 45 C.F.R. Pts 160 and 164; and the re-disclosure of this information to a party other than the ones designated above is forbidden without additional written authorization on my part. STAFF Signature NOTE: A witness other than the Supervisor who has requested that the staff member submit to a drug and/or alcohol screen by blood and/or urine tests, and/or medical assessment should also sign the consent form. Supervisor/Manager Witness Union Representative (if present)

10 Drug and Alcohol Free Workplace ATTACHMENT D ORANGE REGIONAL MEDICAL CENTER DRUG AND ALCOHOL FREE WORKPLACE REFUSAL TO SUBMIT TO URINE DRUG AND/ BLOOD ALCOHOL TESTS I hereby refuse to authorize testing by urine drug and blood alcohol for alcohol or drugs. I understand that my refusal will require a review of the evidence/investigation by management that may necessitate discipline, up to and including termination. Staff Member Signature Witness Signature Union Representative (if present) Check here if staff member refused to sign.

11 Drug and Alcohol Free Workplace THE WORKPLACE EMPLOYEE ASSISTANCE PROGRAM NORTH ROAD MEDICAL ARTS BUILDING 243 NORTH ROAD, SUITE 103 POUGHKEEPSIE, NEW YORK Attachment E Name of Institution: RETURN TO WORK AGREEMENT (SAMPLE) Orange Regional Medical Center Name of Employee: : This Agreement is to clarify expectations regarding the employment of (employee) and the Orange Regional Medical Center. This Agreement shall be in effect from through (three years). The contents of this Agreement are mutually agreed upon and may be modified quarterly as deemed necessary and agreed upon by all parties. Work attendance and job performance will be monitored closely. I, (employee name) agree to: 1. Abstain from illegal drugs, alcohol and working under the influence. In the event that legally prescribed medication may be needed as a part of my health care, I agree to notify my employer regarding such medication and provide the Employee Assistance Program with a copy of the prescription. 2. Participate in an appropriate treatment program and subsequent after program as recommended by my treatment provider. I authorize my treatment providers to contact and exchange information regarding my progress with the Employee Assistance Program on a monthly basis or as often as my treatment providers deem necessary. 3. Participate in a return to work blood alcohol and / or drug test prior to the date of return to work. Agree to report for testing within 24 hours of notification and produce a negative result. 4. Participate in random blood alcohol and / or drug testing for a period of three years. 5. Work with the Employee Assistance Program for a minimum of 36 months for the purpose of follow-up to ensure compliance with treatment recommendations. 6. Review, understand and abide by the Medical Center s Drug and Alcohol Free Workplace Policy.

12 Drug and Alcohol Free Workplace Orange Regional Medical Center agrees to keep this agreement in a locked confidential file, outside of the employee s personnel file Any violation of this Return to Work Agreement will result in disciplinary action up to and including termination of employment from Orange Regional Medical Center. Employee Human Resources Director Director/Supervisor Union Representative

13 Orange Regional Medical Center DRUG AND ALCOHOL FREE WORKPLACE EMPLOYEE ASSISTANCE PROGRAM REFERRAL ATTACHMENT F Employee Name Job Title Department Per the Orange Regional Medical Center Drug and Alcohol Free Workplace policy: You are required to contact The WorkPlace, the Medical Center s Employee Assistance Program provider immediately. Call or to make an appointment. This appointment must be accomplished regardless of the outcome of the drug and alcohol test results. Human Resources will also contact The WorkPlace to make the referral. You are suspended until a full evaluation is completed. The Medical Review Officer or the Director of Human Resources, or a representative will contact you, once the results of the Drug/Alcohol test have been received and evaluated. You cannot return to work until you are cleared by Human Resources and Employee Assistance Program.