USA HOSPITALS
SYSTEM POLICY
Policy No: HR002
Approved By: Stan Hammack
Origin Date: Aug 1994
Revision Date: Oct 2009
Page: 1 of 10
SUBJECT: DRUG TESTING
I.
PURPOSE:
The goal of this policy is to provide and maintain a drug free work environment for all
employees of the University of South Alabama Hospitals. Such an environment is
supportive of the objective of University of South Alabama Hospitals to establish a safe
and productive work place and is necessary to assure the highest standards of care
rendered to patients.
II.
POLICY:
The use, presence in the body, sale, distribution or possession of drugs by employees of
University of South Alabama Hospitals while working or while present on any
University Hospital property is prohibited. Use by the employee of over-the-counter
drugs or drugs prescribed by a physician for the employee’s personal use in quantities
not exceeding reasonable or specified dosage requirements does not subject the
employee to the evaluation/treatment/disciplinary measures of this policy provided the
employee can produce, on demand, by one of the following means, proof that the
subject drug(s) was (were) prescribed in the employee’s name prior to the
administration date of the drug test:
A.
A prescription bottle with complete and legible label no older than 24
months from the last date filled; or
B.
A pharmacy listing of prescriptions no older than 24 months form date
prescribed; or
C.
A written statement from the employee’s physician providing the date
the drug in question was prescribed. Said date must be within the 24
month period immediately preceding the administration date of the drug
test.
Employees using medication prescribed by a physician for the employees’ use or using
over-the-counter drugs are responsible for being aware of any potential effects such
drugs may have on their reactions, judgment, or ability to perform their duties, and if
impairment is possible, to report such use to their immediate supervisor and/or
department head either at the time of reporting to work or prior to reporting to work.
III.
PRE-EMPLOYMENT DRUG TESTING:
Each person accepted for employment by the University of South Alabama Hospitals is
required, as a condition of employment, to submit to a drug test. The health nurse or
USA HOSPITALS
SYSTEM POLICY
Policy No: HR002
Approved By: Stan Hammack
Origin Date: Aug 1994
Revision Date: Oct 2009
Page: 2 of 10
SUBJECT: DRUG TESTING
his/her designee administers the drug test during the pre-employment physical.
Prospective employees should advise the health nurse or designee, at the time of
testing, if they are under the care of a physician and receiving prescribed medications
which might cause a positive drug test. Individuals testing negative, or positive with
satisfactory proof of prescription as stated in II. A., B., or C. above, who complete all
other aspects of the pre-employment process will be eligible for employment.
Individuals with unsatisfactory drug test results will not be eligible for employment.
IV.
EMPLOYEE DRUG AND ALCOHOL TESTING:
The University of South Alabama Hospitals recognize that drug and alcohol abuse or
dependency are medical/behavioral conditions that can be successfully treated.
Assistance with these types of problems is available through the University of South
Alabama Employee Assistance Program.
All temporary employees, student employees, regular staff and administrative
personnel, and physician housestaff of the University of South Alabama Hospitals are
subject to alcohol and/or drug testing at the determination of the employees' department
head, administrator-on-call or hospital administrator, as a condition of continued
employment, under the following conditions:
1.
If there is reasonable cause to suspect that the employee is in violation of this
policy*;
2.
If the employee is or may have been involved in a job site accident or incident
which results or could have resulted in serious bodily injury or property loss or
damage*;
3.
If the employee is included in a random testing to monitor and ensure
compliance by employees with this policy, or
4.
If the employee self reports a violation of the drug policy1 and/or self refers for
treatment of a drug or alcohol related issue2.
*
1
An employee tested pursuant to #1 or #2 above will be placed on administrative
For purposes of this policy, the term “self report” shall mean a report by an employee that he/she has committed
a violation of the USA Hospitals System Drug Testing Policy.
2
For purposes of this policy, the term “self referral” shall refer to the situation where an employee, of his/her own
initiative, seeks treatment of a drug or alcohol related issue. In the event of self referral, continued employment is
dependent upon notification by the employee to his/her immediate supervisor and the employee’s licensing board
that the employee has self referred.
USA HOSPITALS
SYSTEM POLICY
Policy No: HR002
Approved By: Stan Hammack
Origin Date: Aug 1994
Revision Date: Oct 2009
Page: 3 of 10
SUBJECT: DRUG TESTING
leave pending receipt of test results.
All positive results of the testing described above are reported to the Medical Review
Officer of the Hospitals as well as the Hospital Human Resource Office for review and
disposition. Negative results are reported to the Hospital Human Resources Office for
review and disposition.
The first time an employee tests positive under conditions stated in #1., #2., or #3.
above, or self-reports a policy violation under #4. above, for alcohol or for drugs that
are neither over-the-counter nor acceptably prescribed as set forth above, the employee
is required to accept a referral to the University of South Alabama Employee
Assistance Program as well as any subsequent referral made by said Center for further
evaluation/treatment. If the employee self-refers under #4. above, the facility to which
he/she has self-referred must be acceptable to the Employee Assistance Program
Counselor in order for the employee to remain employed pursuant to this policy. In all
cases outlined above, the employee must also execute the Authorization for Release of
Confidential Information to enable the University’s Employee Assistance Program
Counselor to communicate with the employee’s health care provider(s) regarding the
condition, treatment, and progress of the employee. Failure of the employee to accept
such referrals, and/or complete an evaluation/treatment program established/approved
by the Employee Assistance Program Counselor, and/or sign the Authorization referred
to above will result in termination.
Notwithstanding the above, in instances where an employee has diverted drugs from a
hospital, health care unit, or patient, or endangered or caused bodily harm or death to a
patient, another employee, or individual at the work place, and a positive drug or
alcohol test has followed such an occurrence, disciplinary action, up to and including
termination, may be taken. Further, this policy is in addition to and does not supersede
any other University policy or procedure or applicable disciplinary actions.
Upon completion of a University/licensure agency approved evaluation/treatment
program, the employee must direct the treating facility to send a letter of release
directly to the University’s Employee Assistance Program Counselor indicating the
employee’s readiness to return to work as well as any required follow-up treatment.
The University Employee Assistance Program Counselor will then assess the employee
and, if he/she deems it appropriate, will issue an authorization to return to work on
behalf of the employee. This authorization is required before the employee will be
allowed to return to work. The University Employee Assistance Program Counselor
will also continue to monitor any follow-up treatment prescribed for the employee. If
after successful completion of the evaluation/treatment program an employee is placed
USA HOSPITALS
SYSTEM POLICY
Policy No: HR002
Approved By: Stan Hammack
Origin Date: Aug 1994
Revision Date: Oct 2009
Page: 4 of 10
SUBJECT: DRUG TESTING
on probation or restricted duty by a licensing agency and cannot perform all of the
essential functions of his/her job, (such as administering controlled substances and/or
taking call) the employee is placed on personal leave of absence and the position is held
for the employee for up to one year from the date of initial referral/presentation to the
University Employee Assistance Program Counselor. However, if a temporary
licensure restriction is placed on an employee who has voluntarily self- reported a
violation of the drug policy and/or sought treatment completely independent of and
before any testing or initiation of testing by the employing unit or facility and the
employee is not in violation of any other University policy or procedure, an exception
to the leave requirement may be made. In such a case, if the employee has fully
cooperated with the requirements of USA and the University Employee Assistance
Program Counselor, and has successfully completed the evaluation/treatment program,
the employee may be allowed to return to active employment in the same job
classification within the same department with modified job duties to fit the restriction
imposed by the licensing agency, if deemed reasonably practicable by the employing
unit. If such return is not practicable, the employee will be placed on the
aforementioned personal leave of absence until the restriction is lifted, for up to one
year from the date of initial referral/presentation to the University Employee Assistance
Program Counselor. In either case, during this period of personal leave, neither paid nor
unpaid sick leave may be utilized; however, paid vacation may be used as available.
When the affected employee returns to work, he/she is subject to individual,
unannounced alcohol and/or drug testing for a period of twelve (12) months. If an
employee has a positive drug or alcohol screen at any time within seven (7) years from
the date of his/her return to work following the first offense, he/she will be immediately
terminated from his/her position at University of South Alabama Hospitals. This is also
true for positive results of such testing conducted by the Board of Nursing or any other
agency governing the profession of the employee. If an employee’s second offense is a
self-report/self-referral within seven (7) years of his/her return to work, the
referral/treatment/return to work procedures in the immediately preceding three
paragraphs will be followed. If, however, an employee has a third self-report of a drug
policy violation (or a second self-report if first offense was a positive drug/alcohol
screen) within seven (7) years of his/her return to work from his/her first positive
drug/alcohol screen or self-report/self-referral, he or she will be terminated
immediately. If he/she has a third self-referral to treatment (or second self-referral if
first offense was a positive drug/alcohol screen) with no violation of hospital policies or
procedures, within seven (7) years of his/her return to work from his/her first selfreport/self-referral or positive drug/alcohol screen, the Employee will be entitled to
only such leave as he/she is qualified under University sick leave and/or FML policies.
A full report of any and all positive drug and/or alcohol screens, self-reports or self-
USA HOSPITALS
SYSTEM POLICY
Policy No: HR002
Approved By: Stan Hammack
Origin Date: Aug 1994
Revision Date: Oct 2009
Page: 5 of 10
SUBJECT: DRUG TESTING
referrals are forwarded to the impaired employee’s licensing agency as necessary or as
required by subject agency.
Failure to abide by this policy in any way, including refusal to submit to alcohol and/or
drug testing as provided for in this policy, results in termination.
V.
TESTING PROCEDURE:
FOR-CAUSE DRUG SCREEN: Arrangements for drug and/or alcohol testing is made
between the health nurse and the department head or administrator-on-call ordering the
test. If an employee is being tested for cause and alcohol is suspected, a blood sample
is obtained. If other controlled substances are suspected, a urine and/or blood specimen
is obtained as applicable. If a question exists as to the origin of the impaired behavior,
both tests are administered. An employee tested because he/she appears to be impaired
will not be allowed to continue to work the shift. The employee is placed on
administrative leave until test results are received.
If the test is required after normal working hours of the health nurse, the Nurse
Administrator on duty will be responsible for contacting the department head and for
obtaining the blood/urine sample.
RANDOM DRUG SCREEN: The health nurse notifies the employee that he/she has
been randomly selected for a drug screen and tells the employee he/she has thirty
minutes to report to the health nurse office unless otherwise excused by his/her
department head or designee. Once the employee reports to the Health Nurse’s office,
he/she may not leave until an acceptable specimen has been provided. Failure to report
within the designated time of leaving before and acceptable specimen is obtained is
considered refusal to submit to testing and is grounds for termination.
BREATH TEST FOR ALCOHOL: A breath test for alcohol use is administered with
each random drug screen. The health nurse documents results of the test on the Test
Request/Consent/Chain of Custody Form.
MISCOUNT OF NARCOTICS: When a miscount of narcotics occurs,
management/administration may order a drug screen of all the parties who may have
played a role in the count process. The health nurse or nurse administrator obtains a list
of persons to be tested, contacts these employees and follows the specimen collection
procedure as detailed herein.
USA HOSPITALS
SYSTEM POLICY
Policy No: HR002
Approved By: Stan Hammack
Origin Date: Aug 1994
Revision Date: Oct 2009
Page: 6 of 10
SUBJECT: DRUG TESTING
VI.
DONOR IDENTIFICATION:
Each donor is identified with a number assigned by the health nurse or designee.
Confidentiality is maintained.
VII.
URINE COLLECTION PROCEDURE AND CHAIN OF CUSTODY:
The urine collection kits contain one collection container and two specimen containers
with chain of custody forms. Both specimen containers must be filled with urine as
specified in the collection kits and the form for each completed. One specimen is used
for the initial screen and the other for confirmation of any positive screen.
A. Step 1 of the USA Test Request/Consent/Chain of Custody Form must be
completed by collector.
B. The donor’s identity is verified by the employee I.D. or other photo identification.
C. The donor is asked to remove all unnecessary clothing, e.g., coats, jackets and
personal belongings (purse, briefcase, bags,) for the duration of the collection
process.
D. The donor is instructed to wash with soap (not alcohol based gel) and dry hands.
Access to the water supply and soap dispensers should be restricted during
collection if they cannot be monitored by the collector.
E. If this is a random drug screen, the breath test is performed and the results written
on the U.S.A. Hospital Test Request/Consent/Chain of Custody Form.
a. The donor opens the plastic tube packaging and attaches the tube to top of
the breathalyzer machine (there is a hole in the tube that fits onto the gray
spike).
b. While the donor is holding the machine so the collector can see the front
panel, the collector presses the “set button”.
c. The donor is instructed to take a deep breath and to blow slow and long into
mouth piece. When the “A” and “B” buttons light up, the collector presses
the “read button” and continue to hold the “read button” for 20-30 seconds,
at which time the final reading is obtained.
d. If the results are ≥0.02, the collector will follow the blood alcohol collection
procedure, and notify the department head or clinical administrator. The
employee will not be allowed to continue his shift.
USA HOSPITALS
SYSTEM POLICY
Policy No: HR002
Approved By: Stan Hammack
Origin Date: Aug 1994
Revision Date: Oct 2009
Page: 7 of 10
SUBJECT: DRUG TESTING
F. The collector opens the urine collection kits in the presence of the individual to be
tested. The collector or designee witnesses the collection.
G. To the maximum extent possible, collector shall keep the individual’s collection
container within sight before and after the individual has voided.
H. After completion of the collection, the donor hands the container to the collector
prior to flushing the toilet.
a. The collector takes all precautions necessary to ensure a valid specimen is
collected.
b. The collector checks the temperature of the specimen using the indicator
strip on the container within four minutes from the time of collection and
notes the temperature on the USA Test Request/Consent/Chain of Custody
Form. If the temperature is out of range, the collector ends the procedure
and contacts the Director of Human Resources for further instructions.
c. The collector inspects specimen for any discoloration or signs of
contamination and notes discoloration in the remark section on the USA
Test Request/Consent/Chain of Custody Form.
d. The collector pours adequate amount of urine into the specimen containers
and tightly secures the cap on the confirmation specimen in the presence of
the donor prior to performing Point of Care Test.
e. The collector performs a standard panel of controlled substances testing at
time of collection on urine in the Point of Care Test specimen container.
i. If initial result is negative, the collector completes documentation
requirements and discards urine specimens.
ii. If initial result is positive, the collector sends specimen for
confirmation testing by the reference laboratory using the following
procedure.
1. The collector affixes the security seal on the urine specimen
container.
2. The collector dates and donor initials security seal after seal
has been placed on the urine specimen container.
3. The collector and donor return to the desk area and complete
Reference Lab Chain of Custody Form.
4. The collector instructs the donor to read the certification
statement and sign/initial as appropriate.
5. The collector places the specimen and Reference Lab Chain
of Custody Form in the designated bags for transport and
seals the bag.
USA HOSPITALS
SYSTEM POLICY
Policy No: HR002
Approved By: Stan Hammack
Origin Date: Aug 1994
Revision Date: Oct 2009
Page: 8 of 10
SUBJECT: DRUG TESTING
6. The collector transports specimen to designated area for
commercial transport carrier pickup.
I. If the donor cannot urinate, he/she is given beverages and retries in 30 minutes to 1
hour. The donor is not allowed to leave employee health office until he/she
urinates.
J. If other substances are suspected, the employee may be tested specifically for those
substances.
VIII. BREATH TESTS:
Breath tests for alcohol use may be administered on a random basis. Such tests are
administered by authorized hospital personnel in accordance with standard testing procedures.
Follow collection procedure as defined in section VII.
If an employee tests positive for alcohol at a level of >.02, then the employee is required to
immediately provide a blood sample for further testing.
IX.
BLOOD ALCOHOL COLLECTION PROCEDURE AND CHAIN OF CUSTODY:
A. The blood specimen collection kit should be used if blood is to be collected for a
blood alcohol test.
B. The collector:
a. Prints all information on USA Test Request/Consent/Chain of Custody
Form and the two blood tube labels
b. Cleans intended draw site thoroughly with Povidone pad
c. After collection, places blood in the 2 vials and cover vials with the security
seal, making sure vial label is visible. Collector dates and donor initials
both security seals.
d. Places sealed vials in bag and seal bag in the presence of the donor
e. Has donor complete step 5 on the USA Test Request/Consent/Chain of
Custody Form
C. Laboratory Personnel sign for blood sample upon receipt from Health Nurse/Nurse
Administrator/courier.
D. Hospital laboratory tests sample for alcohol and confirms results. If other
substances are suspected, employee’s blood sample may be sent to appropriate
USA HOSPITALS
SYSTEM POLICY
Policy No: HR002
Approved By: Stan Hammack
Origin Date: Aug 1994
Revision Date: Oct 2009
Page: 9 of 10
SUBJECT: DRUG TESTING
laboratory and screened specifically for those substances.
X. REPORTING RESULT PROCEDURE:
A. Confirmatory test and blood alcohol test results are sent to the Health Nurse.
B. Negative results are kept in the Employee’s health file.
C. Positive results are reported by the Health Nurse to the Human Resources Manager
who provides the results to the Medical Review Officer. The Human Resources
Manager notifies the Hospital Administrator of all positive results.
D. The Medical Review Officer reviews presumptive positive results and provides a
recommendation to the Human Resources Manager.
E. If test results are determined to be positive by the Medical Review Officer, the
employee is referred to the Employee Assistance Program. The Human Resources
Manager and Department Head instruct the employee on referral procedure and
responsibilities and the consequences of failing to accept referral or complete the
rehabilitation program.
F. Employees who are required to attend rehabilitation programs, may receive sick pay
while in the treatment/rehabilitation program and unable to work. If sick pay is
exhausted prior to completion of rehabilitation, the employee may receive vacation
or holiday pay with the approval of their department head.
G. Positive results are kept in the Human Resources Manager’s office.
Reviewed: Aug, 2001; Dec 2004
Revised: Feb. 2003, Oct. 2005, Sep 2007, Oct 2009