Is your home health nurse using drugs? Testing promotes safety, limits liability
New hire, random, and for-cause drug screens work best
Six percent of home care, community, and public health nurses in the United States use addictive prescription drugs without a prescription, and 16% binge drink, which means they drink at least five drinks in one sitting.1
Because home health personnel are not directly supervised in most situations and are directly responsible for the safety of patients, it is important for all home health agencies to recognize and take steps to minimize the risk of an impaired employee, points out Arlene Maxim, RN, a home care consultant in Grand Rapids, MI. "I recommend that home health agencies test all new employees and perform random tests as part of an ongoing substance abuse prevention program," says Maxim.
Two years ago, when a nurse who was accused of stealing a patient’s pain medication admitted to being a recovering addict who relapsed, Progressive Home Care in Bath, OH, developed and implemented a drug-testing program for all employees. "We now test new employees and perform random tests on all employees," says John Corbett, compliance officer for the agency. In addition to the random tests, the agency will conduct drug tests on employees who are suspected of having a problem, he adds.
"We perform random tests on all employees who are in positions that we’ve determined to be safety sensitive, such as patient care staff and drivers," says Kay B. Sykes, SPHR, director of human resources for Alacare Home Health & Hospice in Birmingham, AL, an agency that has conducted drug screens on new hires since 1991 and developed a formal substance abuse policy in 1992 that incorporated a process for random, post-accident, and reasonable cause testing.
Before you implement a substance abuse policy or enhance the policy you now have, be sure to have the support from the members of your board of directors, says Maxim. "Once you have their support, put the policy in writing and have it reviewed by a labor attorney who can make sure you are in compliance with state and federal laws as well as professional licensing boards in your state," she adds.
"In the past, we asked employees to notify us of all prescription medicines that they were taking but that request is no longer allowed under the Americans with Disabilities Act," says Sykes. Asking for all medications is an invasion of privacy, but Alacare can and does ask for employees to self-report any medication that might affect their job performance, she adds.
Use an employee assistance program
Be sure that your substance abuse policy includes referrals to an employee assistance program (EAP), suggests Maxim. "Not every incident should automatically result in termination, so you need a resource for employees who need help with a substance abuse problem. "An EAP will not only provide this resource but can also be available to employees with personal problems that can be addressed before a substance abuse problem develops," she adds. Be sure your policy defines incidents that require disciplinary measures and EAP referral as opposed to automatic termination.
To find a good EAP for your agency, contact other health care organizations, home health agencies, or companies in your area, suggests Maxim. "Also check with your local chamber of commerce," she adds. "You want to make sure the EAP is legitimate and has a good track record," she says. Find out if the EAP has services in all of the areas in which your employees are located, Maxim says.
Once an Alacare employee has been referred to the EAP, he or she is required to sign an agreement in which the employee agrees to comply with the counselor’s recommendations and successfully complete any plan of treatment recommended, says Sykes. "They are also subject to periodic, unannounced drug tests for one year," she adds. If the employee does not meet these requirements or commits a second offense, the employee is terminated, Sykes explains.
Check with any professional licensure boards that apply to your employees, because some state boards of nursing have programs in place in which registered nurses with substance abuse problems must participate in order to keep their license, says Corbett. "We work with our state board of nursing because we would rather fix the problem of the employee’s substance abuse than terminate the employee so that someone else gets the problem," he says.
Some of the requirements of the nursing board might present problems, points out Sykes. "While we do want to rehabilitate the employee, we have had one instance in which a nurse admitted to a problem and entered the nursing rehab program," she says.
When the rehab program staff approved the nurse’s return to work, the stipulation was made that the nurse must work in a closely supervised environment. "This nurse was a home care staff nurse. Unfortunately, we did not have a suitable position in the office that was available and we could not meet the requirement of close supervision, so we had to terminate her employment," she explains.
The agency has experienced few incidents of substance abuse in employees, and this was the only separation of employment that has resulted due to the board’s requirements in Sykes’ 13 years with Alacare, she says.
Train supervisors, inform employees
Your supervisors must be well trained in both the details of the policy as well as signs that might indicate reasonable cause to test an employee for substance abuse, says Maxim. While no one or two of these signs is proof that there is a substance abuse problem, they should trigger a closer look at job performance and employee behavior, she suggests. Also, be sure your employee orientation program includes a discussion of your substance abuse policy and explains random testing, says Maxim.
"You should also obtain the proper consent from every employee that applies to random testing," she says. The consent should be reviewed by an attorney to make sure it is valid in your state and will be in effect throughout the duration of the employee’s tenure at the agency. (See example of consent form.)
Maxim also points out that any drug screening information obtained from new hires or existing employees who undergo random testing must be stored in the locked medical file rather than the regular personnel file to protect employees’ privacy.
When planning the actual collection of test samples, be sure you choose a reputable lab. Alacare uses only labs that are certified by the National Institute on Drug Abuse, a division of the National Institutes of Health in Bethesda, MD. "We require them to adhere to strict chain of custody protocols, closely monitor employees when they come in for a test, and automatically conduct a confirmation test on all non-negative results," says Sykes. Non-negative results and the follow-up confirmation test results are reviewed by a medical review officer, she adds.
If you choose to collect the test specimen in your facility, be sure you follow chain-of-custody protocols, emphasizes Corbett. "The specimen jar is sealed in front of the employee with an adhesive strip that covers the lid and bottle, then the employee initials the tape," he says. "The bottle then goes into a tamper-proof bag along with all of the paperwork," he adds. If the outside lab used by his agency receives a bag or specimen jar that appears to be opened or if the lab personnel suspect tampering, Corbett is contacted and he calls the employee to provide another specimen.
"Urine samples are collected for the drug tests, and we conduct a 10-panel screen that includes amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, methadone, methaqualone, propoxyphene, opiates, and phencyclidine," says Sykes.
In addition to protecting patient safety and reducing liability risks for the home health agency, there are other benefits to a well-planned, carefully implemented substance abuse program, says Sykes. "We receive discounts on our workers’ compensation insurance, and we feel our practices minimize risk and liability in other areas to the extent possible," she says.
Make testing a normal business practice
Sykes emphasizes that the program needs to be well planned and communicated to all employees. "If handled inappropriately, a substance abuse program can be demoralizing to the staff," she says. The trick is to make sure that employees know that this is just a normal part of doing business for the home health agency, Sykes explains. "We have signs in our offices that job applicants can easily see that notify them at that point that we test for substance abuse, and we make sure we cover our policies on substance abuse testing thoroughly in orientation so that everyone knows this is done on a random basis," she adds.
For more information on drug testing staff, contact:
- Arlene Maxim RN, Home Care Consultant, 1734 Timberlane N.E., Grand Rapids, MI 49505. Tele-phone: (616) 361-8372. E-mail: [email protected].
- John Corbett, Compliance Officer, 3700 Ira Road, Bath, OH 44210. Telephone: (440) 230-1220.
- Kay B. Sykes, SPHR, Director of Human Resources, Alacare Home Health & Hospice, 4752 Highway 280 E., Birmingham, AL 35242. Telephone: (205) 981-8000. E-mail: [email protected].
Reference
1. Trinkoff AM, Storr CL. Substance use among nurses: Differences between specialties. Am J Public Health 1998; 88:581-585.
Six percent of home care, community, and public health nurses in the United States use addictive prescription drugs without a prescription, and 16% binge drink, which means they drink at least five drinks in one sitting.
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