Wyoming STATE BOARD OF NURSING

Transcription

1 Matthew H Mead Governor Wyoming STATE BOARD OF NURSING Mary Kay Goetter, PhD, RNC, NEA-BC Executive Director 1810 Pioneer Avenue Cheyenne, Wyoming Phone: FAX: MONITORING CONTRACT 1. This contract is a legally binding written agreement between the Wyoming State Board of Nursing (WSBN) Nurse Monitoring Program (NMP) and (nurse) detailing what is expected of you while being monitored. 2. You will be held accountable for all terms and conditions of this contract. 3. You are required to sign the monitoring agreement upon entering the program. a. This is a monitoring contract as a result of a Board order or an open complaint for a substance use issue. b. The program records are non-public and have necessary exceptions for disclosure, such as to Board of Nursing members, other State Boards and other states alternative programs regarding the participants in the Nurse Monitoring Program (NMP). c. You are required to have work site monitoring upon return to work. d. The consequences of relapse and noncompliance with the monitoring contract will result in notification to the Disciplinary Committee for possible further disciplinary action against your license. e. Relapse is defined as any unauthorized use or abuse of alcohol, medications, or mind-altering substances. f. You are required to sign a document acknowledging receipt and understanding of the NMP policies and procedures handbook. g. The period of monitoring will be months, per your WSBN Settlement Agreement Contract. Conditions may be gradually decreased after a minimum of one (1) year of full compliance and/or evidence of other recovery parameters. If you are not fully compliant, your contract conditions may be increased. 4. The terms and conditions set forth in this contract are as follows. You shall: a. Abstain from all alcohol and alcohol-containing products without prior approval from the NMP. b. Abstain from drug use including all over-the-counter medications and other mindaltering substances unless lawfully prescribed and with prior approval of the NMP. c. Maintain current Wyoming nursing licensure. d. Sign release forms necessary for monitoring and consents to exchange information between: i. Employer and NMP; ii. Healthcare providers and NMP; iii. Treatment professionals and NMP; iv. Medical Review Officer and NMP; v. Other state boards and alternative programs and NMP.

2 e. Complete substance abuse/dependency evaluations and/or mental health assessment, treatment, continuing care, and aftercare at your own expense. f. Enter treatment and participate in all treatment recommendations at your own expense. g. Submit a progress report from your treatment provider or counselor to the NMP monthly or as directed by your WSBN Settlement Agreement. h. Notify NMP of co-occurring conditions, e.g., psychiatric or medical diagnoses. i. Obtain an assessment by a physician who is approved by the NMP and has a subspecialty in addictions and pain management as required by your individual treatment plan. j. Sign and adhere to pain management contract if you have a diagnosis of chronic pain as well as Substance Use Disorder. k. Undergo any additional evaluation as requested by the NMP or treatment provider. l. Attend a minimum of three (3) 12-step meetings/week and one(1) peer support group/week and submit monthly documentation to the NMP. m. Maintain an active and consistent relationship with a sponsor. n. Report within twenty-four (24) hours to the NMP any prescriptions for moodaltering drugs as well as over-the-counter medications. o. Provide the NMP the contact information for the following: 1. One (1) pharmacy for prescription needs; 2. One (1) healthcare provider for healthcare needs; 3. One (1) dentist for dental needs. p. Notify the NMP if a prescription is received and provide verification for any medications within twenty four (24) hours of receipt of prescription or medication and prior to returning to nursing practice. q. Notify any and all health care providers of Substance Use Disorder history prior to receiving any prescription. r. Provide a written statement from the prescribing provider that confirms the provider s awareness of your history of Substance Use Disorder. s. Assure that your chosen health and dental care practitioners complete medication verification forms and medication logs provided by the program and submit quarterly by the 10 th of the month following the quarter. Forms will be due March, June, September and December. t. Provide written self-reports monthly by the 10 th of the following month. u. Maintain continuous employment in a nursing position for at least one(1) year of the three (3) to five(5) year contract or as dictated by your Settlement Agreement, in order to be eligible for successful discharge from the program. v. Practice nursing in one state only. Permission to work in any other state requires prior written approval from the Disciplinary Committee and the Board of Nursing in the other state. w. If licensed in another state or seeking licensure in another state, NMP will release participant information to any other state of licensure where you are applying for licensure. x. Notify and obtain approval from the NMP for any healthcare related position or job change before making the change or relocating. y. Abide by return to work restrictions and requirements.

3 z. Inform any prospective or current nursing position employers or nursing schools of your participation in the NMP and provide copy of contract, stipulations and/or final orders from the WSBN. aa. Ensure your supervisor has received a copy of the contract and any other necessary forms. bb. Ensure that the NMP receives the agreement form signed by the direct supervisor before beginning a new or resuming an existing position. cc. Notify within two (2) days the NMP of any change in your supervisor, workplace monitor, or employment. dd. Abide by all policies, procedures, and contracts of employer. ee. Schedule at least monthly check-in meetings with supervisor for the purpose of addressing any concerns of either party. The documentation of the meetings shall be available to the NMP staff if requested. ff. Obtain approval by NMP before any position acceptance, job responsibility change, or other related employment activity. gg. Discontinue access to and administration of controlled substances or any potentially addictive medications for months after returning to work as outlined in your WSBN Settlement Agreement. You will not be allowed to sign out, witness, administer or call in prescriptions for controlled substances. hh. Notify the NMP within two (2) days if you had a disciplinary meeting or employment counseling with employer. ii. Notify the NMP within two (2) days of any changes in residency, contact information, and for any termination or resignation from employment jj. Report within twenty-four (24) hours any crimes committed, criminal arrests, citations, or deferred sentences, and convictions, including a conviction following a plea of nolo contendere. kk. Notify program if a complaint is filed against your license. ll. Report any and all alcohol or drug relapses, regardless of amount or route of administration. mm. Agree to re-assessment by a licensed addiction counselor in the event of relapse. nn. Abide by further recommendations in the event of a relapse, as deemed clinically appropriate. oo. Pay all fees and costs associated with being in the NMP. This includes, but is not limited to, all medical, counseling, prescription and drug screenings. You will also incur the cost of the Medical Review Officer to review positive drug test results to ensure medications are taken as prescribed. pp. Agree to read and abide by the terms and conditions of the program handbook or manual as well as any new policies or procedures received in writing throughout participation in the NMP. qq. Appear in person for all routinely scheduled interviews and any additional interviews with reasonable notice given by the NMP. rr. Inform the NMP verbally and in writing of a pending relocation out of the state. 5. In signing the contract, you agree that you understand the following: a. You have a substance use disorder.

4 b. Any noncompliance with this contract or unsuccessful termination from the program is unprofessional conduct, is in violation of the rules and laws regarding the practice of nursing, and will be used to support any future progressive disciplinary actions. c. Entry into the NMP is a result of a WSBN Board order for discipline or an open complaint for a substance use issue; there was an opportunity to seek advice of legal counsel or personal representative, and there was opportunity to clarify any terms or conditions which were not understood. d. The terms of the contract may be shared with parties who have an official need to know, such as other state boards, other state s alternative programs, and participant s employers. e. The contract does not preclude the program from initiating and/or taking appropriate action regarding any other misconduct not covered by the contract. Such action will result in notifying the DC. f. If you violate any single part, or parts, of the contract, the remaining parts remain valid and operative. g. Any unauthorized missed drug or alcohol testing will be considered noncompliance with the NMP and notification to the DC. h. Any confirmed positive drug screen may be considered noncompliance if the NMP has not received the proper documentation from the prescribing practitioner and will result in notification of the DC. i. Any drug screen that is confirmed as an adulterated or substituted specimen shall result in notification to the DC. j. Noncompliance with drug and alcohol testing will result in an increased level of testing and will result in a notification to the DC. k. In the event of any non-compliance with any of the terms of the contract in any respect, the NMP will notify the DC and the length and terms of this contract may be extended and modified as per the DC s recommendations. l. The DC will be notified of any non-compliance with the terms of the contract. m. You are required to provide a supervisor with a copy of the contract and any other necessary forms before beginning a new or resuming an existing position and agree to notify the program immediately of any change in supervision. Failure to comply will result in a notification of the DC for possible further disciplinary action. n. Random drug screening will be performed two (2) to three (3) times/month or as recommended by your mental health provider. After the first year, there may be a gradual decrease in the frequency of random drug screens for the duration of the contract depending upon compliance and recovery status. o. Drug and alcohol testing will be random. p. Drug and alcohol testing can be requested for cause at any time and within any timeframe. q. Drug testing will be observed. r. The DC will be notified of any report of substituting, diluting or adulterating specimens. s. A strict chain of custody will be followed (observed collection, specimen sealed and signed by participant nurse, collector and lab).

5 t. When indicated, a blood alcohol test or breathalyzer may be done as well as a urine drug screen. u. When indicated, a hair (from any area of the body) analysis drug test may be done in conjunction with urine tests. Hair testing will not be the sole means of testing. Drug and alcohol testing may include body fluid, hair, saliva or any other valid and reliable method of testing. v. You are responsible for payment of charges for the drug and alcohol testing. w. You are required to submit to drug and alcohol testing on the same business day or within two (2) hours for cause drug screen. x. Your Work Site Monitor must be your supervisor and/or licensed to practice nursing with at least your level of credentials (i.e. an LPN may not be a worksite monitor for an RN), whose license is unencumbered and is not a current participant in any alternative program. y. You are required to submit Self-reports to the NMP monthly. z. You are required to have periodic one-on-one visits with worksite monitor and/or supervisor. aa. During the first twelve (12) months of participation in the program you are restricted from working any of the following (or as designated by your Settlement Agreement): 1. Odd schedules-overtime, night shift, anything in excess of a twelve (12) hour shift. 2. No more than three consecutive 12-hour shifts. 3. Without direct supervision. 4. Full access to controlled substances. 5. Home Health or Hospice-type settings, travel, registry/agency, float or on-call (PRN) pool, tele-nursing and disaster relief nursing. 6. Any other unsupervised nursing position. bb. The WSBN NMP will obtain your prescription drug profile quarterly. cc. If relapse, diversion, or other violations of the work-related requirements occur, the NMP will notify the employer and generate a complaint to the Disciplinary Committee. dd. The NMP will continue to monitor you even after being referred to the Disciplinary Committee. ee. Any relapse is considered noncompliance and will result in a complaint to the Disciplinary Committee. Other conditions for monitoring as per your WSBN Settlement Agreement:

6 I have read, understand and agree to the terms of this monitoring agreement. Name (Printed) Date Signature