NORTH CAROLINA BOARD OF NURSING INTERVENTION PROGRAM (IP) CONTRACT

Transcription

1 NORTH CAROLINA BOARD OF NURSING INTERVENTION PROGRAM (IP) CONTRACT This Contract is made and executed by and between the licensed registered or practical nurse (the Licensee ) identified below, and the Intervention Program (the Program ) of the North Carolina Board of Nursing (the Board ). The Licensee,, RN/LPN, State of Licensure holding certificate number(s) admits that his/her license/privilege to practice nursing is subject to formal investigation and administrative prosecution pursuant to the North Carolina Nursing Practice Act and freely and voluntarily admits the following facts to be true: He/she has tested positive for an illicit drug Or He/she has been convicted of a DWI with one or more grossly aggravating factors. Preamble In its mission to protect the health and wellbeing of the public, the Board is mandated by state legislation and the North Carolina Nursing Practice Act to intervene when the Board determines a Licensee [ ] uses any drug to a degree that interferes with his or her fitness to practice nursing [N.C.G.S (3)]; and/or engages in conduct that endangers public health [N.C.G.S (4)]. The Licensee has been advised that he/she may decline participation in the Program. In that event, the following will occur: a. The Board shall initiate a formal investigation and upon a finding of a violation of the North Carolina Nursing Practice Act, the Board has the authority to issue a Letter of Charges imposing sanctions on the license. The Licensee has the right to contest the sanctions, be represented by an attorney and request a settlement or an administrative hearing. OR b. The Licensee may choose to voluntarily surrender the license to practice nursing for a minimum of one (1) year. After a period of one (1) year, the Licensee may petition the Board for reinstatement, at which time the Licensee may have sanctions or restrictions imposed if the license is reinstated. This and subsequent action is public information and is considered disciplinary action. Having been advised by the Board of violations of N.C.G.S (3) and N.C.G.S (4) and the right to have an Administrative Hearing in accordance with N.C.G.S. 150B, Licensee does hereby voluntarily waive the right to an administrative hearing. In consideration of the Board s deferring any disciplinary action, Licensee knowingly and voluntarily agrees to participate in the Program and consents to the following terms and conditions as outlined below and explained to Licensee by (Name and Title) on (Date). Status of License Licensee shall maintain an active licensure status and/or privilege to practice in accordance with the Interstate Compact for Nurse Licensure. 1

2 Privacy and Confidentiality Privacy is respected; however, confidentiality is not assured. Licensee shall sign Authorization for Disclosure and Exchange of Information for employers and healthcare providers to provide pertinent information to the Program and to discuss issues relating to the Licensee s program participation and nursing practice. Licensee understands as long as he/she participates in the Program and compliance is maintained, the Licensee s name will not be published on the Board s website; however privacy is maintained unless disclosure is necessary to protect the health, safety, and welfare of the public or as ordered by a court of competent jurisdiction, or pursuant to a valid subpoena. Should disclosure become necessary, whenever feasible, the Board will notify the Licensee. This document and all information regarding the Licensee s participation in the Program will be shared with other jurisdictions should the Licensee seek endorsement or renewal/reinstatement of license(s). Drug Screening Register with FirstLab, the drug screening company for the Board, within three (3) business days of signing the Contract ( ). Check into the FirstLab System Monday through Friday, 5:00 a.m. to 3:00 p.m. (including holidays). Screen as requested by the Program, FirstLab and/or employer. Submit to random observed screens (to include urine, body fluids, breathalyzer or hair) as requested for analysis following a chain of custody protocol for the duration of participation in the Program. Collection method shall be determined by the Program, FirstLab and/or employer. Comply with policies related to screening process, assume financial responsibility for random body fluid screens and remain current with fees due. Notify the Program via telephone and in writing within twenty-four (24) hours if he/she fails to screen when selected by FirstLab. Continue to drug screen, regardless of employment status, until notified of successful completion of the Program. Not work in any capacity in the healthcare setting if a drug screen tests positive until further testing or investigation is completed. Documentation of Medications Report all prescription medications to the Board and FirstLab for the duration of the Program on a Prescription Identification Form (the Form ). Provide all prescribing licensed practitioners with the Form for completion, every time a new prescription is written, change in dose of an existing prescription is made or samples are provided. File the completed Form documenting all existing prescriptions within ten (10) business days of signing the Contract. File the completed Form documenting any prescription received while monitored within five (5) business days of receipt (whether or not the prescription was filled, consumed or wasted). File an updated Form for all prn controlled or monitored substances (including Ultram and Fioricet) every six (6) months. Report use of OTC antihistamine, decongestant and cough syrup to the Board within seventy-two (72) hours of the first dose, in writing. 2

3 Abstinence from Chemical and Alcohol Substances Licensee acknowledges that some prescription and Over-the-Counter (OTC) drugs may cause a positive drug screen result. It is the Licensee s responsibility to assure that any medication taken will not affect test results. Monitoring Coordinator will address any concerns regarding appropriateness of prescription or OTC medications as they relate to Licensee s participation in the Program. Licensee agrees: To completely abstain from any mood altering chemicals (alcohol, sedatives, stimulants, etc.) unless prescribed for the Licensee for a medical condition by a licensed practitioner. This includes expired and/or outdated prescriptions; He/She shall not self prescribe any medication, including drug company samples; To read all labels on OTC medications prior to consumption to assure the products are alcohol free and safe for use; That accidental consumption of poppy seeds or use of alcohol including communion wine, near beer, alcohol of any kind in foods, OTC medications, use of products containing alcohol (e.g. mouthwash, vanilla extract, hand cleaning gel, and topical medications or gels used on skin or mucous membranes, etc.) may cause a positive drug screen which cannot be differentiated from intentional ingestion/use. If this occurs, Licensee understands that use of these medications and/or products cannot be used as a defense for a positive drug screen and shall be considered a violation of this Contract; and That any drug screen determined to be dilute cannot be treated as a negative drug screen. Nursing Employment In order to successfully complete the Program, Licensee must be employed in nursing for a minimum of one (1) year and the Board must receive four (4) satisfactory quarterly Work Performance Evaluations completed by the supervisor. 1. Notify the employer of participation in the Program by sharing a copy of the Program contract, in full, with the supervisor. 2. Notify the Board of: a. New employment by filing the Notification of Employment Form within five (5) business days of beginning employment/orientation. b. Current employment by filing the Notification of Employment Form within five (5) business days of signing the Contract (Due: ) c. Any change in employment, including new employment or probation, suspension, termination and/or resignation from employment within five (5) business days. d. Any change in supervision within five (5) business days. 3. Submit quarterly Work Performance Evaluations to the Board from all nursing employers, completed by the RN supervisor or, with approval, a work monitor who is a licensed health care provider. To be acceptable, the evaluations must show three (3) consecutive months of employment in the same facility, a minimum of sixty-four (64) hours worked per month. 4. If employed in more than one nursing position, Licensee shall identify one position as primary employment, providing the required minimum monthly hours. 3

4 Additional Program Conditions 1. Not violate the Nursing Practice Act or any rules promulgated by the Board. 2. Continue to perform duties in a safe and competent manner, satisfactory to the Board. 3. Comply with the terms and conditions of the Program established by the Board, and cooperate with representatives of the Board in the monitoring and investigation of compliance with the Program. 4. Appear in person at interviews/meetings as directed by the Board during the period of monitoring. 5. Notify the Board, in writing, within five (5) days of any change in name, address or phone number. 6. Notify the Board, in writing, within five (5) days of any DWI/DUI, misdemeanor and/or felony charges. Following final disposition of the charges, notify the Board, in writing, within three (3) days of the outcome. 7. Submit Probation Reports completed by the probation officer if on or placed on supervised court probation related to the reason for entering the Program. If the period of probation extends beyond the date of the fourth quarterly Work Performance Evaluation due, Licensee will continue to be monitored; however Licensee may stop drug screening and no further Work Performance Evaluations will be due. Licensee may not complete the Program until supervised court probation is successfully terminated. 8. Notify the Monitoring Coordinator of the following: Hospitalization for any reason, including urgent care and emergency department settings; Surgery scheduled on an inpatient or outpatient basis including urgent care and emergency department settings; and Planned travel. 9. Provide the Monitoring Coordinator with copies of medical records following surgery (inpatient/outpatient), hospitalization, urgent care and emergency department visits. Termination of Program Participation and Discipline Action Participation in the Program may be terminated and the license/privilege to practice suspended for a minimum of one (1) year based on noncompliance including but not limited to the following: Licensee requests to withdraw from the Program. Licensee fails to begin drug screening as required. Licensee fails to comply with drug screening policies and procedures. Licensee submits a positive drug screen. Suspension of the license is public, discipline information. Licensee will be required to petition for reinstatement of the license/privilege to practice before the Licensure Review Panel (LRP) after submitting evidence of one (1) year of no failed drug screens with FirstLab. This and subsequent action is public information. If Licensee is on or placed on supervised court probation unrelated to reason for entering Program, case may be transferred to Manager of Discipline Proceedings for whatever action is deemed appropriate. This may result in the transferring of participation into a published disciplinary program. 4

5 Disciplinary action taken by the Board shall be reported to the appropriate entities as outlined in Board policy and as required by State and/or Federal guidelines. Those entities include but are not limited to: Nursing license database (NURSYS); National Practitioner Databank (NPDB); Office of Inspector General (OIG); and Any other state/jurisdiction in which it is known the Licensee is or has been licensed. Licensee fully understands and agrees, that if suspended, Licensee shall not practice nursing in North Carolina during the time license/privilege to practice is held by the Board; and in turn, the Board agrees to consider Licensee s petition for review of licensure status at some point in the future. It is the Licensee s responsibility to contact the Program if the Licensee has any questions concerning this Contract. I,_ voluntarily agree to participate in the Intervention Program of the North Carolina Board of Nursing and by signature (below) agree to adhere to this Contract. I understand that this Contract is effective immediately upon signature. I hereby consent and authorize that Board staff be permitted to examine and obtain copies of all medical records relating to medical treatment. For purposes of this document, medical records include all documents within the file(s) pertaining to me and my diagnosis, examination, patient and progress notes. I further consent and authorize that Board staff to be permitted to confer with my health care professionals, and to interview them about their knowledge of my medical history and how it relates to my participation in the Intervention Program. Licensee hereby agrees that in accordance with the Interstate Compact for Nurse licensure, Licensee shall NOT engage in the practice of nursing in any other party state while participating in the Intervention Program without PRIOR WRITTEN AUTHORIZATION from the North Carolina Board of Nursing AND the other party state. Licensee SHALL provide evidence of such authorization from the other party state to the North Carolina Board of Nursing. Signature of Licensee Signature of Board Staff Date Date Revised 8/7/08, 1/18/11, 2/1/11, 2/6/13, 3/4/14 5