AFFLIATION PROCESS (Internship/Externship) PEACEHEALTH ST. JOHN MEDICAL CENTER LONGVIEW, WA

AFFLIATION PROCESS (Internship/Externship) PEACEHEALTH ST. JOHN MEDICAL CENTER LONGVIEW, WA

PEACEHEALTH STANDARDS FOR COMPLIANCE PeaceHealth Mission: At PeaceHealth, the fulfillment of our Mission is our shared purpose. It drives all that we are and all that we do. To those who embrace the spirit of these words and our commitment to Exceptional Medicine and Compassionate Care, we offer the opportunity to learn and grow as a member of the PeaceHealth family. This information has been developed to assist you with a process essential for ensuring that everyone accepted into PeaceHealth have met the necessary requirements. TABLE OF CONTENTS PAGE 1. Clinical Affiliation Agreement 1 2. Criminal Background Check a. Process 1-2 b. Matrix 2-3 c. Contact information to set up an account 3 3. Health Screen a. Process 3-4 b. Contact information to set up an account 3 4. Confidentiality Agreement a. Process 4 5. Orientation Manual a. Process 4 b. Test Answer Score Sheets 7-11 6. Liability Insurance 4 7. Confirmation of Standards Checklist a. Process 5 b. Checklist form 6 8. Curriculum 5 9. Badge 5

CLINICAL AFFILIATION AGREEMENT A Clinical Affiliation Agreement must be secured prior to an Intern/Extern s acceptance into PeaceHealth, St. John Medical Center. To coordinate the Agreement you will need to contact our Contract Management Department at (360) 414-2243. CRIMINAL BACKGROUND INVESTIGATIONS 1.a. A criminal background must be completed by the school for all individuals. If criminal background checks are not standard for your company, PeaceHealth can help connect you to the service currently being utilized. (Refer to 1.c.) Each category must be completed as follows: Cowlitz County/Washington State Investigation: This search provides felony and misdemeanor arrests/convictions located at the county of the state in which the charge was brought and tried. Examples of criminal records include theft, assault, robbery, drug possession and murder. State Investigation: Conduct a statewide record search for felony and misdemeanor convictions for all applicable state/county lived in for the past 7 years. Social Security Check: This search can determine the following crucial information (a) whether the Social Security Number (SSN) is validly issued (b) to whom does the SSN belong (c) in which year and state the SSN was issued (d) the current and other known or previous addresses to that SSN. The SSN Verification process can reveal that the number belongs to another individual, has more than one name associated therewith, produces other aliases, including maiden and divorced names, is associated with fraud, is not a validly issued SSN, belongs to a deceased person, produces additional addresses not stated by the application/request form, or has other SSN s associated with that individual. FACIS: The Fraud & Abuse Control Information System health care data repository reports on disciplinary actions and sanctions at all levels of government, including the Offices of Inspectors General, the Department of Justice, Medicaid Fraud Control Units, state health departments and other quality assurance agencies. Professional License/Drivers License/Certification (If applicable by position): A search of the State or national licensing board or agency to verify a license type, license number, status, original issue date and other available information. NOTE: When the tests are successfully completed, mark appropriate box on the Confirmation of Standards checklist 1.b. Page 1 Matrix: 1. Refer to Matrix for disqualifiers. If there is criminal activity equaling 30 or greater points or the activity is congruent with the essential function of the position, this person would not be acceptable for work. Example: (if a person has a criminal history of Theft/Larceny, we wouldn t have them in our Payroll department even though the points don t equal 30.)

MATRIX TYPE OF CRIME OCCURRENCE LESS THAN 3 YEAR AGO CONVICTION OCCURRENCE 3 OR MORE YEARS CONVICTION Abduction 20 20 *Abuse 30 30 *Abuse of Corpse 30 30 *Accessory to a crime 30 30 Alcohol Violation (Driving, Public Nuisance, Minor, Etc) 20 10 *Armed Robbery 30 30 *Arson 30 30 Assault/Battery 15 15 *Assault with intent to murder 30 30 Bad Check 10 5 Blocking a Medical Facility 20 20 *Breaking and Entering 30 30 *Bribery 30 30 *Burglary 30 20 *Child Prostitute 30 30 *Coercion or Intimidation 30 30 Controlled/Dangerous Substances (drugs) 20 20 Conveying false information and threats 20 20 *Credit Card Fraud 30 20 Cruelty to animals 20 20 Destruction of Property 20 20 Driving Unlawfully 30 30 *Embezzlement 30 30 *Escape 30 30 *Extortion 30 30 False Alarms 20 20 *Forgery/Counterfeiting 30 30 Gaming 20 20 Handgun Violations 20 20 *Harboring a Fugitive 30 30 *Harassment/Stalking 20 20 *Hate Crimes 30 30 *Incest 30 30 *Impersonation of Police Officer 30 30 Indecent Exposure 20 20 *Kidnapping 30 30 *Maiming 30 30 *Murder 30 30 Obscene Matter 20 20 *Obstruction of Justice 30 30 *Perjury 30 30 Page 2

*Poison 30 30 Prostitution 20 10 *Racketeering 30 30 *Rape or Sexual Abuse 30 30 Receiving Stolen Goods 20 10 *Robbery 30 30 Rogue/Vagabond 10 10 Theft/Larceny 20 20 Trespassing 10 10 Unlawful Possession, Use, Sale, Distribution, or manufacture of a Weapon 20 20 Welfare Fraud 20 20 Any conviction for an attempt, solicitation or conspiracy to commit any crime listed above is assigned the same value as a conviction for that crime. *A conviction for this crime(s) (if assigned a value of 30) is an absolute bar to the facility. 1.c. Criminal Background Company: As an agency affiliated with PeaceHealth we would like to offer you contact names to obtain the Criminal Background Checks and the Health Screens. If you choose to utilize these contacts you will have the opportunity to take advantage of our Corporate rates. (You are not required to use these contacts as long as the organizations that you utilize maintain our standards.) If you have any questions please call Intern Coordinator at (360) 414-7560. Kroll Background America, Inc 1900 Church St., Suite 400 Nashville, TN 37203 Contact Name: Raymond Jacobs 1-800-697-7189 x268 (Mention PeaceHealth Corporate rate to Raymond to receive our corporate discount.) HEALTH SCREEN REQUIREMENT Health screens may be conducted through our Workplace Wellness facility. You are not required to use our facility as long as the standard of compliance is met. If you would like to utilize our facility please call Workplace Wellness at 414-2324 to set up an appointment. A health screen must be completed prior to reporting to work to include: (If these standards have been completed as part of your requirements as an employer, retesting is not necessary as long as they meet PeaceHealth Standards.) NOTE: Tuberculosis test (TB) UA (Drug screen) - TEST MUST BE A NON-NIDA PERFORMED BY A CERTIFIED PROFESSIONAL COLLECTOR. Immunization background to be Measels, Mumps, Rubela, and Chicken Pox. The school must receive a copy of the results from the collection site. When the above requirements are successfully completed, check the appropriate box on the Confirmation of Standards checklist form. Page 3

CONFIDENTIALITY AGREEMENT A copy of the PeaceHealth Confidentiality Agreement has been provided in the orientation manual. The student must read and sign the confidentiality agreement. Keep this document in the student file at the school. NOTE: When the student has completed this requirement and returned the form to you, check the appropriate box on Confirmation of Standards checklist. ORIENTATION Each student must complete the Orientation Manual section. Testing is to be completed by the student. All tests must be completed and successfully passed, scoring keys have been included. Tests must be scored by the school personnel coordinating the internship placement. Keep a copy in the student file. NOTE: When the tests are successfully completed, mark appropriate box on the Confirmation of Standards checklist. LIABILITY INSURANCE The student must be covered by liability insurance prior to starting the intern/externship. Proof of Liability insurance must be met either by: Self insured (A copy of the insurance policy must be provided to PeaceHealth) School carries insurance (covered under contract) Amount of Insurance to be maintained for duration of Internship: Minimum of $1,000,000 per occurrence $3,000,000 in the aggregate NOTE: Check the appropriate box on Confirmation of Standards checklist. Page 4

CURRICULUM A copy of a Curriculum must be presented to the PeaceHealth department manager at time of starting the internship. This will help us meet the needs of the student. BADGE Students must bring their school pictured identification badge with them upon their first day. CONFIRMATION OF STANDARDS The Confirmation of Standards checklist indicates that all phases have been successfully completed maintaining PeaceHealth standards. Once the list is complete, the school needs to fax copy to PeaceHealth, Human Resources, fax # located on the Confirmation of Standards checklist. Page 5

CONFIRMATION OF STANDARDS CHECKLIST INTERN/EXTERN NAME OF SCHOOL: NAME OF STUDENT: meets the standard requirements for PeaceHealth. If at any time the contracted employees status changes, regarding any type of infraction, PeaceHealth will be notified immediately and termination could/will occur. These steps must be completed and standards are within compliance agreed upon by PeaceHealth and School prior to starting Internship. It is the responsibility of the school to process and maintain requirements PeaceHealth has requested. [] Criminal Background Check, refer to Matrix for standards. PeaceHealth must receive a copy from the school, via fax, of this document along with the Confirmation of Standards. [] State/County Investigation in which person has lived for the past 7 years []Washington State Investigation [] Social Security Check [] Professional License (If applicable) [] F.A.C.I.S. (to include MEDICARE FRAUD & ABUSE) [] Health Screen (Completed and results are favorable staying within PeaceHealth standards) [] Tuberculosis Test (TB) (Must have yearly test to maintain clearance, results must be reported to PeaceHealth) [] UA (Drug screen) (Will participate in our Drug Free Workplace Program) [] Immunization background [] Insurance Coverage (Please identify how the student is covered.) [] Self insured (A copy of the insurance policy must be provided to PeaceHealth) [] School carries insurance (covered under contract) [] Licensure/Certification (Washington State) (Must have evidence of valid licensure if required for internship.) [] Confidentiality Agreement (PeaceHealth, located in the Orientation Manual ) [] Orientation Manual (Must be successfully completed) [] Curriculum (A copy of the Student Curriculum must be presented to PeaceHealth) **Please return Confirmation of Standards checklist to PeaceHealth Representative so authorization can be given to begin Internship. (Attn: Michele Wagner phone #: 360-414-7560, Fax information to 360-578- 3348.) Representative Signature: Date PeaceHealth Rep.Signature: Date PeaceHealth Dept/Mngr Signature: Date Page 6

TEST ANSWER SCORE SHEETS Organizational Integrity Test Answers Instructions: Please complete the following quiz, sign, and return this document to your supervisor 1. At PeaceHealth, our Standard of Conduct is based on what? Answer: Mission and Values 2. In your own words, what does PeaceHealth's Non-retaliation/Non-retribution policy say? Answer: No action will be taken against me for asking questions regarding Integrity or reporting behaviors that are not in keeping with the Integrity policies of the organization. 3. What is the PeaceHealth Integrity Line? Answer: A contact service available 24 hours a day, 7 days a week that an employee can call to report concerns about actual or potential wrongdoing or ask for clarification regarding an Integrity issue. 4. True or False: The Office of the Inspector General could fine PeaceHealth for hiring or doing business with an individual or organization on the Excluded List. (Circle the right choice) TRUE 5. True or False: PeaceHealth's Organizational Integrity program covers only policies having to do with billing and confidentiality. (Circle the right choice) FALSE 6. True or False: You have a responsibility to report in good faith, concerns about actual or potential wrongdoing and are not permitted to overlook such situations (Circle the right choice) TRUE Page 7

Confidentiality Test & Acknowledgement Instructions: Please complete the following quiz, sign, and return to your supervisor. 1. Write down two examples of specific rights every patient has regarding his or her health information? Any of the following: Right to request access, inspect and copy health information Right to a Notice of PeaceHealth s Privacy Practices Right to request an amendment to their health information Right to request restrictions to the use and disclosure of their health information Right to an accounting of the disclosures made of their health information 2. What telephone # would you call to contact your Regional Privacy Officer? extension 2049 3. Where is the PeaceHealth Privacy and Security Policy Manual located? On the Crossroads Policy Center or on the Organizational Integrity website on Crossroads 4. Define the term minimum necessary as it relates to confidential information. Disclosure of confidential information should be limited to the minimum necessary to meet the need. A request for disclosure of the entire medical record must be justified. 5. Why is it important to identify and question unfamiliar individuals (that is, those who apparently don t belong) in your work area? For the safety of our patient and employees and for the protection of our confidential information. 6. Can a breach of confidentiality be grounds for termination? YES 7. If I overhear a conversation outside the clinical area regarding sensitive patient information, should I let the offenders know immediately that they are violating the confidentiality policy? YES 8. Should I access a medical record (other than my own) for any reason other than a work-related purpose (need-to-know)? NO Page 8

Safety Basics Test Instructions: Please complete the following quiz and return this document to your supervisor 1. In which of the following scenarios should you contact Infection Control? a. You suspect a patient has Influenza. b. You initiate airborne precautions for a suspected TB patient. c. Some you live with acquires Chickenpox. 2. Why is it important to notify Infection Control within 1-2 hours if you've had a blood borne pathogen exposure? HIV Infection may be prevented with appropriate medication if initiated within 1-2 hours of the time of injury. 3. How do you call a code? a. Dial 911 b. Dial 4199 and explain situation and location c. None of the above 4. A Trauma or Modified Trauma is announced when confirmed disaster victims begin arriving at the Emergency Department. a. True b. False 5. During a Disaster where do you check in for job assignment if you do not have patient care duties? a. Medical Library b. Health Education Center c. Department Manager 6. Define each step in the RACE procedure. R RESCUE A ALARM C CONTAIN E EXTINQUISH 7. What does the acronym PASS stand for when using a fire extinguisher? Pull, Aim, Squeeze, Sweep 8. A CODE is paged overhead to announce a fire or fire drill. Code Red Page 9

Safety Basics Test 9. Match the following codes with their definitions. F Code Orange C Code Gray H Code Red E Code Pink D Level I, II or III Internal Disaster G Code Purple B Code 6 A Code Blue A. cardiopulmonary arrest B. person out of control C. First Responders needed D. large chemical spill E. infant/child abduction F. bomb threat G. hostage/weapons threat H. fire 10. The Incident Report can only be found on-line. a. True b. False 11. Describe the steps to be followed if you discover an unsafe medical device? Immediately discontinue use of the equipment Save all equipment and packaging which may include lot numbers involved in the event Clearly mark the device and equipment as defective with a red tag Complete an electronic work order on Crossroads If immediate replacement is needed, contact customer service at 7480 12. What type of equipment should be sent to Maintenance for repair? Non-Clinical Equipment 13. When should switchboard be notified in the event of a hazardous spill? c. If it cannot be cleaned up by the department 14. Name one location where you can find a spill kit. In Your Department 15. Where can you find information about a chemical? a. MSDS b. Container label c. Safety office d. All of the above Page 10

Safety Basics Test 16. Workplace violence can be defined as any behavior that you perceive as threatening. a. True b. False 17. Signs of anxiety are usually displayed before signs of aggression. a. True b. False 18. You ve tried a combination of different interventions in an attempt to calm an anxious client. However, the client is becoming more and more frustrated and starts using loud, threatening language. What should be your very first action? a. Try another attempt at using the interventions for dealing with anxiety b. Establish proper space (at least 4 feet between yourself and the aggressor) c. Call Security or 911 Page 11