INSTRUCTIONS FOR SCHOOL PLACEMENT PROCESS (Internship/Externship) PEACEHEALTH ST. JOHN MEDICAL CENTER LONGVIEW, WA 2
Requesting School Directions 1. Request for student placement made to St. John Learning and Development Department. 2. Start on the preplacement requirements below. 3. Fax this completed form, and only items 2 & 3, as directed below. Deadlines for Requests / Placements 1. More than one month prior to date of requested placement. 2. 1 month prior to date of requested placement 3. 2 weeks prior to date of requested placement If these items are not received by this date, it will be an automatic 2 week delay in their placement. 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 of this along with the background check and class curriculum to 360.636-4138. CLINICAL AFFILIATION AGREEMENT A Clinical Affiliation Agreement must be secured prior to an Intern/Extern s acceptance into PeaceHealth, St. John Medical Center. This process should begin one month prior to the anticipated start date. To coordinate the Agreement you will need to contact our Contract Management Department at (360) 414-2243. The student must be covered by liability insurance prior to starting the intern/externship. Proof of Liability insurance must be met. 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. 3 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, please refer to 1.c. for a partial list of companies who provide this service. Each category must be completed as follows: State and County Investigation: Conduct a state and county wide record search for felony and misdemeanor convictions for all applicable state/county lived in for the past 7 years. This is defined to mean a separate search for EACH and EVERY State and EACH and EVERY County in which person has lived for the past 7 years
Example: Student has lived in Portland, OR and Vancouver, WA in the last 7 years Response: Check should show 4 DIFFERENT searches - OR state, WA state, Multnomah county, and Clark county Washington State Investigation (Must be done even if the student has never resided in the state of Washington): 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/OIG: 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. When the above requirements are successfully completed, check the appropriate box on the Confirmation of Standards checklist form and save a copy to send to PeaceHealth. 1.b. 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 Please note that this list is not all inclusive, if you have questions please call 360-414-7560 OCCURRENCE LESS THAN 3 YEARs CONVICTION OCCURRENCE 3 OR MORE YEARS CONVICTION TYPE OF CRIME 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 4
*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 *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. 5
1.c. Background Check Companies, Pricing and Contact Information: As an agency affiliated with PeaceHealth we would like to offer you contact names to obtain the Criminal Background Checks. (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. Please note that the school must set up an account with them for the students to perform their checks. certifiedbackground.com $36.00 $70+ (Dependent on the number of state and counties they have lived) Mark Gorges Castle Branch, Inc. 888.723.4263 x7244 Fax: 910.772.1528 validityscreening.com $35.50 Academic Omni - Standard Jennifer Rieken Business Development Manager Validity Screening Solutions Direct: 913.322.5960 Fax: 913.322.5901 acxiom.com Pricing varies based on volume hireright.com Call for pricing. Anthony Gildone National Client Representative (Phone) 216-615-7613 (Email) Anthony.Gildone@acxiom.com HireRight Sales Team HireRight, Inc. 1-949-794-5426 Option #4 When the above requirements are successfully completed, check the appropriate box on the Confirmation of Standards checklist form and save a copy to send to PeaceHealth. 6
7 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. When the above requirements are successfully completed, check the appropriate box on the Confirmation of Standards checklist form and save a copy to send to PeaceHealth. 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 clinical area which includes: Tuberculosis test (TB) UA (12 Panel Drug screen) Must be a NON-NIDA, performed by a certified professional collector Immunization background to be Measles, Mumps, Rubella, and Chicken Pox. (If the above requirements were completed upon entry to school, retesting is not necessary as long as they meet PeaceHealth Standards and were completed within the past two years.) The school must receive a copy of the results from the collection site and maintain in the student file. When the above requirements are successfully completed, check the appropriate box on the Confirmation of Standards checklist form. Do not send to PeaceHealth CONFIDENTIALITY AGREEMENT A copy of the PeaceHealth Confidentiality Agreement has been provided on pages 37-38 in the Student Experience Orientation Information manual. The student must read and sign the confidentiality agreement. Maintain in student file. When the student has completed this requirement and returned the form to you, check the appropriate box on Confirmation of Standards checklist. Do not send to PeaceHealth ORIENTATION Each student must read the Student Experience Orientation Information located online. The student is responsible for the content within the orientation manual. When the student has validated that they have read the Student Experience Orientation Information, check the appropriate box on the Confirmation of Standards checklist. Do not send to PeaceHealth BADGE Students must bring their school pictured identification badge with them upon their first day. Upon completion of required documentation, a PeaceHealth representative will submit a badge request. Prior to reporting to assigned
clinical area, student must pick up PeaceHealth student badge from Human Resources (brick building across from the Cancer Center.) Q. What do I need to submit to PeaceHealth? FREQUENTLY ASKED QUESTIONS A. A completed and signed copy of the Confirmation of Standards, a copy of the class curriculum and a copy of the criminal background check. The background check must show the following information or a new background check will need to be obtained. 1. Social Security check which verifies that the number matches that person and which shows a residence history. 2. Conduct a state and county wide record search for felony and misdemeanor convictions for all applicable state/county lived in for the past 7 years. This is defined to mean a separate search for EACH and EVERY State and EACH and EVERY County in which person has lived for the past 7 years Example: Student has lived in Portland, OR and Vancouver, WA in the last 7 years Response: Check should show 4 DIFFERENT searches - OR state, WA state, Multnomah county, and Clark county 3. A Washington state search even if they have never lived in Washington. All other documents are to be kept in their student file at your school, available to us upon request. Q. Do we have to rerun the background check and health screen if one was done upon their entry to our program? A. No, if it was done to the specifications we require, then you do not have to get an updated check. Q. Can I have the student give any of the required items to PeaceHealth? A. No, we require that all required documents are submitted by the school. By signing the Confirmation of Standards, the school is verifying that all PeaceHealth requirements have been met and that the necessary documentation resides in the student files (available to PeaceHealth upon request). Q. What if they have never been to Washington State, do I have to get a Washington State check? A. Yes PeaceHealth requires Washington State check including a check done on every county and state that they have lived in. Q. Where can I get a background check? A. Please see page 5 for section 1.c. Background Check Companies, Pricing and Contact Information Q. How long does the background check take? 8
A. It can take anywhere from 24-72+ hours depending on the number of places they have lived over the past 7 years. Q. How expensive is the background check? A. Please see page 5 for section 1.c. Background Check Companies, Pricing and Contact Information Q. How long does the placement process take? A. If there is no Affiliation Agreement in place between PeaceHealth and your school it can take upwards of a month from start to finish. Even with an agreement in place we ask that all student placement requests be submitted no earlier than a month before the anticipated start date. If you have any questions that were not addressed above please call 360.636.4130 9