POLICY TITLE: Non-Facility Personnel File, Orientation, Evaluation & Check-In Requirements (Centura) DEPARTMENT: Human Resources ORIGINATION DATE: 04/01/2011 CATEGORY: Employment-Recruitment EFFECTIVE DATE: 09/17/2012 SCOPE This policy applies to all contract staff providing services to a Centura Health (Centura) hospital. It does not apply to contract staff who enter patient care areas that are escorted by hospital staff, contract staff that enter employee designated areas only, and Shared Services as defined below. This policy also does not apply to facility medical staff, allied health professionals or non-employees brought in by Licensed Independent Practitioners (LIP). Refer to Medical Staff policies and procedures for expectations regarding physicians, LIPs, and residents. PURPOSE 1. To be compliant with regulatory mandates regarding contract staff. 2. To ensure that the level of care provided by and requirements for on-site contract staff entering patient care areas is consistent with that provided by and required of employed staff. 3. To provide guidance for determining pre-employment, Occupational Health screening, orientation, and other requirements by contracted parties doing business at a Centura hospital. 4. To establish the role of the facility managers and administrators who are responsible to ensure delivery of safe, effective and efficient care, treatment and services delivered by non-facility personnel. 5. To ensure contract staff entering patient care areas sign-in prior to performing work functions. STATEMENT OF POLICY Compliance 1. This policy is intended to meet regulatory mandates which will result in safe and competent contract staff. This policy does not pertain to patients, visitors, and their families, including clergy and friends of patients. 2. Contract staff with access to patient care areas will be required to have criminal background checks and comply with Occupational Health screening requirements. 3. Category 1 and 2 contract staff have the following requirements: a. Personnel files will be maintained on the facility site and will contain a job description or attestation acknowledging review of the relevant Centura job description, evidence of facility and department-specific orientation, ongoing and competencies, current licensure/ certification, Occupational Health screening summary, and evaluation. The contract staff organization will provide proof of criminal background check, Occupational Health screening and primary source verification of licensure upon request. b. Category 1 and Category 2 contract staff requiring licensure and/or certification must be primary source verified by the contract staff organization. c. Category 1 contract staff will be evaluated at least annually by facility personnel. Category 2 contract staff will be evaluated at least annually by managers of the outsourced services. d. Receive orientation to facility and department worked (requirements in Attachment A). Non-Facility Personnel File, Orientation, Evaluation & Check-In Requirements (Centura) Page 1 of 6
4. Category 3 and 4 contract staff with access to patient care areas will receive and acknowledge information regarding safety, infection prevention and control, patient rights and responsibilities, and HIPAA. The contract staff organization will provide proof of criminal background checks and proof of initial and ongoing Occupational Health screening requirements upon request. 5. Non-employees who have an individual contract with a Centura entity (regardless of which category of contract staff) will have included as part of their contract a requirement that they either provide proof of influenza vaccination or a valid for each year that the person has a contract with the Centura entity. Non-employees with individual contracts must provide the Human Resources office of the contracted entity with documentation of annual influenza vaccination, date of vaccination and provider where the vaccine was administered or proof of. Badging/Reporting/Sign-In 1. Category 1 contract staff will report directly to the staffing office or department responsible for contract staff to sign in and obtain a facility badge per the Identification Badge policy. 2. Category 2 contract staff will obtain facility-issued badges when they are initially on-boarded. Category 2 contract staff are not required to check in and out daily. Outsourced services management must keep worked time records of all Category 2 contract staff. 3. Category 3 contract staff will, upon initial visit and annually thereafter, submit the non-facility personnel attestation form to Human Resources. Upon receipt of this form, Human Resources will issue a facility contractor badge with expiration date. Category 3 contract staff will report as follows: a. Discharge coordinators (LTAC/SNF/AL/Rehab/Psych) and insurance liaisons to the facility case management department or other designated department as determined by facility. b. Contracted through the Supply Chain Management department (e.g., baby photographers, prosthetic device providers, etc.) to the Vendor Management kiosk. c. All others will report to Human Resources or other designated department as determined by facility. 4. Category 4 contract staff contracted through the Supply Chain Management department will report in and out daily utilizing the Vendor Management kiosk and obtain a daily temporary ID badge. 5. Category 4 contract staff providing construction and facilities maintenance service will, upon initial visit and annually thereafter, submit the non-facility personnel attestation form to Human Resources. Upon receipt of this form, Human Resources will issue a facility contractor badge with expiration date. Category 4 contract staff providing construction and facilities maintenance services will check in and out daily in the facilities department. 6. All Centura associates are responsible to verify that contract staff are wearing a badge. Any contract staff without badges will be escorted to Human Resources, the staffing office, or other designated area. PROCEDURE 1. Attachment A outlines expectations for contract staff doing business with a Centura hospital. The description and characteristics in the attachment outline expectations for contract staff providing direct patient care, outsourced services, indirect patient care, or acting as a service representative. Examples are given to provide clarity, but do not represent an all-inclusive list of applicable groups. 2. These expectations reflect minimum requirements. Additional requirements specific to the area of services may also apply. Non-Facility Personnel File, Orientation, Evaluation & Check-In Requirements (Centura) Page 2 of 6
3. Centura Floats: Each facility where a Centura associate floats to must have the following: a. Acknowledgement of facility job description where they are floating to; b. Periodic facility-specific evaluations; c. Department-based orientation (note: excludes hospital-based orientation since this is completed at primary employment location); and d. Personnel file with all of the required items is maintained by their primary employment location within Centura. This information will be available upon request by any area to which this associate floats. 4. The Vendor Management badging system should not be used by any contracted staff member who is not registered with the Vendor Management company. DEFINITIONS 1. Contract Staff: Individuals or entities providing services independently under a contract, agreement, or as authorized by the organization, to supplement or complement care, treatment and services provided by Centura facilities. 2. Category 1 (Clinical Direct Patient Care): Contract staff assigned to patient care where contact with patients may range from minimal to full care. These contract staff have access to personally identifiable health information and report to nursing or other clinical department for assigned care, treatment or service. 3. Category 2 (Outsourced Services): Contract staff assigned to services that would normally be a function of a Centura hospital, but the hospital has chosen to provide that function through an external company. These contract staff may serve in functions that include, but are not limited to, services such nutrition services, environmental services and/or physical medicine. 4. Category 3 (Clinical Indirect Patient Care): Contract staff not assigned to patient care, though have minimal patient care contact and may perform interviews or limited assessments for screening, discharge coordination, or measurements. These contact staff may have access to personally identifiable health information and are not consistently escorted in patient care areas. 5. Category 4 (Service Representative): Contract staff providing non-patient care services, including vendor, supplier, delivery, disposal, construction, facility maintenance, and transportation services. These contract staff may interact with staff regarding patient care, but do not interact with patients unless supervised. 6. Facility Contractor Badge with Expiration Date: A contractor-specified picture identification badge issued through the Centura facility Human Resources department or other designated department containing an expiration date (DD/MM/YYYY) indicating that the contracted staff personnel has presented a non-facility personnel attestation form, attesting that the person has met all the requirements per this policy, and is eligible to work in the facility for up to a year, per their contract. 7. Patient Care Areas: Include but are not limited to patients rooms, patient hallways, stairways, patient waiting areas, operating rooms, therapy rooms, nurses stations, areas where patients receive treatment and/or diagnostics such as x-ray and therapy areas. This does not normally include areas such as associate lounges/break rooms and vending areas. 8. Safety Training: Includes fire and electrical safety (RACE, PASS, evacuation, facility safety codes). 9. Infection Prevention and Control Training: Includes infection transmission, hand hygiene, and isolation precautions. 10. Occupational Health Screening: Upon initial contract work, proof of MMR and chickenpox immunity or vaccinations and proof of drug screen (7 panel plus synthetics), plus proof of Hepatitis B immunity Non-Facility Personnel File, Orientation, Evaluation & Check-In Requirements (Centura) Page 3 of 6
or vaccinations for Category 1 non-facility personnel. Upon initial contract work and ongoing, proof of annual influenza vaccination or valid by December 15 and TB skin test every 2 years. 11. Criminal Background Checks: At a minimum includes criminal background check (minimum 3 years), Office of Inspector General and Excluded Parties List System. 12. Centura Floats: Centura associates who float to a Centura facility that is not considered their primary work location. 13. Shared Services: Centura associates who provide services and assistance to a variety of Centura facilities. These may be corporate associates or associates hired specifically to be shared amongst more than one Centura facility. These associates will have their personnel file with all of the required items maintained by their primary employment location within Centura. REFERENCES AND SOURCES OF EVIDENCE 1. June 2009, CMS Governing Body Condition of Participation 482.12. 2. Identification Badges (Centura) 3. Centura Health Oversight of Contracted Services Patient Care Areas Policy & Procedure 4. The 2011 Joint Commission Leadership Standards 5. Influenza Vaccination (Centura) POLICY VIOLATION Any Centura associate or contract staff who fails to abide by this policy may be subject to disciplinary action, up to and including termination. REVIEW/APPROVAL SUMMARY REVIEW/REVISION DATES: 09/15/2012 (Dates in parentheses include review but no revision) APPROVAL BODY(IES): Senior Executive Council APPROVAL DATE: 09/17/2012 Non-Facility Personnel File, Orientation, Evaluation & Check-In Requirements (Centura) Page 4 of 6
Category 1: Clinical Direct Patient Care Category 2: Outsourced Services ATTACHMENT A CATEGORIES, EXAMPLES & REQUIREMENTS OF CONTRACT STAFF DOING BUSINESS WITH A CENTURA HEALTH HOSPITAL Category 3: Clinical Indirect Patient Care Category 4: Service Representatives, Construction/ Facilities Examples: Examples: Examples: Agency (RN, RT, etc.) In Person Interpretive Services Paper shredder disposal Travelers Fitting for prosthetics/braces Sharps container disposal Regional Float Pool Newborn photos External Biomed Techs/Reps Dialysis Discharge Coordinators Transportation services (LTAC/SNF/AL/Rehab/Psych) Centura Float Hearing screens Hazardous waste removal services Mobile Imaging Services Insurance Liaisons Construction and construction project management entering patient care areas Contracted Sitters Psych Evaluators Contracted Housekeeping entering patient care areas Contracted Nutrition Services entering patient care areas Infection Prevention & Control Contracted Security Outsourced Services (i.e., Sodexo and Therex not all inclusive list) Behavioral Security Technicians Not applicable: Non-employees brought in by LIPs and any Clinical-Indirect or Service Representatives that are escorted by facility personnel when in patient care areas. Requirements: Requirements: Requirements: Pre-employment verification Criminal background available on request Criminal background available on request Criminal background available upon request (not kept at facility) Current licensure and certifications Acknowledgement of facility job description (might also be part of orientation) Occupational health screening available on request Individuals with contracts must provide HR with documentation of annual influenza vaccination, date of vaccination and provider where the vaccine was administered or proof of Must sign into HR or other designated area to obtain badge and to return badge at Occupational health screening available on request Premier Supply Chain vendors sign in via RepTrax to obtain badge Facility department vendors sign in via Facilities department and provide attestation of Non-Facility Personnel File, Orientation, Evaluation & Check-In Requirements (Centura) Page 5 of 6
Occupational health screening summary form Individuals with contracts must provide HR with documentation of annual influenza vaccination, date of vaccination and provider where the vaccine was administered or proof of Facility/dept orientation to minimally include --Safety --Infection Prevention & Control --HIPAA --Cultural diversity & sensitivity --Occurrence reporting Performance evaluation by facility or outsourced services management at least annually Facility-issued badge Daily sign-in and out and return badge (except outsourced services) Any contracted clinical nursing provider engaged through contracts overseen by MedAssets follows the Prosource process, and above file information is available electronically end of visit Signed Non-Facility Personnel Attestation Upon initial visit must have documented: --Safety --Infection Prevention & Control --HIPAA --Patient rights & responsibilities compliance via signed Non- Facility Personnel Attestation Premier Supply Chain vendors must provide RepTrax with documentation of annual influenza vaccination and date of vaccination or proof of Facility department vendors or individuals with contracts must provide HR with documentation of annual influenza vaccination, date of vaccination, & provider where the vaccine was administered or proof of Upon initial visit must have documented: --Safety --Infection Prevention & Control --HIPAA --Patient rights & responsibilities Non-Facility Personnel File, Orientation, Evaluation & Check-In Requirements (Centura) Page 6 of 6