Policy. Page 1 of 8. Applies To: UNMH Responsible Department: Human Resources Revised: 3/2017

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1 Applies To: UNMH Responsible Department: Human Resources Revised: 3/2017 Policy Patient Age Group: (X) N/A ( ) All Ages ( ) Newborns ( ) Pediatric ( ) Adult 1. POLICY STATEMENT It is the policy of University of New Mexico Hospitals (UNMH) to establish and maintain a drug and alcohol free workplace. UNMH does not permit employees who use illegal drugs or who are impaired by any legal or illegal drugs or alcohol to place patients, visitors, themselves and co-workers at risk for injury, or UNMH property at risk for damage. Employees must be physically and mentally able to perform their assigned duties in a safe and efficient manner when they report to work and must maintain that ability throughout their shift. Any use of illegal drugs, the use of alcohol during work hours, and working while impaired by any legal or illegal drugs or alcohol are all violations of this policy. Possession of alcohol, illegal drugs, or possession of prescription drugs for reasons other than legally prescribed are also violations of this policy. (The giving or receipt of alcohol as a gift shall not be a violation of this policy provided such gifts remain unopened at work.) Pursuant to the requirements of the Drug-Free Workplace Act, any employee engaged in the performance of work under an applicable federal contract or grant shall notify his/her supervisor of any criminal drug statute conviction for a violation occurring in the workplace no later than five (5) days after such conviction. UNMH is committed to helping employees resolve alcohol and drug use problems by facilitating professional assistance through the Employee Assistance Program. Employees who have successfully recovered from alcohol/drug dependence may be permitted to work at UNMH subject to continued abstinence, acceptable work performance and work location. Further, UNMH may test employees post-accident and post-rehabilitation. 2. DETAILED POLICY STATEMENT This policy is intended to ensure the delivery of safe and effective patient care services and efficient management of UNMH. The institution is obligated by The Joint Commission (TJC) and state and federal laws and regulations to maintain a drug-free workplace. To accomplish this objective, it is necessary to ensure that all UNMH employees refrain from using illegal drugs and perform their assigned duties without impairment caused by the use of alcohol or other legal or illegal drugs. This policy has two purposes: 2.1 To provide a consistent procedure to protect patients, visitors, and employees from the potential risks created by employees who use drugs, whose ability to perform is Page 1 of 8

2 impaired by drugs or alcohol and/or who illegally procure drugs from the hospital for distribution or personal use; 2.2 To encourage employees to seek treatment or assistance through the Employee Assistance Program, medical or other community resources. 3. APPLICABILITY Everybody employed by UNM Hospitals. For employees who are required to possess a Commercial Driver s License, the provisions of this policy shall apply except to the extent superseded by governing U.S. Department of Transportation regulations. 4. POLICY AUTHORITY UNM Hospitals CEO and Administrator Human Resources authorize this policy. 5. REFERENCES 130 Discipline 147 Drug and Alcohol Testing - Pre-Employment 177 Felony Charges Reporting 378 Vehicle Use 6. IMPLEMENTATION PROCEDURES 6.1 Reasonable Suspicion or Cause The supervisor should proceed as described in this Section 6.1 if: (1) the supervisor believes or suspects that an employee is using drugs, alcohol, and/or their ability to perform assigned job duties is impaired; (2) the supervisor believes or suspects that an employee diverted drugs from a patient or from UNMH property; (3) the employee is involved in an accident with an official UNMH vehicle, as set forth in HR 378 Vehicle Use; or (4) drugs are missing from a workplace and cannot be accounted for. NOTE: This procedure should be treated as an investigation of possible employee misconduct. If a represented employee believes that disciplinary action may result from this assessment, the employee is entitled to request union representation during these investigatory procedures. However, the investigation will not be unduly delayed while waiting for the union representative NON-IMMEDIATE: In the event that an employee s conduct raises general, non-immediate concerns that the employee s physical or mental health may be compromised by the use of alcohol or drugs, but no physical signs of impairment are evident and no immediate detriment to the employee s job performance is demonstrated, the Administrator of Human Resources or designee shall be contacted for approval before the employee is referred to the Employee Assistance Program for assessment. Examples of employee conduct that may trigger this type of referral include change in attendance Page 2 of 8

3 pattern, change in relationship with supervisor or coworkers, change in employee s attitude or demeanor, etc. Such referral may trigger drug and alcohol testing IMMEDIATE: In the event an employee s conduct or demeanor raises immediate concerns that the employee may be using drugs, alcohol, and/or the employee s ability to perform their assigned duties is impaired, the supervisor will assess the employee s condition by observation: e.g., cognitive level, dexterity, breath odor, pupils, speech (quality and tone), demeanor (argumentative, hostile, defensive), affect, behavior changes, etc. Whenever feasible, another supervisor should make an independent assessment based on observations of the same factors. If the supervisor concludes that the employee may be using drugs or alcohol or that their ability to perform the assigned duties is impaired, the supervisor should proceed as set forth below. Similarly, if a supervisor believes or suspects that an employee diverted drugs from a patient or from UNMH property, or if drugs are missing from a workplace and cannot be accounted for, the supervisor should proceed as follows: The Employee and Labor Relations department of Human Resources should be contacted during normal working hours in order to authorize and facilitate the drug and/or alcohol testing process. After normal work hours, the Administrative Supervisor on duty or the Administrator on call shall authorize and arrange the testing The authorizing official or designee will contact a certified laboratory for testing. The authorized official or designee will identify the location where the employee will undergo testing. The employee will be asked to consent to the test and to sign a consent and release form provided by the laboratory conducting the test. Refusal to submit to testing will result in disciplinary action, up to and including termination of employment If an employee demonstrates reasonable suspicion of impairment, the authorizing official or designee shall also place the employee on paid administrative leave pending receipt of the test results. The supervisor should attempt to make alternative transportation arrangements for the employee, if necessary. If no assistance is available, the supervisor should arrange transportation of the employee at UNM Hospitals expense. Under no circumstances should the employee be allowed to drive home alone. If the employee leaves with the apparent intent to drive, the supervisor should notify the Security Office. The supervisor should not attempt to physically restrain the employee. Security will contact UNM Police Department if an employee leaves with the apparent intent to drive. Page 3 of 8

4 The supervisor will document on the Substance Abuse Investigation Form the rationale for determination of reasonable suspicion within twenty-four (24) hours of the incident. This form must be submitted to the Department of Human Resources If testing is the result of a drug missing from a workplace, but the employee does not demonstrate reasonable suspicion of impairment, then the employee shall not be placed on administrative leave following testing completion. The employee shall be permitted to continue with his or her regular work schedule pending receipt of the test results. Moreover, testing in this circumstance will be limited to the drug class of the drug that is missing. 6.2 Random Testing for Safety Sensitive Positions General Notice to Employees in Safety Sensitive Positions Each employee in a safety sensitive position will acknowledge in writing that the employee has received and read a notice which states the employee s position has been designated for random drug and alcohol testing, and that refusal to submit to testing shall result in disciplinary action, up to and including termination. The acknowledgement will be forwarded to Human Resources for filing in the official personnel file. If the employee refuses to sign the acknowledgement, the employee s supervisor will document on the acknowledgement form that the employee received the notice. This acknowledgement will be forwarded to Human Resources for filing in the official personnel file. An employee s failure to sign the notice will not preclude testing that employee, or otherwise affect the implementation of this program Selection of the Safety Sensitive Positions Safety Sensitive positions involve work that may impact patient care, UNMH security, public health and safety, protection of life and property, or otherwise require a high degree of trust and confidence. Positions may be added or deleted based on directions from the Administrator of Human Resources Random Testing Requirements Random drug and alcohol tests are unannounced and conducted throughout the calendar year. A minimum of 10 percent of the employees in the covered positions will be administered random alcohol testing per year. A minimum of 50 percent of the employees in the covered positions will be administered random drug testing per year. Employees selected for random testing must proceed immediately to the testing site upon notification of being selected. 6.3 Drugs Except as provided by Section , the certified laboratory will test all samples for the following: Page 4 of 8

5 Amphetamines Barbiturates Benzodiazepines Cocaine Ecstasy Opiates Marijuana Methadone Phencyclidine Propoxyphene With approval from the Human Resources Administrator or designee, a specific request may be made to the certified laboratory to test the specimen for a specific drug not listed above, if there is a reasonable suspicion that an employee is using or is impaired by the drug, if the supervisor believes or suspects that the employee diverted the drug from a patient or from UNMH property, or if the drug is missing from the workplace and cannot be accounted for The appropriate use of prescribed drugs that are legal under both state and federal law and non-prescription medications is not prohibited. The misuse or abuse of a prescription and/or non-prescription drugs while performing job duties is prohibited If the employee is tested by urinalysis and a diluted sample is detected, UNMH may require the sample be retested or may require the employee submit to another form of testing. 6.4 Alcohol Testing Alcohol testing is done by testing breath, using an Evidential Breath Testing Device (EBT) or saliva alcohol screening device (ASD). The EBT is a scientific instrument that determines the concentration of alcohol in the bloodstream by analyzing a specific amount of exhaled breath. The test result is a number representing the blood alcohol concentration (BAC), which is expressed in grams of alcohol per 210 liters of breath. Only EBTs may be used for confirmation tests. The EBT prints out numbered copies of the test results. A BAC of greater than 0.04 indicates alcohol impairment. A BAC of less than 0.02 indicates no alcohol impairment. A BAC of 0.02 to 0.04 indicates likely alcohol impairment. The test is conducted by a certified and trained breath alcohol technician whose job it is to administer the test and ensure the equipment work properly. If the initial test shows a reading less than 0.02 the test is recorded as negative. If the initial result indicates a BAC of 0.02 or greater, a confirmation test will be conducted after 15 minutes to ensure sample was not tainted by recent use of food, tobacco or other products. The same instrument is used for the second test. Page 5 of 8

6 If the two results are different, the lower of the two BAC numbers is used to determine the consequences of the test. An employee who is incapacitated to the point that he/she cannot provide a sample at the time of an incident shall later provide the necessary authorization for releasing hospital or medical reports that would indicate whether or not the employee was under the influence of a drug or alcohol. 6.5 Discipline In the event a supervisor believes that an employee has violated a work rule or policy and that disciplinary action may be warranted, established investigatory and pre-disciplinary procedures will be followed. The supervisor must also notify the Human Resources Department for consultation and assistance when these investigatory procedures are initiated. Referral to the Employee Assistance Program will not delay initiation of investigatory or disciplinary actions. 6.6 Criminal Referral The Human Resources Department will notify the UNM Police Department if its investigation suggests that criminal conduct has occurred. If a supervisor has information or belief that criminal conduct requiring immediate police response or investigation has occurred, he/she should contact the UNM Police Department. The supervisor should notify the Human Resources Department whenever such a police referral is made. Criminal conduct includes sale or use of controlled substances as well as diversion and/or theft of controlled substances. 6.7 Required Reporting for Licensed Professionals In the event a supervisor has information or belief that a professionally licensed employee has a problem with alcohol or drug use that impairs the employee s ability to perform his/her professional duties, the supervisor must notify his/her appropriate administrator. The ranking licensed professional will report the impairment to the appropriate licensing board and send a copy to UNMH, Human Resources Department, Employee and Labor Relations section. 6.8 UNM Hospitals Employee Assistance Policy Employees may seek assistance from the Hospitals Employee Assistance Program or request a leave of absence to obtain treatment for their drug or alcohol use. Approval will be subject to Management s discretion. 6.9 Workers Compensation Workers compensations benefits may be reduced if an employee s drug/alcohol intoxication/influence in violation of this policy contributes to a workplace injury Return to Work Employees who successfully complete treatment and wish to return to work may do so subject to conditions mutually established between UNMH and the employee. Any decision to rehire will be at the sole discretion of UNMH. Page 6 of 8

7 6.11 Searches Based upon reasonable suspicion of conduct prohibited by this policy, an employee may be requested to: 1) Submit to the search of his/her person and/or any personal article brought upon Hospitals property. 2) Submit to seizure of any illegal drug or unauthorized controlled substance(s) found in the employee s possession. Suspected illegal drugs and unauthorized controlled substances will be turned over to the appropriate law enforcement authorities. The employee will be required to furnish prescription information for any prescription drugs found in the employee s possession. A personal search may also include a search of items within the employee s work area The Employee and Labor Relations department of Human Resources should be contacted during normal working hours in order to authorize and arrange searches. After normal work hours, the Administrative Supervisor on duty or the Administrator on call shall authorize and arrange searches. Searches shall be conducted by the Security Office Failure to submit to a search will result in disciplinary action up to an including termination for insubordination Employees will not be touched or have clothing removed except for outer garments. 7. DEFINITIONS For the purpose of this policy, the following definitions will be applied: Employee: All employees regardless of classification or status. Supervisor: An individual who has responsibility for the work of one or more employees. Illegal Drug: Any drug illegal under state or federal law. Medical marijuana is an illegal drug since marijuana is illegal under federal law. Impaired: The fact or state of being impacted, damaged, weakened, or diminished in the performance of job duties. Refusal to submit to a controlled substance test means: (1) Failure to show up for any test within a reasonable time after being directed to do so by the employer or to remain at the testing site until the testing process is complete. (2) Failure to provide a specimen for any drug test required by this policy. (3) Failure to permit the observation or monitoring of the provision of a specimen in the case of a directly observed or monitored collection in any drug test. (4) Failure to provide a sufficient amount of a specimen when directed unless it has been determined through a medical evaluation that there was an adequate medical explanation. (5) Failure or declines to take a second test the employer has directed following a negative dilute result. Page 7 of 8

8 (6) Failure to undergo an additional medical examination as directed by the MRO. (7) Failure to cooperate with any part of the testing process. Reasonable Suspicion: A clear, expressed belief, drawn from specific and particularized facts and reasonable inferences from those facts, that an employee is using drugs or is impaired by the use of illegal or legal drugs or alcohol. Verified Positive Test Result: A specimen screened positive by a Federal Drug Administration- approved immunoassay test, confirmed by a gas chromatography/mass spectrometry assay (or other confirmatory tests approved by HHS), evaluated by the MRO, if required, and determined to be a result of unauthorized use of legal drugs, illegal drugs or alcohol. SUMMARY OF CHANGES 1. Added subsection (3) to Section Updated Section to be consistent with the 10 panel currently in use, and added introductory clause Except as provided by Section Added new Section 6.9. Supersedes HR 145 Drug and Alcohol Free Workplace, 2/14/2014. RESOURCES/TRAINING Resource/Dept Internet/Link DOCUMENT APPROVAL & TRACKING Item Contact Date Approval Owner Sara M. Frasch, HR Administrator, UNMH Y Consultant(s) Felix Funes, Security Director, UNMH Y Human Resources Sara M. Frasch, HR Administrator, UNMH Y Official Approver Stephen W. McKernan, Hospitals CEO, UNMH Y Official Signature Stephen W. McKernan Date: 3/2017 Origination Date 8/20/2000 Issue Date Clinical Operations Policy Coordinator 3/2017 Page 8 of 8