Clinical Compliance Requirements

Clinical Compliance Policy

Policy approved by Mercy College Board of Trustees, March 2020

Mercy College of Ohio (“the College”) is committed to the health, safety, and well-being of all patients cared for by its students, as well as the health, safety, and well-being of the students who participate in its programs and represent the College in clinical agencies. On January 1, 2004, the Joint Commission updated regulations for hospitals, home health agencies, clinics, and other healthcare providers to gain or maintain accreditation status. One of the regulations requires all persons working at the facility – including employees, volunteers, and students – to have a criminal background check. Other requirements such as drug screens, verification of immunizations/titers/testing/health history and Basic Life Support (BLS) certification may be necessary pursuant to agreements with a clinical agency. Guidelines for required immunizations/titers and tuberculosis (TB) screenings, as recommended by the Centers for Disease Control (CDC), are for the safety of patients, students, faculty, staff, and the public.

This policy applies to all College students who participate in clinical/practicum/field experiences with an affiliated clinical agency (“Clinical Agency”).

To meet Joint Commission or other Clinical Agency requirements, the College requires all students entering a College program which includes a clinical component, practicum, or field experience (hereinafter referred to as “College Health Program”) to undergo a criminal background check and drug screen. Students in College Health Programs must also provide verification of required immunizations/titers/testing/health history and BLS certification as outlined in Appendix A. The results of a background check and drug screen, as well as the ability to provide documentation of immunizations/titers/testing/health history and/or BLS certification, can impact a student’s ability to participate in a College Health Program, and/or become licensed, credentialed or employed in a particular state.

It is the responsibility of all students to conduct themselves in a manner consistent with College requirements for maintaining an environment free from threat to person, property, efficiency or reputation because of illegal use, sale, transfer, or possession of alcohol or dangerous drugs as defined by Section 2925.01 of the Ohio Revised Code and United States Code 21, Section 811 and 844. Students must also abide by the College’s Drug and Alcohol Abuse/Prevention Policy.

Affiliation agreements between a Clinical Agency and the College outline legal/contractual requirements, including criminal background check, drug screen, and verification of Health History and/or BLS certification.

Required Background Check, Drug Screen, Immunizations/Titers/Testing/Health History and Basic Life Support (BLS) Verification

All students who have been accepted into a designated College Health Program are required to successfully complete a criminal background check (including fingerprint screen) and drug screen through the vendor designated by the Office of Compliance and Risk Management (“Vendor”) and submit satisfactory immunizations/titers/testing/health history verification from a medical provider (collectively, the "Health Program Assessments”). Previously conducted criminal background checks, drug screens, and/or immunizations/titers/testing/health history verifications unrelated to the College Health Program are not acceptable for purposes of this policy. The College Health Programs also abide by the requirements of each specific Clinical Agency, which periodically may require updated Health Program Assessments. Students may not be permitted to participate in their designated program if: a) the criminal background check includes findings of the following: any felony or misdemeanor criminal convictions, arrests, charges, pending charges or probation/diversion (not including minor traffic violations), b) confirmed positive drug screen results, c) the immunizations/titers/testing/health history and/or BLS requirements are not satisfactorily met.

New Students

Students are responsible for the costs and activities associated with meeting all clinical requirements and completing the Health Program Assessment process. Students retain access to their account information after graduating from the College Health Program.

Students Who Have Failed a Course

Students who have failed a course will not be required to order a new Vendor account if:

They have been continuously enrolled at the College (an official Leave of Absence is not considered continuous enrollment).
However,
Students may be required by the Clinical Agency to complete updated Health Program Assessments.

Students Who Have Been Absent from the Health Program but Return within Three Semesters

Students re-entering a health program within three semesters will not be required to order a new Vendor account but must ensure compliance prior to returning to classes and clinical participation.

Students whose vendor accounts have been archived should contact the vendor or Clinical Compliance Coordinator to have the account unarchived.
Any incomplete or overdue requirements must be completed.
Students may be required to complete updated Health Program Assessments (communicated by program administrator).

Students Returning After an Absence of Less than Three Semesters

Students re-entering a College Health Program after an absence of less than three semesters will not be required to order a new Vendor account if:

They have been continuously enrolled at the College (an official Leave of Absence is not considered continuous enrollment);
Original Health Program Assessments were all completed less than one year earlier;

Students Returning after Three Semesters

Students who return to a College Health Program after three semesters are required to order a new Vendor account to meet all current requirements, including completion of new Health Program Assessments.

Students Who Withdraw and/or Change Programs

Students who begin a College Health Program and subsequently withdraw may be allowed to transfer their Vendor account upon acceptance into the new College Health Program if:

Original Health Program Assessments were all completed less than one year earlier;

Drug Screens

It is the policy of the College to prohibit the purchase, possession, use or abuse, sale, distribution, or manufacture of any controlled substance on campus, on any College property, or on the premises of student’s clinical assignment. Students are responsible for complying with the College’s Drug and Alcohol Abuse/Prevention Policy; failure to comply with the policy may result in immediate dismissal.

The College recognizes chemical dependency as a major health problem and as a health, safety, and security concern. As part of a prevention program, all incoming students are required to participate in substance abuse training during orientation and again annually in an online training module.

Readmission after Dismissal due to a Positive Drug Screen

If a student is dismissed from the College after a positive drug screen, the student may apply for readmission to the College according to the readmission guidelines outlined in the College Catalog. If readmitted, the student must agree to random drug testing. Students who wish to be readmitted to the College must comply with all program changes and catalog revisions at the time readmission is requested. An additional positive drug screen will result in dismissal from the College with no opportunity for readmission.

Additional Health Program Assessments

In most circumstances, Health Program Assessments are only performed after a student has been accepted into a College Health Program (or is ready to begin the clinical/practicum/field experience portion of their program). However, some Clinical Agencies require current results from the student prior to clinical placement at that site.

The cost of any additional testing, updated criminal background checks, or medical visits is the responsibility of the student. Criminal background check and drug screen must be coordinated through the contracted Vendor.

Reasonable Suspicion Drug Screening

Students who are performing in a clinical setting in an unsafe manner, and/or whose behaviors are suspect, may be subject to an assessment by a healthcare provider and may be asked to submit to an immediate drug screening. For purposes of this policy an assessment may include, but is not limited to, a drug/alcohol screen, medical or mental assessment, and/or rehabilitation. Action and/or pattern of behaviors that may warrant an assessment include, but are not limited to, the following:

Sudden changes in work performance;
Violation of safety policies;
Repeatedly not following work direction;
Disorientation;
Personality changes;
Behavior problems;
Drowsiness;
Slurred speech;
Glassy or bloodshot eyes;
Suspicious odors;
Frequent absences;
Incoherent communication or inexplicable behavior;
Possession of drugs or drug paraphernalia;
Observation of drug use;
A report of drug use provided by a reliable and credible source; or
A self-report of a drug-related arrest, charge, or conviction.

Student Duty to Self-Report

Students are asked on their application for admission to indicate whether they have been convicted of child or dependent adult abuse; whether they have been convicted of a crime in this state or any other; whether they are currently incarcerated; or if they have been excluded from or served with notice of exclusion from any governmental programs, i.e. Medicare, Medicaid, financial aid, student loan default. Students are then asked to explain any “yes” answers.

Students are informed during the admission process that a past felony or misdemeanor may disqualify them from entering a Clinical Agency setting, testing for licensure, or being hired by potential employers in a healthcare profession. It is the responsibility of the student to check with the program administrator, the licensing/credentialing organization and/or state prior to application into the College Health Program.

Failure to disclose or providing material misrepresentation of information to any application question, including questions about any criminal conviction, arrest, charge, pending charge or probation/diversion, may result in disciplinary action up to and including dismissal from the College.

Students currently enrolled in a College Health Program have an ongoing duty to report any arrests, charges, or convictions that occur after they are enrolled in the College Health Program. The student must notify the program administrator of the College Health Program in which he/she is enrolled as soon as is reasonably possible - and no later than five (5) calendar days (in accordance with the Drug and Alcohol Abuse/Prevention Policy) - after the incident occurs.

Immunizations/Titers/Testing/Health History and/or BLS Certification

Students must complete all required immunizations/titers, including TB testing, as outlined in program clinical requirements found in Appendix A, and complete and submit a satisfactory Health Screening form from a qualified medical provider. Students must provide documentation of immunizations/titers/TB testing/health history, and/or BLS certification in their accounts with the College’s designated third-party Vendor.

Requests for Waiver/Exemption/Extension

Student may request a waiver/exemption or extension for immunization requirements with the Clinical Compliance Coordinator.

Even if a waiver/exemption or extension request is received by the Clinical Compliance Coordinator, clinical placement is not guaranteed. Approval of such requests is subject to each clinical site’s policies and/or guidelines established in the Clinical Agency Agreement.

Placement at Clinical Agencies

Acceptance into a College Health Program despite negative information on a background check or drug screen, or submission of a waiver/exemption from a required immunization does not guarantee placement at a Clinical Agency. For a student already placed at a Clinical Agency site, subsequent criminal history may result in the Clinical Agency prohibiting the student from continuing in the clinical experience. If a student is unable to participate in a clinical experience as required for a program of study, student will not be able to progress and will be dismissed from the College Health Program in which student is enrolled.

When a student who has negative information on a criminal background check self-reports subsequent criminal history and attempts to be placed at a specific Clinical Agency site or wishes to continue at student’s current site, the appropriate personnel at the Clinical Agency site evaluate the information and surrounding circumstances. Clinical Agency site personnel have sole discretion to determine whether the student can participate in a clinical experience at the Clinical Agency site or continue with the current placement. The College makes no final decisions regarding student acceptability for a Clinical Agency site or the ability of the student to continue with a current placement based on the results of a criminal background check or in a self-report of new criminal activity as required above.

College faculty and staff will not provide advice on a student’s ability to obtain licensure, credentialing or employment notwithstanding an adverse criminal background check, and students should not rely on any general information provided by College personnel in that regard. It is the responsibility of students to check with the licensing/credentialing board and/or state in which they want to practice to determine if they are able to sit for exams; however, some states may not advise about the inability of students to sit for exams until the students are prepared to do so.

Failure to provide documentation of required immunizations/titers, testing, health history and/or BLS certification may prevent Clinical Agency site placement, which may prevent College Health Program progression or completion.

Sharing Information Concerning Health Program Assessments

Information concerning Health Program Assessments is initially shared with the student and appropriate College personnel. College Health Program administrators or designees are responsible for monitoring students’ accounts. Findings may require further action, and students will be notified of such by the program administrator and/or the Vendor. Students are responsible for monitoring their account for such notifications.

In order to share information concerning Health Program Assessments with Clinical Agencies, students must sign 530-A Student Consent. Without confirmation all Health Program Assessments and clinical requirements were obtained, and results are acceptable to the assigned Clinical Agency, placement in a clinical setting is unlikely. Non-placement will result in dismissal from the College Health Program.

Confidentiality

Results of a student’s Health Program Assessments are not kept as part of the student’s educational file. The results are protected on the Vendor’s website and are accessible only by the student, the Vendor, and authorized College personnel as long as the College is contracted with the Vendor. Students have access to their online records with the Vendor while they are enrolled and post-graduation, even if the College is no longer contracted with the Vendor. All ancillary materials collected from the students regarding review of criminal background checks or drug screen investigations will be maintained as confidential and stored in a secure fashion by the Office of the Clinical Compliance Coordinator.

The procedures associated with the Clinical Compliance policy are as follows.

Required Background Checks, Drug Screens, and Health History

The Clinical Compliance Coordinator establishes instructions for ordering Vendor accounts and communicates the due date for each College Health Program. Instructions for completing the background check and drug screen are provided by the Vendor. Students are responsible for ordering an online account, scheduling, and completing the Health Program Assessments in a timely fashion, so results can be returned to the Vendor or College prior to the due date established by the College Health Program. Students will not be permitted to participate in their designated College Health Program if they have not cleared the background check and drug screen and satisfactorily completed the Health History verification by the College Health Program’s due date, unless an extension is granted by the program administrator, i.e., in the instance of late admittance to the College Health Program.
Background check and drug screen results are returned directly to student accounts, where they are available to both students and authorized College personnel. Health History verifications are uploaded by students into their online account. Additional documents related to background check findings, positive drug screens, reasonable suspicion drug test results, etc. will be uploaded by the program administrator to the administrator portal of the student account.
Students aware of findings which may show up on the background check or drug screen should be prepared to discuss with their program administrator whether findings may impact participation in clinical rotation, licensing or credentialing.

Findings on Criminal Background Checks

Students disputing background check results must contact the Vendor to initiate an investigation. Status of the dispute will be communicated to the program administrator.
Findings on a student’s background check require the following actions:
1. If student has findings on the Background Check Summary Report:
  1. Student may be asked to request additional official documents.
  2. Student may be asked to provide detailed, legibly written (or typed) explanation of the recorded information.
  3. Program administrator will schedule a meeting with student (face-to-face or conference call)
2. If student has findings on the BCI&I (Ohio Bureau of Criminal Identification and Investigation) or FBI (Federal Bureau of Investigation) fingerprint results, the computerized criminal history record based on fingerprints will be uploaded to Vendor account.
  1. Student must prepare a detailed, legibly written (or typed) explanation of the recorded information.
  2. Program administrator will schedule a meeting with student (face-to-face or conference call).
At the face-to-face meeting or conference call, the program administrator reviews the information to assess whether the findings will potentially affect clinical placement or licensure/credentialing. The information will be reviewed, and a final decision rendered based on the following:
1. Seriousness, circumstances, and frequency of the offense(s);
2. The relationship between the duties to be performed as part of the College Health Program and the offense(s);
3. The length of time that has passed since the offense(s);
4. Evidence of successful rehabilitation;
5. The accuracy of the information provided by the student; and
6. The guidelines established by the clinical affiliation agreement.
The program administrator:
1. Reviews criminal history record, student’s written explanation of the events, and any other documentation provided by the student, such as police reports, certified court records, and other information that is pertinent to the case, with the student.
2. Program administrator and student complete and sign 530-D Criminal Background Findings.
3. If there are no issues that will affect the student’s Clinical Agency placement, as determined by the program administrator and/or Dean:
  1. Student signs 530-F Student Waiver - Criminal Background/Drug Screen to continue the clinical experience. Program administrator uploads the signed 530-F Student Waiver – Criminal Background/Drug Screen, completed 530-D Criminal Background Findings, and student’s detailed written explanation to the student’s Vendor account.
4. If the issue(s) would affect the student’s Clinical Agency placement and/or constitute an automatic bar from licensure or credentialing, according to the Ohio Board of Nursing:
  1. Based on an assessment of all information available, program administrator and/or Dean advises the student that he/she WILL NOT be allowed to continue with the clinical experience.
  2. Program administrator and student complete and sign 530-D Criminal Background Findings.
  3. Program administrator uploads the completed 530-D Criminal Background Findings, student’s detailed written explanation and any other documentation provided by the student to the student’s Vendor account.
If student wishes to dispute the decision of the program administrator and/or Dean, student must submit a request for appeal in writing to the Vice President Academic Affairs (“VPAA”) within five (5) business days of the determination. A written decision will be provided to the student within five (5) days of the appeal submission. The decision of the VPAA is final and not subject to appeal.
If student has signed a waiver to continue in the College Health Program but a finding is found from a subsequent report received after the waiver was signed:
1. Program administrator determines whether there is new information that affects student’s clinical placement.
2. If the new finding appears on the FBI/BCI results, student may be asked to provide additional documentation.
3. If new findings are the same as that which was previously discussed with the student:
  1. Program administrator communicates this with student.
  2. Program administrator provides an electronic notation in student’s Vendor account stating that the findings are the same and that no further action is required.
  3. Program administrator uploads any new documentation to student’s Vendor account.
4. If the findings are different from the previously reviewed charges:
  1. The process outlined previously in Findings on Criminal Background Checks should be repeated.

Drug Screens

The Vendor conducts a 10-panel drug screen checking for amphetamine [methamphetamine], barbiturates, benzodiazepine, cocaine, marijuana, methadone, methaqualone, opiates [codeine, morphine], phencyclidine, and propoxyphene.
If drug screen results are returned as “dilute negative” or “dilute positive,” student will be told that they must order a new drug screen and provide another sample. Results of the second test are considered final. If student declines to take a required retest because of a dilute specimen, the action will be considered a “refusal to be tested” and treated the same as a confirmed and positive result.
The program administrator monitors student accounts for drug screen finding alerts.
All positive test results are automatically sent to the Medical Review Officer (MRO) contracted by the Vendor.
1. If student tests positive for a drug for which there could be a legitimate prescription, the MRO contacts student for that prescription and validates the information. If prescription information is validated, the MRO will update the test results to show a negative drug screen.
2. If prescription information cannot be validated, the drug test results will show a positive drug screen.
3. If the MRO is unable to reach the student, a notation will be made on student’s drug screen and program administrator will be notified.
  1. The program administrator emails student and advises that any additional prescription information must be provided to the MRO immediately. If drug screen results remain unchanged after seven days, the test results will be considered positive.
  2. If test results are changed to a negative drug screen, no additional action is required.
  3. If test results are changed to a verified positive drug screen:
Drug screen results and the rules set forth by the specific College Health Program’s accrediting or credentialing agency determine whether there are immediate consequences.
1. Program administrator consults with the Dean, VPAA, and Vice President Student Affairs/Dean of Students (“VPSA”) to determine additional steps for student.
  1. Program administrator:
    1. Prepares 530-E Drug Screen Findings, including what additional steps (random drug testing, etc.) are required.
    2. Notifies student of the positive drug screen and sets up a face-to-face meeting or virtual meeting/conference call) .
    3. Informs student they have the right to initiate a formal dispute of the findings (as outlined in the following section Disputing Drug Screen Finding).
    4. Student and program administrator review and sign 530-E Drug Screen Findings.
2. If allowed to continue, 530-F Student Waiver – Criminal Background/Drug Screen must be signed.
  1. Permission to continue in the College Health Program does not guarantee participation in required clinical experiences or licensure in certain states.
  2. If student is currently attending classes:
    1. Student will be suspended from participating in the clinical experience until the drug screen is fully reviewed by the program administrator, VPAA, and VPSA.
    2. Student may be allowed to continue attending class instruction until the drug screen issue is resolved.
3. Disciplinary action according to the College’s Drug and Alcohol Abuse/Prevention Policy and Program will be determined by the VPSA/Dean of Students.
  1. Program administrator documents all communication with student,
  2. Program administrator uploads 530-E, 530-F and any additional documentation including communication with student to administrative portal of student’s Vendor account. All original documentation is provided to Clinical Compliance Coordinator.

Disputing Drug Screen Findings

Students wishing to dispute the drug screen results must initiate a formal dispute within five (5) business days of notification by the program administrator. Student must contact program administrator to initiate a re-test of the original specimen. The drug screen re-test package code will be provided to student by the program administrator or Vendor. Cost of the new drug screen package is paid by the student. Vendor will coordinate testing of the same specimen sample at a different lab. If the result is overturned, Vendor will refund the cost of the new drug screen package to the student.

Additional Required Background Checks and Drug Screens

Reasonable Suspicion

If a faculty or staff member at the College feels that a “reasonable suspicion” drug/alcohol screen is required consistent with College policy, the faculty or staff member should:

Contact the program administrator, Program Director, Dean and/or (in the event of occurrence at a clinical site) another medical healthcare professional to observe the student.
Remove student from the clinical or classroom setting.
Advise student there is concern for student and/or patient safety.
Advise student that they will be required to submit to a screening within 24 hours.
Advise student that they will not be allowed to attend clinicals until proof of a negative drug/alcohol screen has been verified by the program administrator (student will be given the opportunity to make up lost clinicals if the drug/alcohol screen report is negative).
Advise student that they will be allowed to continue attending classroom instruction only until the drug/alcohol screen result has been received and reviewed for further action.

Students must provide results of alcohol or drug screen to the program administrator, who will upload the results to student’s Vendor account.

Failure to participate in an assessment at the request of a College faculty or staff member will result in the assessment being considered a violation of the College’s Drug and Alcohol Abuse/Prevention Policy and grounds for disciplinary action up to and including dismissal from the College.

If results are positive, student will be immediately suspended from the College by VPSA/Dean of Students and subject to the policies and procedures outlined in the Student Code of Conduct. Student is encouraged to contact the Director of Counseling for an assessment appointment with possible referral to a drug and/or alcohol counseling program.

Sharing Information Concerning Criminal Background Checks, Drug Screens, and Health History

Students are required to complete and sign 530-A Informed Consent permitting the College to discuss results with Clinical Agencies. This is in accordance with the Family Educational Rights and Privacy Act (FERPA).
If a student refuses to provide this consent, the College will not be able to inform the Clinical Agency of results, which may prevent the student from participation in clinical experiences.

Health Requirements

The College requires all students entering programs which include a clinical component, practicum, or field experience (health program) to comply with specific health requirements, such as documentation of positive titers, vaccinations other health requirements. Students may request waivers or extensions of vaccinations and other health requirements, which may be approved or denied by clinical facilities. If waivers/extensions are denied, it will prevent placement in clinical experiences and progression in the academic program. The College will make a reasonable attempt to find alternate clinical placements for students seeking waivers or extensions of vaccinations, but it is at the discretion of clinical sites whether students are permitted to participate in clinical experiences. The requirements may vary depending on the program of study and the clinical agency. Students in such programs can find information on criminal background checks, drug screens, and health requirements at (https://www.mercycollege.edu/background). Current information is maintained on the College website and is subject to change. Students are responsible for all costs associated with criminal background checks, drug screens, and health requirements. Students who do not meet listed health requirements may not be able to fulfill the clinical, practicum, or field experience requirements and complete their program of study. Please see the program administrator with questions regarding documentation for health records, including titer and vaccination requirements.

Clinical Liability Insurance

Mercy College students who are enrolled in a health program are required to have clinical liability insurance. The cost of the liability insurance is included in the matriculation fee, and these students are enrolled in clinical liability insurance coverage by the Clinical Compliance Coordinator at the College. Questions regarding clinical liability insurance may be directed to the Clinical Compliance Coordinator and/or the Office of Compliance and Risk Management.

Health Insurance

Mercy College students who are enrolled in a health program are required to have health insurance, either through the Mercy College Health Insurance policy (United Healthcare) or through a personal policy. Students are automatically enrolled in the insurance offered through the College unless the online Health Insurance Waiver form is completed in EMPOWER (the link is directly below the billing detail summary). Waiver is available each fall semester and for new students only in the spring and summer semesters. General information regarding the coverage is available in the Office of the Bursar. For specific questions regarding coverage information, please contact United HealthCare Customer Service at 1-800-505-4160.