Internship Handbook HP480 Guidelines for Students and Preceptors For all internship students in Health Services, Health Informatics and Information Management, and Associated Minors.
College of Nursing and Health Professions 8600 University Blvd.
Evansville, Indiana 47712
(812)461-5329
Fax (812)461-5356
Table of Contents 1. 2.
Introduction ....................................................................................................................................... 4 Planning for the Internship Experience ............................................................................................. 4 a. Early Planning (Freshman/Sophomore) ...................................................................................... 4 b. Later Planning/Applying (Junior/Senior) ..................................................................................... 5 3. Overview of the Internship Experience ............................................................................................. 5 a. Purpose/Goals............................................................................................................................. 5 b. Eligibility ...................................................................................................................................... 6 c. Health Services Application, Approval, and Referral Process ..................................................... 7 d. Health Services Internship Requirements and Activities ............................................................ 9 e. Health Services Contact Hours/Credit Hours .............................................................................. 9 f. Health Informatics Application, Approval, and Referral Process.............................................. 11 g. Health Informatics Internship Requirements and Activities ..................................................... 13 h. Health Informatics Contact Hours/Credit Hours....................................................................... 13 4. Internship Site Selection .................................................................................................................. 14 a. Identifying an Appropriate Internship Site ............................................................................... 14 b. Using Your Place of Employment as the Internship Site ........................................................... 14 c. Paid Internships ........................................................................................................................ 14 5. On-site Internship Interview............................................................................................................ 14 a. Purpose of the Interview .......................................................................................................... 14 b. Preparation for the Interview ................................................................................................... 14 c. Information to obtain during your interview:........................................................................... 15 d. Accepting an Offer .................................................................................................................... 15 6. Internship Pre-placement Documentation...................................................................................... 15 a. Internship Work Agreement Form (see Forms, Appendix II) .................................................... 15 b. Job Description / Goals ............................................................................................................. 16 c. Internship Start & End Dates .................................................................................................... 16 d. Registering for the Internship Course ....................................................................................... 16 e. Expectations to be Shared with Preceptor (see Appendix III) .................................................. 16 7. Professional Conduct ....................................................................................................................... 16 a. Code of Conduct........................................................................................................................ 16 8. Required Internship Components ................................................................................................... 18 a. Internship Weekly Activity Tracking Form (see Appendix II) .................................................... 18 b. Classroom Meetings & Midterm Review .................................................................................. 18 c. Professional Development ........................................................................................................ 18 d. Project Materials ....................................................................................................................... 18 e. Reflection Report /Electronic Poster Symposium (see Appendix III) ........................................ 19 f. Evaluation ................................................................................................................................. 19 g. Receiving a Grade for the Internship ........................................................................................ 19 9. Unanticipated Situations Can Arise ................................................................................................. 19 a. Activities not specified on the Internship Agreement Form..................................................... 19 b. Activities that compromise your personal or professional values or beliefs............................ 19 c. Discrimination/Harassment ...................................................................................................... 19 10. Glossary ........................................................................................................................................... 19 APPENDIX I: Castle Branch Corp., Profile Instructions, Policy & Procedures ............................................. 21 APPENDIX II: Career Services Forms/HP 480 Forms and Internship ........................................................... 35 APPENDIX III: Expectations for Preceptor ................................................................................................... 43 APPENDIX IV: Internship Reflection Report Instructions ............................................................................ 47 APPENDIX V: Infection Control Policy ......................................................................................................... 49
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HP 480 Internship Checklist Date
This checklist will guide you through your internship. Steps are explained in the handbook.
Complete all Castle Branch requirements before applying for an internship – see Appendix 1 for codes to place an order and information about all the requirements
File an internship application with the Health Services or Health Informatics Department (for Fall Interns – by April 15; for Spring Interns – by September 15; for Summer Interns – by February 15)
Receive an "Approved for an internship" email Schedule a meeting with the internship Career Services Liaison Have an on-site internship interview with your potential Preceptor Accept an internship offer and notify the Internship Program Instructor and Career Services Liaison Complete and submit the following forms to the Health Services of Health Informatics Department: HP 480 Internship Work Agreement – see Appendix 2 HP 480 Preceptor Contact Information – see Appendix 2 HP 480 Health Services or Health Informatics Requirements Contract – see Appendix 2 Receive Notice to Register – you will be emailed the CRN# and how to register Register for the internship course (HP 480) Post schedule to Blackboard Course site Begin internship By the end of your 1 week, submit your HP 480 Internship Learning Goals form - see Appendix 2 Before your mid-term review, submit your HP 480 Job Description for Internship form - see Appendix 2 3 weeks before midterm, submit possible dates for the review to the Career Services Liaison Mid-term review Post on Blackboard all HP 480 Weekly Tracking Forms to the Career Services Liaison - see Appendix 2 Notify the Career Services Liaison upon completion of your internship The Career Services Liaison will email your Preceptor an evaluation form Complete all In-Class Requirements and Castle Branch requirements. Receive a "pass" or "no Pass" grade or an “incomplete” if requirements are not met from above. Send your Preceptor a "Thank You" st
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1. Introduction This handbook outlines much of the information you will need to progress through the preparation and participation in an internship. It is your responsibility to be familiar with this information and act on the instructions without being prompted. For a quick reference of the steps, turn to pg. 3 of the handbook to the Checklist. Detailed explanations are found in the body of the handbook. The internship (HP 480) is required of all USI students pursuing a Bachelor’s Degree in Health Services who enrolled in the Specialty Track Option, all Health Informatics and Information Management students and Food and Nutrition Majors with a minor in Health Promotions & Worksite Wellness. As the culminating experience of the program, the internship offers students in Health Administration, Health Informatics, Gerontology, Long Term Care Administration, Public Health and Worksite Wellness the opportunity to apply the theories and skill sets learned in the classroom to the real world of healthcare. The internship is completed under the supervision of a qualified and experienced healthcare professional in the community setting. The chance to observe and share in the knowledgebase of those already working in the field offers students a bridge between the academic setting and the work world. Students are afforded the occasion to grow professionally under the supervision of a healthcare expert who recognizes the tangible contribution that can be made by an intern.
All students admitted to a Specialty Track in Health Services are required to complete HP 480 for a total of 6 credit hours (equal to 300 hours of field experience) in two consecutive semesters of their senior year. Food and Nutrition majors with a Wellness Minor are required to complete HP 480 for a total of 3 credit hours (equal to 150 hours of field experience). All students admitted to the Health Informatics degree program are required to complete HP 480 for a total of 6 credit hours (equal to 300 hours of field experience) in two consecutive semesters of their senior year.
All Health Services internships are offered in conjunction with Association of University Programs in Health Administration (AUPHA) and/or the National Commission for Health Education Credentialing, Inc. (NCHES), along with the National Association of Colleges and Employers (NACE) which connects employers and career services professionals to provide best practices, trends, research, professional development and conferences. All Health Informatics and Information Management internships are offered in conjunction with Association of University Programs in Health Administration (AUPHA), the American Health Information Management Association (AHIMA) and/or the Technology Informatics Guiding Education Reform (TIGER) initiative focused on education reform and interprofessional community development in partnership with the Healthcare Information and Management Systems Society (HIMSS). 2. Planning for the Internship Experience a. Early Planning (Freshman/Sophomore)
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Review and consider financial viability when considering the timing of the internship Schedule courses to complete pre-requisite course requirements prior to application period. A course in Microsoft Office is strongly recommended.
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Consider your career goals and what type of internship experience might best help you prepare for your desired position after graduation. Note which courses in your program interest you the most, and which health care settings you prefer. Talk to other students about their internship experiences. Join HOSA, STELLAR and/ or Sigma Phi Omega and discuss options with student members. Discuss ideas with your academic advisor and/or instructors. Attend an orientation session and look at Castle Branch requirements.
b. Later Planning/Applying (Junior/Senior)
File an internship application (prior to the stated deadlines) with the Health Services or Health Informatics Department. o Health Services applications are available online at https://www.usi.edu/health/health-services/health-services-internship-hp480 or in the Health Services office (Room HP 2145). o Health Informatics and Information Management applications are available online at https://www.usi.edu/media/5611188/hiim-internship-application.pdf or in the Health Informatics and Information Management office (Room HP 2145).
Once your application has been approved, schedule a meeting with the Internship Career Services Liaison (464-1865), months PRIOR to the desired start date (See time table in 3c). Come to this meeting prepared: o Know the information included in this document. o Bring your updated resume to the meeting o Identify your areas of interest and be prepared to discuss them with the Career Services Liaison. o Bring ideas of possible internship sites or contacts.
3. Overview of the Internship Experience a. Purpose/Goals The major purpose of an internship is to provide you with professional experience outside of the classroom that is consistent with your career goals. It provides you opportunity to integrate and apply what you have learned in your coursework to enhance your academic and professional development. The goals of this experience are to: provide relevant and practical professional experience enhance understanding and application of health management or health education principles, concepts, and procedures establish professional contacts within the healthcare community strengthen oral and written communication skills strengthen presentation ability strengthen interpersonal skills strengthen critical thinking and problem solving skills Internships are conducted in a professional work environment and MUST be approached as professional employment. The internship gives you an opportunity to demonstrate your ability to Revised 3/18
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apply knowledge to practice. Clinical hours from other programs may NOT be used toward an internship. b. Eligibility The internship is required for: Students previously admitted to the Health Services Specialty Track Food and Nutrition majors with a Wellness minor Students admitted to the Health Informatics and Information Management program The internship is optional for: Interdisciplinary Gerontology Minors
See Pre-requisites below for the Interdisciplinary Gerontology minor: *2.75 GPA required *Completion of GERO215 or SOCW223 – see specific application online http://www.usi.edu/health/health-services/health-services-internship-hp480
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Health Services internships are to be completed near the end of your academic program so that you can apply knowledge gained from your coursework. Eligibility for participation in an internship is as follows: Fall Internship Applicant Requirements:
Spring Internship Applicant Requirements:
Apply no later than April 15
75 hours completed
Completed Background Profile and
Health Requirements
Apply no later than Sept. 15 75 hours completed Completed Background Profile and Health Requirements
Summer Internship Applicant Requirements:
Apply no later than Feb. 15 75 hours completed Completed Background Profile and Health Requirements
See Pre-requisites below: *Admittance into the Health Services Specialty Track - 2.75 GPA required – see specific application online http://www.usi.edu/health/health-services/health-services-internship-hp480 *Successful completion (C or above) of HP475 *Completion of the following courses: GERO CIS151
HA
LTCA
PH
HPWW
Required
Recommended
Recommended
Recommended
ENG210
Recommended
Required
Recommended
Recommended
Recommended
GERO215
Required
Required
Required
Required
Required
Recommended
Recommended
Required
Required
Required
Required
Required
Required
HP115 Required
HP211
HPWW Minor
Required
HP305
Required (Fall)
Required (Fall)
HP306
Required (Spring IP)
Required (Spring IP)
Recommended
Recommended
Recommended
HP475 PHIL200 or 201 or 363 or HP356 PH284
Recommended
Recommended
Recommended
Required Required
Required
Required
Required
Required
If you are applying for two separate internships (in different semesters), you will need to fill out an application for each semester. One time application for 300 hrs. in a semester. Completion of the required Castle Branch Profile. (see Appendix I) o Castle Branch Profile includes a background check. In the case of questionable results, students will not be admitted to the internship program until results have been reviewed by the Program Chair and/or Dean's office.
c. Health Services Application, Approval, and Referral Process You should plan your class schedule and finances in order to accommodate distance learning experiences. Some internship sites may be an hour or more drive from the USI campus. Summer internships may be located in a student’s home area and in some cases, students may apply for and be awarded opportunities in specific disciplines and locations throughout the region and Tri-state area. STEP 1: You must complete a Health Services Internship Application to be considered for an internship no later than the dates listed below. Those applying for the second internship must also follow these
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steps. If you are applying for two separate internships (in different semesters), you will need to fill out an application for each semester. April 15 for the Fall Semester September 15 for the Spring Semester February 15 for the Summer Semester These deadlines are fixed in order for the Career Services Liaison to have enough time to assist you in scheduling interviews and setting up internship sites throughout the Evansville area and other communities as needed. It may sometimes take several months for the University to put Affiliation Agreements into place, so time is of the essence in completing and submitting an application for your internship. Note that failure to meet these deadlines may delay your graduation date. Students applying for internships in a health professions setting need to be aware that they will be expected to complete the Castle Branch Profile including physical exam, verification of immunizations and/or titers, TB test, flu shot, Background check, Drug Screen and other clinical requirements. This will be at the student’s expense. Step 2: After submission of the application, you will be notified via e-mail of a decision by the Health Services Department. Step 3: After receiving approval of your application, you should arrange an appointment with the Career Services Department Liaison to discuss the internship as one of the final steps in preparing for a job in healthcare. Appointments with the Career Services Department, 812-464-1865, must be scheduled on the following time table:
Before or during the month of March for the Summer semester Before or during the month of May for the Fall semester Before or during the month of October for the Spring Semester
Failure to meet this deadline may mean that your internship will be postponed to the next semester due to inability to arrange placement in a timely manner. Note: Those applying for a continuation of the second internship with the same facility must apply and notify Career Services, in addition to the Health Services Department, and complete a second agreement as well as forming new internship goals. The Career Services Liaison will help you augment your academic training with an appropriate internship by:
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Assessing academic preparation, interests, strengths and weaknesses Clarifying the intern’s objectives and establishing realistic expectations for the internship experience. Designing a meaningful, goal-directed internship by aligning the needs and skills of each intern with an appropriate healthcare organization. Page 8 of 71
Agreeing on the time commitment, beginning and ending dates. Reviewing internship logistics such as work requirements, dress code, hours, office space, and other related issues as needed. Clarifying agency requirements such as immunizations, fingerprinting, etc. Some agencies/facilities may require a lengthy orientation prior to the beginning of the internship. The student must plan to accommodate these requirements.
Meaningful internship experiences will offer the students:
Real tasks that need to be accomplished for the healthcare agency Activities that are significant, but not critical to the functioning of the organization. Exposure to the internal workings of the healthcare organization Activities that can be completed within the timeframe provided, assuming the student puts in a reasonable amount of time and effort. Tangible, measurable outcomes for the goals established. Challenges commensurate with the student’s knowledge, skills and personal attributes.
d. Health Services Internship Requirements and Activities Generally, you will be assigned at least one project to complete at your internship site. The project(s) and goals will be determined in consultation with your Site Preceptor to/at the facility. In addition to on-site internship hours, there is an internship course that meets weekly. This course is essential to developing professional skills. You will be expected to develop goals, keep a work log, attend class meetings, submit a final reflection paper, and evaluation forms (both student and Site Preceptors). All internship students will formally present their internship experience to their peers, faculty and staff members in a symposium setting at the conclusion of the semester. Note: There are additional fees involved in the internship process. The College of Nursing and Health Professions has adopted the Castle Branch Profile as the standard for verification of preplacement documents. Fees include but are not limited to the costs for the Castle Check, CPR training (which will be offered within the class time setting), the Dinner View Experience, and any other requirements set forth by the student’s community placement site. The cost of coverage under the University’s Professional Liability Plan is attached to tuition for the HP 480 course. e. Health Services Contact Hours/Credit Hours The Health Services Department requires students in a Health Services Specialty Track to complete a total of 6 credit/300-hour internship experience. Students majoring in Nutrition with a Wellness Minor are required to complete a 3 credit/150-hour internship experience. Health Services students may opt for two 3-credit/150-hour experiences completed in two semesters (with two separate applications) at the same, or at different sites, or a single 6credit/300-hour experience completed over one or two semesters at the same location or renew the experience at the same location for a second semester (as long as the details are worked out with the agency site and preceptor). Any second experience requires a second set of HP 480 Work Agreement, HP 480 Contact Information and HP 480 Health Requirements Contract forms.
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“Contact hours” (150-300) must be completed on site at the agency and/or under the supervision of a qualified Preceptor. Internship-related work performed at home (such as class assignments) does not count as “contact hours.” Class time requirements are not counted as “contact hours.”
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Health Informatics and Information Management internships are to be completed near the end of your academic program so that you can apply knowledge gained from your coursework. Eligibility for participation in an internship is as follows: Fall Internship Applicant Requirements:
Spring Internship Applicant Requirements:
Apply no later than April 15
75 hours completed
Completed Background Profile and
Health Requirements
Summer Internship Applicant Requirements:
Apply no later than Sept. 15 75 hours completed Completed Background Profile and Health Requirements
Apply no later than Feb. 15 75 hours completed Completed Background Profile and Health Requirements
See Pre-requisites below: *Admittance into the Health Informatics and Information Management Program - 2.75 GPA required – see specific application online at https://www.usi.edu/media/5611188/hiim-internship-application.pdf *Successful completion (C or above) of HP475 *Completion of the following courses:
Course Number Grade Requirement
HP475
CIS151
HI301
HI302
HP302
HP356
2.75 GPA for Each Course
Eligibility for participation in a Health Informatics and Information Management internship is as follows:
Please note that since Health Informatics and Information Management students are expected to complete the internship over two semesters. You will need to fill out an application for each semester. Completion of the required Castle Branch Profile. (see Appendix I) o Castle Branch Profile includes a background check. In the case of questionable results, students will not be admitted to the internship program until results have been reviewed by the Program Chair and/or Dean's office.
f. Health Informatics Application, Approval, and Referral Process You should plan your class schedule and finances in order to accommodate distance learning experiences. Some internship sites may be an hour or more drive from the USI campus. Summer internships may be located in a student’s home area and in some cases, students may apply for and be awarded opportunities in specific disciplines and locations throughout the region and Tri-state area. STEP 1: You must complete a Health Informatics and Information Management Internship Application to be considered for an internship no later than the dates listed below. Those applying for the second internship must also follow these steps. If you are applying for two separate internships (in different semesters), you will need to fill out an application for each semester.
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April 15 for the Fall Semester September 15 for the Spring Semester February 15 for the Summer Semester
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These deadlines are fixed in order for the Career Services Liaison to have enough time to assist you in scheduling interviews and setting up internship sites throughout the Evansville area and other communities as needed. It may sometimes take several months for the University to put Affiliation Agreements into place, so time is of the essence in completing and submitting an application for your internship. Note that failure to meet these deadlines may delay your graduation date. Students applying for internships in a health professions setting need to be aware that they will be expected to complete the Castle Branch Profile including physical exam, verification of immunizations and/or titers, TB test, flu shot, Background check, Drug Screen and other clinical requirements. This will be at the student’s expense. Step 2: After submission of the application, you will be notified via e-mail of a decision by the Health Informatics and Information Management Department. Step 3: After receiving approval of your application, you should arrange an appointment with the Career Services Department Liaison to discuss the internship as one of the final steps in preparing for a job in healthcare. Appointments with the Career Services Department, 812-464-1865, must be scheduled on the following time table:
Before or during the month of March for the Summer semester Before or during the month of May for the Fall semester Before or during the month of October for the Spring Semester
Failure to meet this deadline may mean that your internship will be postponed to the next semester due to inability to arrange placement in a timely manner. Note: Those applying for a continuation of the second internship with the same facility must apply and notify Career Services, in addition to the Health Informatics Department, and complete a second agreement as well as forming new internship goals. The Career Services Liaison will help you augment your academic training with an appropriate internship by: Revised 3/18
Assessing academic preparation, interests, strengths and weaknesses Clarifying the intern’s objectives and establishing realistic expectations for the internship experience. Designing a meaningful, goal-directed internship by aligning the needs and skills of each intern with an appropriate healthcare organization. Agreeing on the time commitment, beginning and ending dates. Reviewing internship logistics such as work requirements, dress code, hours, office space, and other related issues as needed. Clarifying agency requirements such as immunizations, fingerprinting, etc. Some agencies/facilities may require a lengthy orientation prior to the beginning of the internship. The student must plan to accommodate these requirements. Page 12 of 71
Meaningful internship experiences will offer the students:
Real tasks that need to be accomplished for the healthcare agency Activities that are significant, but not critical to the functioning of the organization. Exposure to the internal workings of the healthcare organization Activities that can be completed within the timeframe provided, assuming the student puts in a reasonable amount of time and effort. Tangible, measurable outcomes for the goals established. Challenges commensurate with the student’s knowledge, skills and personal attributes.
g. Health Informatics Internship Requirements and Activities Generally, you will be assigned at least one project to complete at your internship site. The project(s) and goals will be determined in consultation with your Site Preceptor to/at the facility. In addition to on-site internship hours, there is an internship course that meets weekly. This course is essential to developing professional skills. You will be expected to develop goals, keep a work log, attend class meetings, submit a final reflection paper, and evaluation forms (both student and Site Preceptors). All internship students will formally present their internship experience to their peers, faculty and staff members in a symposium setting at the conclusion of the semester. Note: There are additional fees involved in the internship process. The College of Nursing and Health Professions has adopted the Castle Branch Profile as the standard for verification of preplacement documents. Fees include but are not limited to the costs for the Castle Branch Check, CPR training (which will be offered within the class time setting), the Dinner View Experience, and any other requirements set forth by the student’s community placement site. The cost of coverage under the University’s Professional Liability Plan is attached to tuition for the HP 480 course. h. Health Informatics Contact Hours/Credit Hours Health Informatics and Information Management students are required to complete a total of 6 credits and 300 hours of internship experience over two semesters. Health Informatics students may not complete their internship in one semester. Any second experience requires a second set of HP 480 Work Agreement, HP 480 Contact Information and HP 480 Health Requirements Contract forms. “Contact hours” (150-300) must be completed on site at the agency and/or under the supervision of a qualified Preceptor. Internship-related work performed at home (such as class assignments) does not count as “contact hours.” Class time requirements are not counted as “contact hours.”
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4. Internship Site Selection a. Identifying an Appropriate Internship Site You play an important role in identifying an appropriate site. You are encouraged to discuss preliminary ideas with your advisor and Career Services. Bring your ideas to your meeting with the Career Services Liaison, who will assist with aligning your interests with participating sites. b. Using Your Place of Employment as the Internship Site You may only use your current place of employment as your internship site if you can document that:
The internship assignment is distinct from your employment responsibilities and will be completed in a department or division distinct from your regular position The hours devoted to the internship are distinct from your hours of employment There is a qualified Preceptor, other than your immediate supervisor, who can supervise your work The above criteria are reviewed by your employer and your supervisor is willing to submit a written statement that the criteria are acceptable and that each will be met. The feedback on using one’s place of employment as an internship site is mixed. Two of the major disadvantages reported are role confusion and job-related interruptions. The major advantage reported is convenience.
c. Paid Internships Paid internships are rare, however, these opportunities are acceptable if the facility offers compensation for the experience. 5. On-site Internship Interview a. Purpose of the Interview You must have a face-to-face interview with your potential Preceptor. The Preceptor will assess your interests and whether you are a good fit for their organization. You must be able to articulate your interests during this interview. b. Preparation for the Interview Employers tell us that they are seeking interns who demonstrate professional behavior and appearance, a positive attitude toward learning, dependability, flexibility, initiative, quality work, and the ability to collaborate and work well in teams in a diverse environment. It is essential that you demonstrate these qualities during your interview. An interview does not guarantee that you will be accepted! You should research the organization before the interview so you are familiar with their services, department and specialties. This will allow you to ask informed questions and help articulate why you are interested in working with them. Preceptors will ask you what you are interested in learning, please be prepared for this question!
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c. Information to obtain during your interview:
Will I have assigned project and related activities? Will I have opportunities to attend meetings/conferences within and outside of the program or agency? Will I receive supervision by my Preceptor on a regular basis? Will my Preceptor give me feedback on my performance during my internship? Will I have the resources required to complete my assignments (e.g. office space, phone, fax, photocopier, computer, etc.)? Will I be expected to work independently or as part of a team? Will I be working with other interns? What is the procedure for requesting a change in schedule or for reporting an absence? When I complete my assignments can I request additional projects? Will I report to an additional person other than my Preceptor? In the event that my Preceptor is unavailable, who will be authorized to assign activities to me? How will my schedule be arranged?
d. Accepting an Offer Once you accept an internship offer, please notify (via email is acceptable) the Internship Program Instructor and the Career Services Liaison. Once an HP 480 Internship Work Agreement form is signed, it is expected that you will honor your commitment. 6. Internship Pre-placement Documentation The HP 480 Internship Work Agreement, HP 480 Internship Site Contact Information form, and HP 480 Health Services Requirements Contract must be returned to the Health Services or Health Informatics Department in Room HP2145 (see Forms, Appendix ll).
It is desirable to be onsite at least twice per week. This provides you with adequate exposure to the agency so that you can become acquainted with the organization personnel and to maximize your learning opportunities.
a. HP 480 Internship Work Agreement Form (see Forms, Appendix II) HP 480 Internship Site Contact Information Form HP 480 Health Services Requirements Contract The Purpose of these forms is to promote a clear understanding of the focus and substance of the internship. These forms protect all parties and can be referenced if questions arise relative to any aspect of the experience. These forms must all be signed by both the student intern and the site preceptor and returned to the Health Services or Health Informatics and Information Management Department in HP2145.
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b. Job Description / Goals The Job Description should be completed and uploaded to the Course Blackboard site. This form delineates the internship responsibilities and expected skill set.
If the Internship includes a project, then it should be described briefly on the project/job description form.
Goals are learning points that the student and Preceptor create together. The student must have an idea of what they want to learn. Goals should be aligned with the student’s specialty and should be measurable. The Internship Learning Goals form should be completed and uploaded to the Course Blackboard site. c. Internship Start & End Dates Internships generally begin at the start of the term, but cannot be started until the requirements for the Castle Branch Profile have been met, successful completion of HP 475 and enrollment in HP 480 is complete. These dates should be reflected on your HP 480 Internship Work Agreement Form. Unforeseen circumstances may arise that may interfere with the timeline of the experience. It is imperative that communication be made with all parties involved to adjust the timeline if necessary. Tracking entries are required for all hours if you want them counted toward the total hour requirement. Internships (which include your Castle Branch Profile) not completed by the end of the term will receive an "Incomplete" grade until all requirements are met. Note: POST YOUR SCHEDULE! Once your internship schedule is established, it is imperative that you provide the University with your planned schedule – there is an area on the Course Blackboard site for this information to be uploaded. In the event that your schedule changes over the course of the internship, you must UPDATE. d. Registering for the Internship Course Upon completion of all pre-registration requirements, the Health Services or Health Informatics Department will clear the student to register online for the appropriate section(s) of the course. e. Expectations to be Shared with Preceptor (see Appendix III) Please share with your Preceptor, the documents found in Appendix III. They will be valuable in guiding both your preceptor and you to a successful internship experience. 7. Professional Conduct a. Code of Conduct Conducting yourself in a professional manner with the highest standards of personal ethics is an absolute requirement. Violations of professional conduct and/or generally accepted standards of ethical behavior will be grounds for termination from the internship with assignment of a not passing grade.
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As an intern you will be expected to behave in a professional and ethical manner. Your conduct should be honorable, productive and represent the University in a manner such that hosts will want more USI students to follow. The College of Nursing and Health Professions (CNHP) has adopted a Social Media Policy. It is expected that all interns abide by this policy. Failure to do so will mean an administrative withdrawal from the internship experience and subsequent course. (See the Social Media Policy as a part of your Castle Branch Profile Information). You will read and sign the Social Media Policy as a part of the Castle Branch Profile. The following is expected of you as you participate in your internship and represent USI in the community.
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Assert yourself and your ideas in an appropriate and tactful manner Be fair, considerate, honest, trustworthy and cooperative when dealing with coworkers. DO NOT gossip. Communicate- keep people informed in a useful succinct way, listen and ask questions Do not conduct personal business during work hours (This is the use of any emails, cell phone, internet or appointments) Be observant- watch how people organize their thoughts, share them and how they respond to communications both positive and negative. Remain drug and alcohol free. Maintain confidentiality of work related projects and personnel. Familiarize yourself with and adhere to, relevant organizational arrangements, procedures and functions – this includes OSHA and HIPAA requirements. Understand what constitutes a permissible work absence and who to notify if absent, be prompt with being on time to work and with assignments. Always give your best effort! Changes in your work schedule, supervision or problems at your site must be reported to the internship coordinator. IF you feel victimized by a work related incident, contact the USI Internship program Instructor or Career Services Liaison. Dress appropriately for the work setting Follow through on commitments Be positive and look for opportunities to lend a hand or contribute. Keep an open mind. Practice developing Global Perspective by being an informed participant. Seek feedback from your supervisors, accept suggestions for corrective changes in behaviors and broaden your perspectives. Continuously strive to improve performance.
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8. Required Internship Components a. Internship Weekly Activity Tracking Form (see Appendix II) The internship tracking form is a detailed account of your daily activities: a record of your internship dates, hours and significant learning exercises, noting gaps between what you are learning and what you expected to learn.
Entries may briefly summarize your day’s events including points of interest or difficulties encountered Your entries may include a description of meetings attended, data compiled or materials read. It is the means by which you can track your own progress and provides necessary information for the integrative internship research paper. You and your Preceptor must sign and date weekly. o Forms will be submitted to the course Blackboard site.
b. Classroom Meetings & Midterm Review Periodic internship class meetings are conducted by the Internship Program Instructor and Career Services Liaison which are the on-campus, instructional component of the internship. These sessions provide an opportunity to exchange ideas and experiences, provide support, engage in problem solving, explore internship and work-related issues with other interns, and other professional development skills. Such exchanges also provide a chance to refine goals and objectives, and evaluate internship progress.
Attendance is mandatory (please notify your Preceptor of upcoming scheduled meetings so you may be excused from your scheduled internship hours if needed - meeting time does not count towards your required contact hours). You will discuss strategies so you can get the most benefit from your internship experience. Class meetings scheduling will vary and be determined each semester. You are responsible for coordinating a time with your Preceptor and Career Services Liaison for a midterm review of your goals and progress 3 weeks before midterm, please call career services for possible dates for the midterm review. The meeting can be by phone or face-toface and will last about an hour. You should plan several weeks before to schedule the meeting date. This is a mandatory requirement for successful completion of the Internship.
c. Professional Development
A pre-requisite for HP480 is the successful completion (C or above) of HP475.
d. Project Materials You are expected to complete at least one project for the agency. The project will be decided in consultation with your Preceptor. Your Preceptor will familiarize you with the overall functions/activities of your site and help you to identify appropriate projects. A summary of the experience will be presented to the class at the end of the semester.
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e. Reflection Report /Electronic Poster Symposium (see Appendix III) Please see the syllabus for details f. Evaluation This evaluation will have several components that may include, but not limited to: Midterm review with student and preceptor Online preceptor final evaluation g. Receiving a Grade for the Internship A "pass" or "no pass" grade will be recorded upon completion of the internship hours and all requirements. See the Course Syllabus for further details. 9. Unanticipated Situations Can Arise a. Activities not specified on the Internship Agreement Form As it is impossible to anticipate every internship activity, you may be asked to perform a function that you did not anticipate, but that is within the general expected duties of any internship. Certain tasks are common practice for most internship placements including photocopying, answering telephones, data management, letter-writing, delivery of documents, and on occasion, stuffing envelopes. However, as important as these activities are to the operation and success of any agency or program, they should not constitute the substance of your internship. If you feel that you are being asked to perform duties not in line with your goals, please feel free to contact either the Career Services Liaison or Program Instructor. b. Activities that compromise your personal or professional values or beliefs In the unlikely situation, that you are asked compromise your personal or professional values or beliefs, please contact either the Career Services Liaison or Program Instructor for further direction. c. Discrimination/Harassment You should not feel you are being harassed or discriminated against in any way. If such should occur, please contact either the Career Services Liaison or Program Instructor for further direction. 10. Glossary Affiliation Agreement: A formal Affiliation Agreement established between USI and your internship site – is only required by some agencies. It describes issues related to liability, scope of responsibility among other issues. If required, this inter-institutional agreement must be in place prior to the internship start date. AUPHA: The Association of University Programs in Health Administration, the accreditation and certification body for the Health Administration program. (http://www.aupha.org). Career Services: The professional currently employed by USI’s Career Services Department and Internships who has been assigned the responsibility of managing the relationship between USI and the community healthcare site. This person also ensures that NACE guidelines are met.
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Health Services/Health Informatics Students: Students enrolled in USI’s 120 credit hour Bachelor’s Degree in Health Services program, Specialty Track option or students enrolled in USI’s 120 credit hour Bachelor’s Degree in Health Informatics and Information Management 4-year program. HIPAA: Health Information Portability and Accountability Act (http://www.hhs.gov/ocr/privacy/) This Act guarantees the privacy of a patient’s/client’s health information. HIPAA Training can be found on the Health Services website at http://www.usi.edu/health/faculty-staff-resources/osha-and-hipaa-training Internship: The Educational experience of a Health Services student, Health Informatics student and a student with a Food and Nutrition major and Health Promotion and Worksite Wellness minor in a community setting where health services are provided. A total of six (6) credit hours must be earned to complete the Bachelor’s Degree in Health Services with a Specialty. This may be done in one internship or in two separate placements (using two separate application) of 150 hours (3 credits) each. Food and Nutrition majors with a Wellness Minor are required to complete HP 480 for a total of 3 credit hours equal to 150 hours of field experience. Internship Program Instructor: A faculty member in the Department of Health Services/Health Informatics, who serves as the instructor for the Internship in Health Services/Health Informatics and who is responsible of supervising/teaching the internship experience (HP 480). Memorandum of Understanding (MOU): The official agreement between the University and external Health Care Agencies and Facilities, generally referring to clinical settings such as hospitals. It is this legal agreement that will allow students to be a part of the agency/facility in a student intern capacity, and to ensure that appropriate liability insurance coverage is in place or any other requirements as established in the agreement. NACE: The National Association of Colleges and Employers, organizations which connects employers and career services professionals to provide best practices, trends, research, professional development, and conferences (http://www.naceweb.org/home.aspx). OSHA: Occupational Safety and Health Administration (https://www.osha.gov/) assures a safe workplace and that all workers are in compliance with standards that keep workers safe on the job. Training is found at http://www.usi.edu/health/faculty-staff-resources/osha-and-hipaa-training Preceptor: An appropriately credentialed and experienced health practitioner, who is employed full-time by a health agency and who serves as your on-site Internship Preceptor and mentor. Ideally, your Preceptor should possess a (graduate degree) with specialized training and experience in his/her chosen field. Other individuals who possess extensive experience, but without advanced degrees may also be approved as a Preceptor. The Preceptor is responsible for supervising your projects, duties and performance, completion of your evaluation, notifying Internship Program Instructor if problems are encountered during the internship period.
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APPENDIX I: Castle Branch Profile Instructions, Policy & Procedures
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Please go the website indicated below to order your Castle Branch Profile and choose your code: To place your order go to: https://portal.castlebranch.com/UE96 Step 1: Step 2: Step 3: Step 4: Step 5:
Click on “Place Order” Click on “Please Select" drop down Click on: Health Services Click on: UF02 package code Follow instructions on the screen
UF02 – Background Check, Drug Test & Medical Document Manager (drug tests are from LabCorp – 1200 Professional Blvd. Evansville, IN – price for drug test is included in the package
The email address you provide will become your username. Contact us: 888.914.7279 or
[email protected]
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Please go the website indicated below to order your Castle Branch Profile and choose your code: To place your order go to: https://portal.castlebranch.com/UE96 Step 1: Step 2: Step 3: Step 4: Step 5:
Click on “Place Order” Click on “Please Select" drop down Click on: Health Informatics Click on: UX09 package code Follow instructions on the screen
UX09 – Background Check, Drug Test & Medical Document Manager (drug tests are from LabCorp – 1200 Professional Blvd. Evansville, IN – price for drug test is included in the package
The email address you provide will become your username. Contact us: 888.914.7279 or
[email protected]
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Medical Document Manager Requirements Measles, Mumps & Rubella (M MR) One of the following is required: • 2 vaccinations OR • Positive antibody titer for (lab report OR physician verification of titer results required) for all 3 components. Varicella (Chicken Pox) One of the following is required: • 2 vaccinations OR • Positive antibody titer (lab report OR physician verification of titer results required) OR • Medically documented history of the disease that has been verified by a physician or nurse practitioner and contains their signature. Hepatitis B One of the following is required: • 3 vaccinations AND a positive antibody titer (lab report OR physician verification of results required) OR • Positive antibody titer (lab report OR physician verification of results required) Tuberculosis (TB) One of the following is required: 2 step TB skin test (2 separate TB Skin Tests within 1-3 weeks apart within the past 12 months), OR QuantiFERON Gold blood test within the past 12 months (negative laboratory report OR physician verification of negative results required), OR T-Spot TB blood test within the past 12 months (negative laboratory report or physician verification of negative results required), OR If positive results, provide a clear Chest X-Ray dated any time after the positive result (lab report OR physician verification of results required) Tetanus, Diphtheria & Pertussis (Tdap) Documentation of a Tdap booster within the past 10 years. Influenza One of the following is required: • Documentation of a flu vaccination administered by 12/01 the current flu season,OR/ • Declination of flu vaccine along with statement from Healthcare provider Physical Examination Download, print and complete the one page Report of Physical Examination and upload to this requirement. Must be signed by a medical professional. Medical History Download, print & complete the 2 page Report of Medical History form and upload to this requirement. CPR Certification One of the following is required: • American Heart Association Healthcare Provider course, OR American Red Cross CPR/AED for Professional Rescuers and Health Care Professionals OR • American Red Cross Basic Life Support for Healthcare Providers Students should submit proof of an approved American Heart Association or American Red Cross card, ecard, or certification of completion. Renewal date will be based on the expiration date.
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HIPAA Score CNHP website https://www.usi.edu/health/faculty-staff-resources/osha-and-hipaa-training/ Take the HIPAA test and print your HIPAA score and upload the document to this requirement. Confidentiality Statement Upload proof of your signed Confidentiality Statement to fulfill this requirement. Workforce Member Review of HIPAA policies Upload your signed Workforce Member Review of HIPAA policies document to fulfill this requirement. OSHA Score CNHP website https://www.usi.edu/health/faculty-staff-resources/osha-and-hipaa-training/ Take the OSHA test and print your OSHA score and upload the document to this requirement. Social Media Policy Download, print & complete the 2 page Social Media Policy form and upload to this requirement.
Document Manager Requirements Drug Test Submit documentation of a drug screen (minimum of 10 panel) administered within the past 3 months with lab report. If results are negative, you will be cleared for placement into your program. If results are positive, you must provide documentation from your physician validating you had a prescription(s) for the drugs in question, prior to being cleared for placement into your program. If your results are positive and you provide no documentation from your physician validating you had a prescription for the drug in question, this requirement will be rejected and you will need to contact your program administrator.
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This is what your profile will look like once you have purchased it. Upload your documents into each required section.
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Click on the (+) to show the drop down instructions for each requirement. This is where you will upload your documents that you have scanned on your computer.
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College of Nursing and Health Professions
HEALTH INFORMATION PRIVACY POLICIES & PROCEDURES Adopted Effective: April 14, 2003, Revised January 2014
These Health Information Privacy Policies and Procedures implement the College of Nursing and Health Professions’ obligations to protect the privacy of individually identifiable health information that we create, receive, or maintain. We implement these Health Information Privacy Policies and Procedures to protect the interests of our clients/patients and workforce; and to fulfill our legal obligations under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), its implementing regulations at 45 CFR Parts 160 and 164 (65 Fed. Reg 82462 (Dec. 28, 2000)) (“Privacy Rules”), as amended (67 Fed. Reg. 53182 [Aug. 14, 2002]), and state law that provides greater protection or rights to individuals than the Privacy Rules. As a member of our workforce or as our Business Associate, you are obligated to follow these Health Information Privacy Policies and Procedures faithfully. Failure to do so can result in disciplinary action, including termination of employment or dismissal from your educational program. In addition, federal penalties for privacy violations can result in fines up to $250,000 and prison sentences of up to 10 years. The workforce includes any individual whose work performance at the University Of Southern Indiana College Of Nursing and Health Professions, (College), is under the direct control of the College. The workforce defined as, but is not limited to, all clinical, administrative, and academic full-time, part-time, temporary, and contract employees, as well as volunteers, and students. These Policies and Procedures address the basics of HIPAA and the Privacy Rules that apply to the College. They do not attempt to cover everything in the Privacy Rules. The Policies and Procedures of the College utilize the terms “individual” to refer to prospective clients/patients, clients/patients of record, former clients/patients, those whose health information is retained by the College, or the authorized representatives of these identified individuals. On a yearly basis very member of the College workforce must participate in online HIPAA education and testing which is accessed through the College website, http://health.usi.edu/. The HIPAA quiz must be completed with a score of 75% or higher. If a score of 75% or higher is not achieved the quiz must be repeated until a passing score is achieved. If you have questions or doubts about any use or disclosure of individually identifiable health information or about your obligations under these Health Information Privacy Policies and Procedures, the Privacy Rules or other federal or state law, consult the College of Nursing and Health Professions Infection Control and HIPAA Committee at 812.464.1151 before you act.
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1. General Rule: No Use or Disclosure The College must not use or disclose protected health information (PHI), except as these Privacy Policies and Procedures permit or require. 2. Acknowledgement and Optional Consent The College will make a good faith effort to obtain a written acknowledgement of receipt of our Notice of Privacy Practices from an individual before we use or disclose his or her protected health information (PHI) for treatment, to obtain payment for that treatment, or for our healthcare operations (TPO). The College’s use or disclosure of PHI for payment activities and healthcare operations may be subject to a “need to know” basis. Consent from an individual will be obtained before use or disclosure of PHI for TPO purposes – in addition to obtaining an Acknowledgement of receipt of our Notice of Privacy Practices. a) Obtaining Consent –Upon the individual’s enrollment in a College education program, employment in the College, or first visit as a client/patient (or next visit if already a client/patient), consent for use and disclosure of the individual’s PHI for treatment, payment, and healthcare operations will be requested. The consent form will be retained in the individual’s file. b) Exceptions – Consent does not need to be obtained in emergency treatment situations; when treatment is required by law; or when communications barriers prevent consent. c) Consent Revocation – An individual from whom consent is obtained may revoke it at any time by written notice. The revocation will be included in the individual’s file. d) Applicability – Consent for use or disclosure of PHI should not be confused with informed consent for client/patient treatment. 3. Oral Agreement The College may use or disclose an individual’s PHI with the individual’s oral agreement. The College may use professional judgment and our experience with common practice to make reasonable inferences of the individual’s best interest in allowing a person to act on behalf of the individual to pick up health records, dental/medical supplies, radiographs, or other similar forms of PHI. 4. Permitted Without Acknowledgement, Consent Authorization or Oral Agreement The College may use or disclose an individual’s PHI in certain situations, without authorization or oral agreement. a) Verification of Identity the College will always verify the identity and authority of any individual’s personal representative, government or law enforcement official, or other person, unknown to us, who requests PHI before we will disclose the PHI to that person. The College will obtain appropriate identification and evidence of authority. Examples of appropriate identification include photographic identification card, government identification card or badge, and appropriate document on government letterhead. The College will document the request for PHI and how we responded. b) Uses, Disclosures, or Access Permitted under this Section 4 – Except where specifically authorized by the individual or appropriate representative or as required by law, protected individual information may only be used, disclosed, or accessed by:
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1. The individual or the individual’s personal representative 2. The College workforce members who require access to protected individual information as defined by their job role. Reasons for which protected individual information are generally needed include: a. delivery and continuity of the individual’s treatment or care. b. educational or research purposes, or c. College business or operational purposes 3. Non-College health care providers who need such information for the individual’s care. 4. Third-party payers or non-College health care providers for payment activities of such entities. 5. Business Associates from whom the College has received written assurance that protected individual information will be appropriately safeguarded. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
The College may use or disclose PHI in the following types of situations, provided procedures specified in the Privacy Rules are followed: For public health activities; To health oversight agencies; To coroners, medical examiners, and funeral directors; To employers regarding work-related illness or injury; To the military; To federal officials for lawful intelligence, counterintelligence, and national security activities; To correctional institutions regarding inmates; In response to subpoenas and other lawful judicial processes; To law enforcement officials; To report abuse, neglect, or domestic violence; As required by law; As part of research projects; and As authorized by state worker’s compensation laws.
5. Required Disclosures The College will disclose protected health information (PHI) to an individual (or to the individual’s personal representative) to the extent that the individual has a right of access to the PHI); and to the U.S. Department of Health and Human Services (HHS) on request for complaint investigation or compliance review. The College will document each disclosure made to HHS. 6. Minimum Necessary All College workforce members must access and use protected individual information on a "need to know" basis as defined by their job role. In addition, when using or disclosing an individual’s information the amount of information used or disclosed should be limited to the minimum amount necessary to accomplish the intended purpose. When requesting an individual’s information from other health care providers, staff should limit the request to the minimum amount necessary. Minimum necessary expectation does not generally apply to situations involving treatment or clinical evaluation. 7. Business Associates The College will obtain satisfactory assurance in the form of a written contract that our Business Associates will appropriately safeguard and limit their use and disclosure of the protected health information (PHI) we disclose to them. These Business Associate requirements are not applicable to our disclosures to a healthcare provider for treatment purposes. The Business Associate Contract Terms document contains the terms that federal law requires be included in each Business Associate Contract.
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a) Breach by Business Associate – If the College learns that a Business Associate has materially breached or violated its Business Associate Contract with us, we will take prompt, reasonable steps to see that the breach or violation is corrected. If the Business Associate does not promptly and effectively correct the breach or violation, we will terminate our contract with the Business Associate, or if contract termination is not feasible, report the Business Associate’s breach or violation to the U.S. Department of Health and Human Services (HHS). 8. Notice of Privacy Practices The College will maintain a Notice of Privacy Practices as required by the Privacy Rules. a) Our Notice – The College will use and disclose PHI only in conformance with the contents of our Notice of Privacy Practices. We will promptly revise a Notice of Privacy Practices whenever there is a material change to our uses or disclosures of PHI to legal duties, to an individual’s rights or to other privacy practices that render the statements in that Notice no longer accurate. b) Distribution of Our Notice – The College will provide our Notice of Privacy Practices to each individual who submits health information to the College. c) Acknowledgement of Notice – The College will make a good faith effort to document receipt of the Notice of Privacy Practices. 9. Individual’s Rights The College workforce will honor the rights of individuals regarding their PHI. a) Access – The College will permit individuals or workforce members access to their own PHI we or our Business Associates hold. No PHI will be withheld from an individual unless we confirm that the information may be withheld according to the Privacy Rules. We may offer to provide a summary of the health information. The individual must agree in advance to receive a summary and to any fee we will charge for providing the summary. b) Amendment – Individuals and workforce members have the right to request to amend their own PHI and other records for as long as the College maintains them. The College may deny a request to amend PHI or records if: (a) we did not create the information (unless the individual provides us a reasonable basis to believe that the originator is not available to act on a request to amend); (b) we believe the information is accurate and complete; or (c) we do not have the information. The College will follow all procedures required by the Privacy Rules for denial or approval of amendment requests. We will not, however, physically alter or delete existing notes. We will inform the individual or workforce member when we agree to make an amendment. We will contact any individuals whom the individual or workforce member requests we alert to any amendment to the PHI. We will also contact any individuals or entities of which we are aware that we have sent erroneous or incomplete information and who may have acted on the erroneous or incomplete information to the detriment of the individual or workforce member. When we deny a request for an amendment, we will mark any future disclosures of the contested information in a way acknowledging the contest. c) Disclosure Accounting – Clients/patients or workforce members have the right to an accounting of certain disclosures the College made of their PHI within the 6 years prior to their request. Each disclosure we make, that is not for treatment payment or healthcare operations, must be documented showing the date of the disclosure, what was Revised 3/18
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disclosed, the purpose of the disclosure, and the name and (if known) address of each person or entity to whom the disclosure was made. Documentation must be included in the client’s or workforce member’s record We are not required to account for disclosures we made: (a) before April 14, 2003; (b) to the individual (or the individual’s personal representative); (c) to or for notification of persons involved in an individual’s healthcare or payment for healthcare; (d) for treatment, payment, or healthcare operations; (e) for national security or intelligence purposes; (f) to correctional institutions or law enforcement officials regarding inmates; or (g) according to an Authorization signed by the patient or the patient’s representative; (h) incident to another permitted or required use disclosure. The College will charge a reasonable, cost-based fee for every accounting that is requested more frequently than every 12 month, provided that the College has informed the individual in advance of the fee and provides the individual with an opportunity to modify or withdraw the request. d) Restriction on Use or Disclosure – Individuals have the right to request the College to restrict use or disclosure of their PHI, including for treatment, payment, or healthcare operations. The College has no obligation to agree to the request, but if we do, we will comply with our agreement (except in an appropriate dental/medical emergency). We may terminate an agreement restricting use or disclosure of PHI by a written notice of termination to the individual. We will document any such agreed to restrictions. e) Alternative Communications – Individuals have the right to request the use of alternative means or alternative locations when communicating PHI to them. The College will accommodate an individual’s request for such alternative communications if the request is reasonable and in writing. The College will inform the individual of our decision to accommodate or deny such a request.
10. Staff Training and Management, Complaint Procedures, Data Safeguards, Administrative Practices a) Staff Training and Management Training – The College will train all members of our workforce in these Privacy Policies & Procedures, as necessary and appropriate for them to carry out their functions. Workforce members will complete privacy training prior to having access to PHI and on a yearly basis thereafter. The College will maintain documentation of workforce training. b.).Violation Levels and Disciplinary /Corrective Actions Below are examples of privacy and security violations and the minimum disciplinary / corrective actions that will be taken. Depending on the nature - Violations at any level may result in more severe action or termination.
Level of Violation
Level 1
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Examples
Failing to log-off/close or secure a computer with protected health information displayed.
Minimum Disciplinary /Corrective Action Staff: Verbal warning with documentation by immediate supervisor
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Carelessness
Level II
Undermining
Accountability
Leaving a copy of protected health information Students: Verbal warning with (PHI) in a non-secure area. documentation by clinical faculty and/or discussing protected health information (PHI) in Program Director a non-secure area (lobby, hallway, cafeteria, elevator) Faculty: verbal warning with documentation by Program Director or Dean Sharing ID/password with another coworker or Staff: Written performance counseling encouraging a coworker to share ID/password. Repeated violation of previous level Students: Written performance counseling by clinical faculty and/or Program Director Faculty: Written performance counseling by Program Director or Dean
Level III Unauthorized Access
Accessing or allowing access to protected health Staff: Final performance improvement information (PHI) without having a legitimate counseling reason. Repeated violation of previous levels. Students: Written performance counseling and Program Director determines disciplinary action. Faculty: Written performance counseling and Program Director or Dean determines disciplinary action.
Level IV Blatant Misuse
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Accessing or allowing access to protected health information (PHI) without having a legitimate reason and disclosure or abuse of the protected health information (PHI). Using protected patient information (PPI) for personal gain. Tampering with or unauthorized destruction of information.
INITIATE TERMINATION Staff: Initiate termination of employment Students: Initiate dismissal procedures
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Repeated violations of previous levels
Faculty: Dean determines disciplinary action/sanction including initiating termination of employment
b) Complaints – The College will implement procedures for individuals to complain about compliance with our Privacy Policies and Procedures or the Privacy Rules. The College will also implement procedures to investigate and resolve such complaints. The complaint form can be used by the individual to lodge the complaint. Each complaint received must be referred to the College Compliance Committee immediately for investigation and resolution. We will not retaliate against any individual or workforce member who files a complaint in good faith. c) Data Safeguards – The College will strengthen these Privacy Policies and Procedures with such additional data security policies and procedures as are needed to have reasonable and appropriate administrative, technical, and physical safeguards in place to ensure the integrity and confidentiality of the PHI we maintain. The College will take reasonable steps to limit incidental uses and disclosures of PHI made according to an otherwise permitted or required use or disclosure. d) Documentation and Record Retention – The College will maintain in written or electronic form all documentation required by the Privacy Rules for six years from the date of creation or when the document was last in effect, whichever is greater. e) Privacy Policies & Procedures – The College of Nursing and Health Professions Infection Control and HIPAA Committee will make any needed changes to the Privacy Policies and Procedures. 11. State Law Compliance The College will comply with state privacy laws that provide greater protections or rights to individuals than the Privacy Rules. 12. HHS Enforcement The College will give the U.S. Department of Health and Human Services (HHS) access to our facilities, books, records, accounts, and other information sources (including individually identifiable health information without individual authorization or notice) during normal business hours (or at other times without notice if HHS presents appropriate lawful administrative or judicial process). We will cooperate with any compliance review or complaint investigation by HHS, while preserving the rights of the College. 13. Designated Personnel The Chairperson of the College of Nursing and Health Professions Infection Control and HIPAA Committee will serve as Privacy Officer and contact person for the College.
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APPENDIX II: Career Services Forms/HP 480 Internship Forms
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HP 480 INTERN SITE PRECEPTOR CONTACT INFORMATION Student Name__________________________________ Student ID#_____________________ Concentration___________________ Class for internship_____________ Semester________ Student email Student phone ________________________________________________________________ Site Supervisor Name __________________________________________________________ Supervisor Title/Position ________________________________________________________ Supervisors phone ____________________________________________________________ Supervisors mailing address _____________________________________________________ Supervisors email _____________________________________________________________ Start date of this Internship Number of site hours needed for this internship ______________________________________ Date of midterm visit ___________________________________________________________
This form must be returned to the Health Services or Health Informatics and Information Management Department – Room 2145.
E-mail
[email protected] with Health Services questions. E-mail
[email protected] with Health Informatics and Information Management questions. Have any further questions? Please e-mail
[email protected]
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HP 480 INTERNSHIP WORK AGREEMENT We, the undersigned, have read the following and agree: This contract and any other forms required by the Faculty Supervisor, Field Supervisor, or Internship Coordinator must be completed before the internship begins. Calculation of hours spent in the field begins after the proper contracts have been returned to the University. No credit will be given if this condition is not met, regardless of time spent in the field. The intern should honor the ethical standards and professional codes and practices of the field of the internship and of the university. The internship should provide varied learning experiences and activities; it should not exploit the intern. The intern’s work responsibilities and work schedule, including vacation time, shall be arranged by the intern and the internship field supervisor. The number of working hours per internship shall be a minimum of 150/300 (circle one) hours per semester. The student will maintain a log or portfolio documenting the internship. The faculty internship supervisor may require additional material which will be stated below. The student will complete all paperwork provided in the internship packet including a goals statement, two (2) evaluations, and a final paper. The legal agreement between the University and the organization shall be effective until formally rescinded by Career Services and the organization. The internship field supervisor will provide continual evaluative information to the intern regarding the intern’s work and will submit a minimum of two written evaluations to the University. The intern shall schedule periodic conferences with the faculty internship supervisor. The number and nature of these conferences shall be determined by the faculty internship supervisor. Failure to adhere to an agreed upon schedule of these conferences will result in the termination of the internship. The internship may also be terminated at any time that (1) one or more of the above conditions is violated; or (2) an agreement to terminate is decided mutually between below signed parties. If termination is due to negative actions of the intern, a failing grade may be assigned. The following additional requirement(s) shall be met: _____________________________________ INTERN
_____________________________________ HOST SUPERVISOR & Company Name
_____________________________________ USI FACULTY SUPERVISOR
_____________________________________ USI INTERNSHIP COORDINATOR
Semester_____________________________________ Date______________________________________________ This form must be returned to the Health Services or Health Informatics and Information Management Department – Room 2145. E-mail
[email protected] for Health Services questions, and
[email protected] for Health Informatics Questions. Have any further questions? Please e-mail
[email protected]
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HP 480 Requirements Contract
Please complete this contract with your Internship Preceptor and return it to the Health Services or Health Informatics and Information Management office in HP2145 or email a copy to the Internship Program Instructor or Career Services Liaison. It is the policy of the Health Services Program, the Health Informatics and Information Management program and the College of Nursing and Health Professions that those students intending to complete HP 480 internships must meet minimum specific training and profile requirements prior to beginning an approved internship. 1. USI HP 480 Specific Training and Profile Requirements: The following information provides a review of the specific training and profile requirements for students wishing to complete an internship in HP 480: Hepatitis B One of the following is required: • 3 vaccinations AND a positive antibody titer (lab report OR physician verification of results required) OR • Positive antibody titer (lab report OR physician verification of results required) CPR Certification One of the following is required: • American Heart Association BLS Provider course, OR • American Red Cross CPR/AED for Professional Rescuers and Health Care Professionals OR • American Red Cross Basic Life Support for Healthcare Providers Students should submit proof of an approved American Heart Association or American Red Cross card, e-card, or certification of completion. Renewal date will be based on the expiration date. Physical Examination Download print and complete the one page Report of Physical Examination and upload to this requirement. Must be signed by a medical professional. Influenza One of the following is required: • Documentation of a flu vaccination administered by 12/01 the current flu season, OR/ • Declination of flu vaccine along with statement from Healthcare provider Tetanus, Diphtheria & Pertussis (Tdap) Documentation of a Tdap booster within the past 10 years. Varicella (Chicken Pox) One of the following is required: • 2 vaccinations OR • Positive antibody titer (lab report OR physician verification of titer results required) OR • Medically documented history of the disease that has been verified by a physician or nurse practitioner and contains their signature. Measles, Mumps & Rubella (MMR) One of the following is required: • 2 vaccinations OR • Positive antibody titer for (lab report OR physician verification of titer results required) for all 3 components. Tuberculosis (TB) One of the following is required: 2 step TB skin test (2 separate TB Skin Tests within 1-3 weeks apart within the past 12 months), OR QuantiFERON Gold blood test within the past 12 months (negative laboratory report OR physician verification of negative results required), OR T-Spot TB blood test within the past 12 months (negative laboratory report or physician verification of negative results required), OR If positive results, provide a clear Chest X-Ray dated any time after the positive result (lab report OR physician verification of results required) Medical History Download, print & complete the 2 page Report of Medical History form and upload to this requirement. OSHA Score CNHP website http://www.usi.edu/health/faculty-staff-resources/osha-and-hipaa-training
Take the OSHA test and print your OSHA score and upload the document to this requirement. HIPAA Score CNHP website http://www.usi.edu/health/faculty-staff-resources/osha-and-hipaa-training
Take the HIPAA test and print your HIPAA score and upload the document to this requirement. Confidentiality Statement Upload proof of your signed Confidentiality Statement to fulfill this requirement. Workforce Member Review of HIPAA policies Upload your signed Workforce Member Review of HIPAA policies document to fulfill this requirement. Social Media Policy Download, print & complete the 2 page Social Media Policy form and upload to this requirement. Drug Test Submit documentation of a drug screen (minimum of 10 panel) administered within the past 3 months with lab report. If results are negative, you will be cleared for placement into your program. If results are positive, you must provide documentation from your physician validating you had a prescription(s) for the drugs in question, prior to being cleared for placement into your program. If your results are positive and you provide no documentation from your physician validating you had a prescription for the drug in question, this requirement will be rejected and you will need to contact your program administrator.
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HP 480 Requirements Contract
The student will incur the cost of these requirements unless otherwise covered by the facility. Please note if any of the above requirements will be completed on site:
Additional Requirements:
Any Additional Comments:
Student Signature ____________________________________________________________ Date __________________ Supervisor/Preceptor Signature ________________________________________________ Date __________________ Work Site ________________________________________________________ Semester Internship ________________
This form must be returned to the Health Services or Health Informatics and Information Management Department – Room 2145. E-mail
[email protected] with Health Services questions. E-mail
[email protected] with Health Informatics and Information Management questions. Have any further questions? Please e-mail
[email protected]
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HP 480 INTERNSHIP LEARNING GOALS Internships are most productive when students articulate and record their learning goals at the beginning of the work experience. First, determine what learning you hope to gain from the internship. Then, discuss with your supervisor to make sure the position will offer you the opportunity of achieving these goals. At mid-term, we will evaluate the progress of your goal achievements. To be meaningful, goal statements must be: Specific Measurable Verifiable Achievable Agreed upon List five goals below which you wish to achieve as a result of participating in this internship experience. These learning goals should be discussed in you final paper. GOAL STATEMENTS: 1. _________________________________________________________________________ _________________________________________________________________________ 2. _________________________________________________________________________ _________________________________________________________________________ 3. _________________________________________________________________________ _________________________________________________________________________ 4. _________________________________________________________________________ _________________________________________________________________________ 5. _________________________________________________________________________ _________________________________________________________________________
Name__________________________________________ Today’s Date__________________ Host Signature __________________________________ Date _________________________ Work Site_______________________________________ Semester Internship____________
Post to Course Blackboard Site
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HP 480 JOB DESCRIPTION SAMPLE FOR INTERNSHIP Title of Preceptor: Title of Project: Skills (needed for this project):
Additional Skills (desired for internship): MS Publisher, music, Excel
Brief Description of Company:
Description of Responsibilities (may include but not limited to):
Project description:
Post to Course Blackboard Site
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Course #_______ HP 480 Internship Weekly Activity Tracking Form Please use this form to track the days, hours and activities completed during your practicum. You are required to complete 150 hours for this practicum. This weekly summary should be submitted to your site supervisor weekly. The documents should be retained for your records.
Date
Hours
Activities for the day:
What I learned from these activities:
Student Signature: __________________________________________ Date: _________________ Site Supervisor Signature: ____________________________________ Date: _________________ Post to Course Blackboard Site
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APPENDIX III: Expectations for Preceptor
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Expectations for Preceptor HP 480 Internship Work Agreement Form The student must submit the signed agreement form to the Health Services or Health Informatics and Information Management department before they can register for the HP480 course. Contact Hours/Credit Hours Students may opt for a 3-credit (150-hour) or a 6-credit (300 hour) Internship, as is arranged with you, as Preceptor. Contact hours (150-300) must be completed on site at the agency, and/or under supervision of the Preceptor. Internship-related work performed at home does not count as “contact hours.” The student is to keep record of their time and activities on the tracking form. The Preceptor is encouraged to sign and date the form each week. It is usually best when interns can be onsite at least twice per week. This provides them with substantial exposure to the agency so that they can become acquainted with agency personnel and to maximize their learning opportunities. Preceptor Responsibilities/ Expectations
Develop meaningful and challenging experiences relating to the intern’s academic and career goals as per Goals/Project Form.
Provide the Intern with appropriate orientation to the organization, work environment, and organization policies and procedure including expected performance standards; office etiquette and attire; work hours; telephone manners; availability of supplies; confidentiality; and process for resolution of ethical dilemmas.
Define the role of the intern and communicate this role to the intern and relevant staff.
If possible, schedule activities that allow the intern to gain broad exposure to the professional field as well as to develop proficiency at more narrow tasks.
Provide oversight of Intern’s projects, duties, and performance.
Schedule regular supervisory meetings with the intern to enable the intern to ask questions, resolve problems, report on his/her progress, receive training and instructions, and receive advice related to his/her future career plans.
At the end of the internship, an exit interview should be conducted with the intern to discuss the Preceptor Evaluation Form (link for evaluation form will be emailed at midterm and upon completion of interns contact hours).
Notify the Internship Instructor or Career Services Liaison immediately of any problems or if you have questions or suggestions.
If internship is conducted at place of employment, Preceptor will assure that internship activities will be different than Intern’s regular job duties/activities.
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Expectations of Intern’s Professional Conduct All interns must conduct themselves in a professional manner (dress, personal hygiene, and minimal use of personal electronic devices). During the winter months, The University of Southern Indiana may designate a snow day. Interns are expected to follow the agencies work calendar (national holidays) not the universities holidays. However, if travel conditions are unsafe they should notify you that they cannot be present. Discrimination/ Harassment Interns should be provided a copy of the agency’s policy on discrimination and harassment. Termination from the Internship Program Please contact the Internship Program Instructor or Career Services Liaison immediately in the event of violations of professional conduct and/or generally accepted standards of ethical behavior.
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USI STUDENT INTERN PRECEPTOR GUIDE The faculty and staff of the USI Health Services and Health Informatics and Information Management Departments want to thank you for hosting one of our students. We believe the best way to learn is through experience and we appreciate you sharing your time and talent to make this possible. We encourage our students to be the contact point and resource for most of your information from the university. This is their learning experience. However, at any point we encourage you to contact Kathy Weinzapfel, Career Coordinator, at 812-464-1865 in the USI Career Services Office with any questions or concerns. We have three points we hope each intern has an opportunity to experience during this 150 or 300 hr. hour internship. We encourage our students to become involved in a project that requires most of their time. This is a project the two of you agree upon. It should allow the student to gain a deeper understanding of your agency and how it works. We believe your Staff is the best teachers to give a student insight into careers within your industry. We hope there is time for the intern to meet with various department personnel to learn their duties, career path and training. Students need a wide variety of experiences to help them develop their academic and professional skills. For many of our students this is the first experience in their chosen academic field. They will depend on your guidance to introduce them to the functions and responsibilities of your company or department. However they should demonstrate the initiative to ask questions and offer assistance at any time. Your role is their coach to guide, encourage, redirect and praise whenever it is appropriate. We sincerely appreciate your partnership in giving USI students an opportunity to experience actual working environment in their chosen field. We hope this will be as rewarding for you as we know it will be for the student. Sincerely, Kathy Weinzapfel Career Services Coord. College Nursing & Health Professions Dept. Education, Social Work, Kinesiology, Exercise Science
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APPENDIX IV: Internship Reflection Report Instructions
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Internship Reflection Instructions The purpose of this paper is for you to describe your internship experience, and discuss how your experience relates to larger issues and challenges facing the health care system. This paper should demonstrate the application of knowledge gained from your coursework to your internship activities and should be included in your professional portfolio! I.
Overview of the Agency/Organization a. Brief history and mission. b. Overview of services provided. c. Organizational Chart and identification of your internship placement within the organization. d. Company policies that affected your placement e. Required knowledge, skills, and attributes to be successful working in this setting
II.
The Healthcare Environment a. What are the major issues facing the current health care environment? b. Discuss how these issues are impacting the organization/agency where you completed your internship. c. How is the organization/agency responding to these challenges? d. In what way was the focus of your internship related to these issues?
III.
Description of internship activities including procedures and responsibilities a. Describe the major activities/projects that you completed or contributed to during your internship. b. What types of computer applications were utilized? c. Describe data compiled, materials reviewed, and work produced (where relevant). d. How did your activities/projects contribute to the organization’s mission? e. How did the organization benefit from your projects/output?
IV.
Activities log summary Include a written, detailed account of daily/ongoing activities including number of hours and meetings attended. i. Identify points of interest and/or difficulties experienced j. Describe inconsistencies/consistencies between what you learned in specific classes and what you experienced during your internship.
V.
Internship Assessment a. Employment and orientation process to the internship site – was this adequate? What was good/missing? b. Self-evaluation of internship. c. Supervisor relationships. d. Benefits gained through internship experience.
VI.
Assessment of Preparation for Internship a. Which classes best prepared you for your internship and why? b. Identify coursework or activities you wish you had prior to your internship. c. Suggested changes that would have strengthened your internship experience.
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APPENDIX V: Infection Control Policy
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College of Nursing and Health Professions Infection Control Policy Academic Year 2017-2018 REVISED May 2014 / October2015/ May 2016/No revisions for May 2017
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Introduction Protecting health care professions students from exposures to pathogenic microorganisms is a critical component of the clinical education environment. Clinical situations present the possibility for contact with blood, body fluid, or biological agents which pose infectious disease risk, particularly risk associated with the hepatitis B virus, hepatitis C virus, the human immunodeficiency virus, and tuberculosis. Medical histories and examinations cannot identify all clients infected with pathogens. Therefore, the concept of STANDARD PRECAUTIONS is to be practiced with all clients during treatment and post-treatment procedures. Standard precautions encompass the standard of care designed to protect health care providers and clients from pathogens that may be spread by blood or any other body fluid, excretion, or secretion. Clients must be protected from disease transmission which can occur via contaminated hands, instruments, and other items. Use of appropriate infection control procedures will minimize this risk of transmission. Guidelines for reducing risk of disease transmission have been issued by many health related organizations. The Bloodborne Pathogens Standard issued through the Federal Occupational Safety and Health Administration along with recommendations from the Centers for Disease Control and Prevention, (CDC), provide the basis for the University of Southern Indiana College of Nursing and Health Professions Infection Control Policy developed by the College of Nursing and Health Professions Infection Control and HIPAA Committee. The policies and procedures contained in the Infection Control Policy are designed to prevent transmission of pathogens and must be adhered to by all students and faculty in the College of Nursing and Health Professions when participating in clinical education experiences where the potential for contact with blood or other potentially infectious materials (OPIM) exists. These experiences include clinical practice on peers. The goal of the Infection Control Policy is to provide procedures and guidelines to be used by students to prevent transmission of infectious diseases while participating in clinical/laboratory activities while enrolled as a student in the College of Nursing and Health Professions. Exposure to infectious diseases is an integral part of practicing as a health care professional (HCP). All students must recognize and accept this risk in order to complete their education and participate fully in their chosen career. Students may not refuse to care for a client solely because the client has an infectious disease or is at risk of contracting an infectious disease such as HIV, AIDS, HBV, HCV, or TB. PROFESSIONAL STANDARDS OF INDIVIDUAL DISCIPLINES MAY NECESSITATE EXCEPTIONS TO THE PRECEDING STATEMENT. All information regarding a client's medical status is considered confidential and shall be used for treatment purposes only. No information about the client's medical status will be disclosed or reported without the client's express written consent, except in those cases as stipulated by law. The curriculum of each program in the College of Nursing and Health Professions includes information regarding the etiology, symptoms, and transmission of infectious diseases, as well as specific methods of preventing disease transmission to be utilized in various clinical sites. This information will be provided to the student prior to initiation of clinical experiences. Information contained in the Infection Control Policy will be reviewed with students on an annual basis or more often if changes in content occur.
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The College of Nursing and Health Professions Infection Control and HIPAA Committee will review the Infection Control Policy annually and will make revisions as additional information becomes available that impacts content. The Committee will also evaluate exposure incidents to determine the need for modification of the Infection Control Policy policies/procedures.
Medical Evaluation, Immunizations, and Record Keeping All students admitted to a clinical program in the College of Nursing and Health Professions are required to undergo comprehensive medical evaluation prior to enrolling in professional courses.
Vaccines Recommendations Adapted from Immunization Coalition www.immunize.org
Vaccine
Recommendations in brief
Hepatitis B
Give 3-dose series (dose #1 now, #2 in 1 month. #3 approximately 5 months after #2). Give IM. Obtain anti-HBs serologic testing 1-2 months after dose #3.
Influenza
Give 1 dose of influenza vaccine annually. Give inactivated injectable influenza vaccine intramuscularly or live attenuated influenza vaccine (LAIV) intranasally.
MMR
For healthcare personnel (HCP) born in 1957 or later without serologic evidence of immunity or prior vaccination, give 2 doses of MMR, 4 weeks apart. For HCP born prior to 1957, see below. Give SC.
Varicella (chickenpox)
For HCP who have no serologic proof of immunity, prior vaccination, or history of varicella disease, give 2 doses of varicella vaccine, 4 weeks apart. Give SC.
Tetanus, diphtheria, pertussis
Give a one-time dose of Tdap as soon as feasible to all HCP who have not received Tdap previously. Give Td boosters every 10 years thereafter. Give IM.
Meningococcal
Give 1 dose to microbiologists who are routinely exposed to isolates of N. meningitidis. Give IM or SC.
Hepatitis A, typhoid, and polio vaccines are not routinely recommended for HCP who may have on-the-job exposure to fecal material
Hepatitis B http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6210a1.htm Vaccination All HCP whose work-, training-, and volunteer-related activities involve reasonably anticipated risk for exposure to blood or body fluids should be vaccinated with a complete, ≥3-dose HepB vaccine series. OSHA mandates that vaccination be available for employees within 10 days of initial assignment. HCP trainees should complete the series before the potential for exposure with blood or body fluids, when possible, as higher risk has been reported during professional training (e.g., residency training). Incompletely vaccinated HCP should receive additional dose(s) to complete the vaccine series. The vaccine series does not need to be restarted for HCP with an incomplete series; however, minimum dosing intervals should be heeded. Minimum dosing intervals are 4 weeks between the first and second dose, 8 weeks between the second and third dose, and 16 weeks between the first and third dose. HCP lacking documentation of HepB vaccination should be considered unvaccinated (when documentation for HepB vaccine doses is lacking) or incompletely vaccinated (when documentation for some HepB vaccine doses is Revised 3/18
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lacking) and should receive additional doses to complete a documented HepB series. Health-care institutions are encouraged to seek documentation of "missing" HepB doses in IIS, when feasible, to avoid unnecessary vaccination. Postvaccination Serologic Testing HCP who have written documentation of a complete, ≥3-dose HepB vaccine series and subsequent postvaccination anti-HBs ≥10 mIU/mL are considered hepatitis B immune. Immunocompetent persons have long-term protection against HBV and do not need further periodic testing to assess anti-HBs levels. All HCP recently vaccinated or recently completing HepB vaccination who are at risk for occupational blood or body fluid exposure should undergo anti-HBs testing. Anti-HBs testing should be performed 1–2 months after administration of the last dose of the vaccine series when possible. HCP with documentation of a complete ≥3-dose HepB vaccine series but no documentation of anti-HBs ≥10 mIU/mL who are at risk for occupational blood or body fluid exposure might undergo anti-HBs testing upon hire or matriculation. Testing should use a quantitative method that allows detection of the protective concentration of anti-HBs (≥10 mIU/mL) (e.g., enzyme-linked immunosorbent assay [ELISA]).
Completely vaccinated HCP with anti-HBs ≥10 mIU/mL are considered hepatitis B immune. Immunocompetent persons have long-term protection and do not need further periodic testing to assess anti-HBs levels. Completely vaccinated HCP with anti-HBs <10 mIU/mL should receive an additional dose of HepB vaccine, followed by anti-HBs testing 1–2 months later. HCP whose anti-HBs remains <10 mIU/mL should receive 2 additional vaccine doses (usually 6 doses total), followed by repeat anti-HBs testing 1–2 months after the last dose. Alternatively, it might be more practical for very recently vaccinated HCP with anti-HBs <10 mIU/mL to receive 3 consecutive additional doses of HepB vaccine (usually 6 doses total), followed by antiHBs testing 1–2 months after the last dose.
Vaccine Nonresponders Vaccinated HCP whose anti-HBs remains <10 mIU/mL after revaccination (i.e., after receiving a total of 6 doses) should be tested for HBsAg and anti-HBc to determine infection status. Those determined not to be HBV infected (vaccine nonresponders) should be considered susceptible to HBV infection. No specific work restrictions are recommended for vaccine nonresponders College of Nursing and Health Profession students should complete the Hepatitis B Nonresponder Acknowledgement Form in CastleBranch. For non-responders: HCP who are non-responders should be considered susceptible to HBV and should be counseled regarding precautions to prevent HBV infection and the need to obtain HBIG prophylaxis for any known or probable parenteral exposure to hepatitis B surface antigen (HBsAg)-positive blood.1 It is also possible that non-responders are persons who are HBsAg positive. Testing should be considered. HCP found to be HBsAg positive should be counseled and medically evaluated. Note: Anti-HBs testing is not recommended routinely for previously vaccinated HCP who were not tested 1–2 months after their original vaccine series. These HCP should be tested for anti-HBs when they have an exposure to blood or body fluids. If found to be anti-HBs negative, the HCP should be treated as if susceptible.1
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Influenza All students admitted to clinical programs and completing internships will receive annual vaccination against influenza. All HCP students participating in volunteer assignments should follow the guidelines of the facility. Live attenuated influenza vaccine (LAIV) may only be given to non-pregnant healthy HCP age 49 years and younger. Inactivated injectable influenza vaccine (TIV) is preferred over LAIV for HCP who are in close contact with severely immunosuppressed persons (e.g., stem cell transplant patients) when patients require protective isolation.
Measles, Mumps, Rubella (MMR) http://www.cdc.gov/measles/hcp/index.html
HCP who work in medical facilities should be immune to measles, mumps, and rubella. For healthcare personnel (HCP) born in 1957 or later without serologic evidence of immunity or prior vaccination, give 2 doses of MMR, 4 weeks apart. For HCP born prior to 1957, see below. Give subcutaneously.
• HCP born in 1957 or later can be considered immune to measles, mumps, or rubella only if they have documentation of (a) laboratory confirmation of disease or immunity or (b) appropriate vaccination against measles, mumps, and rubella (i.e., 2 doses of live measles and mumps vaccines given on or after the first birthday and separated by 28 days or more, and at least 1 dose of live rubella vaccine). HCP with 2 documented doses of MMR are not recommended to be serologically tested for immunity; but if they are tested and results are negative or equivocal for measles, mumps, and/or rubella, these HCP should be considered to have presumptive evidence of immunity to measles, mumps, and/or rubella and are not in need of additional MMR doses. Although birth before 1957 generally is considered acceptable evidence of measles, mumps, and rubella immunity, 2 doses of MMR vaccine should be considered for unvaccinated HCP born before 1957 who do not have laboratory evidence of disease or immunity to measles and/or mumps. One dose of MMR vaccine should be considered for HCP with no laboratory evidence of disease or immunity to rubella. For these same HCP who do not have evidence of immunity, 2 doses of MMR vaccine are recommended during an outbreak of measles or mumps and 1 dose during an outbreak of rubella. Varicella http://www.cdc.gov/chickenpox/hcp/index.html It is recommended that all HCP be immune to varicella. Evidence of immunity in HCP includes documentation of 2 doses of varicella vaccine given at least 28 days apart, history of varicella or herpes zoster based on physician diagnosis and signature, laboratory evidence of immunity, or laboratory confirmation of disease.
Tetanus/Diphtheria/Pertussis (Td/Tdap) http://www.cdc.gov/vaccines/vpd-vac/tetanus/default.htm
All adults who have completed a primary series of a tetanus/diphtheria-containing product (DTP, DTaP, DT, Td) should receive Td boosters every 10 years. HCP of all ages with direct patient contact should be given a 1-time dose of Tdap, with priority given to those having contact with infants younger than age 12 months.
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References www.vaccineinformation.org http://www.cdc.gov All students and faculty who have client contact are required to be immunized or provide documentation of laboratory confirmation of disease or immunity against varicella, mumps, measles, and rubella. All students and faculty who have client contact are required to be immunized against tetanus, pertussis and diphtheria, and to receive annual influenza immunization. All students admitted to a clinical program in the College of Nursing and Health Professions will receive baseline TB screening within 12 months prior to admission, using two-step TST, a single BAMT to test for infection with M. tuberculosis,t-Spot, or quantiFERON Blood Gold Test.
Tuberculosis Exposure/Conversion http://www.cdc.gov/tb/topic/testing/healthcareworkers.htm A student or faculty who is exposed to tuberculosis or whose negative PPD test converts to positive, will be referred to the Vanderburgh County Public Health Department for evaluation
Two-Step TST Testing
After baseline testing for infection with M. tuberculosis, HCPs should receive TB screening annually (i.e., symptom screen for all HCWs and testing for infection with M. tuberculosis for HCPs with baseline negative test results).
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HCPs with a baseline positive or newly positive test result for M. tuberculosis infection or documentation of previous treatment for Latent Tuberculosis Infection (LTBI) or TB disease should receive one chest radiograph result to exclude TB disease. Instead of participating in serial testing, HCPs should receive a symptom screen annually. This screen should be accomplished by educating the HCP about symptoms of TB disease and instructing the HCP to report any such symptoms immediately to the occupational health unit. Treatment for LTBI should be considered in accordance with CDC guidelines.
Record Keeping 1. All records related to a student's medical status and program required documents will be maintained by CertifiedBackground.com also known as CastleBranch. Reports related to medical records and other documents will be available to program administrators. 2. The records will be maintained separately from all other student records. 3. The records will be maintained in a secured and confidential manner and will not be disclosed or reported without the student's express written consent. 4. Student workers will not have access to student or faculty medical records.
HIV Positive, HBV, or HCV Chronic Carrier Students and Faculty A. Students and faculty are encouraged to know their HIV, HbsAG, and anti-HCV status and report positive status to the Dean and the Infection Control and HIPAA Committee of the College of Nursing and Health Professions. Such individuals should consult with their health care provider to assess the risks of clinical practice to their health and to others. The health care provider should make written recommendations related to the student's education experience. The Dean and the Infection Control and HIPAA Committee will review each case individually and, if indicated, will recommend appropriate modifications of the clinical experiences. B. All information regarding a student's medical status will be considered confidential and will not be disclosed or reported without the student's express written consent. C. A student's HIV, HBV and/or HCV status will not determine a student's opportunity to be admitted or progress in a program. The HIV, HBV, and/or HCV status will be considered only as it relates to: (1) the student's ability to safely carry out the normal assignments associated with the course of study and (2) the student's long term health.
Exposure Potential A. All HCP participating in clinical activities have the potential for skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials (contained in the following list) and will adhere to policies and procedures contained in the Infection Control Policy. Adherence is required without regard to the use of personal protective equipment. B. Other Potentially Infectious Materials (OPIM) semen vaginal secretions cerebrospinal fluid synovial fluid pleural fluid pericardial fluid peritoneal fluid amniotic fluid breast milk Revised 3/18
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saliva/sputum airborne infections body fluids visibly contaminated with blood any unfixed tissue or organ (other than intact skin) from a human (living or dead) HIV containing cells or tissues cultures HIV, HBV, or HCV containing culture medium or other solutions blood, organs, or other tissues from experimental animals infected with HIV, HBV, or HCV
Percutaneous/Mucous Membrane Exposure to Blood or Other Potentially Infectious Materials (Exposure Incident) A. An exposure that might place HCP at risk for HIV infection is defined as a percutaneous injury (eg, a needlestick or cut with a sharp object) or contact of mucous membrane or non-intact skin (eg, exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious. In addition to blood and visibly bloody body fluids, semen and vaginal secretions are also considered potentially infectious. Although semen and vaginal secretions have been implicated in the sexual transmission of HIV, they have not been implicated in occupational transmission from patients to HCP. The following fluids are also considered potentially infectious: cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid. Exposures are to be reported immediately, (within 2 hours of the incident), by the student to the clinical instructor so that appropriate post-exposure procedures can be initiated. An exposure is considered an urgent medical concern. A delay in reporting/treatment of the incident may render recommended HIV post-exposure prophylaxis, (PEP), ineffective. If a delay occurs, (defined as later than 24-36 hours after the incident), it is advised that expert consultation for HIV/PEP be sought. The clinical instructor will complete the agency incident report, the University Injury or Illness Report, and the College of Nursing and Health Professions Student Exposure Incident Report, and Acknowledgement of Refusal if applicable. The completed college report and the university report will be submitted to the College of Nursing and Health Professions Infection Control and HIPAA Committee for review. The University report will be forwarded by the College of Nursing and Health Professions Infection Control and HIPAA Committee to appropriate University personnel. The clinical instructor will also notify the course coordinator and program administrator of the exposure incident.
B. After a percutaneous or mucous membrane exposure to blood or body fluids, the student is to follow USPHS and clinical site policy for immediate post-exposure wound cleansing/infection prophylaxis such as cleansing the affected area with antimicrobial soap, irrigation of the eyes or mouth with large amounts of tap water or saline.
C. The source client, if known, should be tested serologically for evidence of HIV, HbsAg and anti-HCV. HIV consent must be obtained from the source client prior to testing. Testing should be within 2 hours if at all possible.
D. The exposed HCP will be referred for medical attention and counseling by a physician immediately. Most current recommendations include:
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If source is unknown, the use of Post Exposure Prophylaxis (PEP) is to be decided on a case by case basis taking into consideration of exposure. If the source patient from whom the practitioner was exposed has a reasonable suspicion of HIV infection or is HIV positive and the practitioner anticipates that hours or day may be required, antiretroviral medications should be started immediately. Page 57 of 71
Severity of the exposure to determine the number of drugs to be offered should no longer be used. PEP should be stopped if source patient is determined HIV negative. The HCP should receive base-line testing for the HIV virus. Follow-up counseling should be within 72 hours of exposure with additional follow up in 6 and 12 weeks and again at 6 months. The full article: Updated US Public Health Service Guidelines for the management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Post-exposure Prophylaxis can be read at: http://www.jstor.org/stable/10.1086/672271
Hepatitis B Post Exposure Procedure http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5516a3.htm?s_cid=rr5516a3_e The following chart outlines the CDC recommendations for hepatitis B post-exposure prophylaxis following percutaneous exposure. TABLE 4. Recommended postexposure prophylaxis for percutaneous or permucosal exposure to hepatitis B virus --- Advisory Committee on Immunization Practices, United States (2016) Vaccination and antibody response status of exposed person Unvaccinated
Source not tested or status unknown
Source HBsAg-positive
Source HBsAg-negative
HBIG x 1; initiate HB vaccine series
Initiate HB vaccine series
Initiate HB vaccine series
No treatment
No treatment
No treatment
No treatment
If known high-risk source, treat as if source were HBsAgpositive
No treatment
If known high-risk source, treat as if source were HBsAgpositive
Previously vaccinated Known responder Known nonresponder
After 3 doses
After 6 doses
HBIG x 1 and initiate revaccination
HBIG x 2 (separated by 1 month)
Test exposed person for anti-HBs Antibody response unknown
If adequate,* no treatment If inadequate,* HBIG x 1 and vaccine booster
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Test exposed person for anti-HBs No treatment
If adequate,* no treatment If inadequate,* initiate revaccination Page 58 of 71
Abbreviations: HBsAg = Hepatitis B surface antigen; HBIG = hepatitis B immune globulin; anti-HBs = antibody to hepatitis B surface antigen; HB = hepatitis B. Source: Adapted from CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP). Part II: immunization of adults. MMWR 2006;55(No. RR-16). * A seroprotective (adequate) level of anti-HBs after completion of a vaccination series is defined as anti-HBs ≥10 mlU/mL; a response < 10 mlU/mL is inadequate and is not a reliable indicator of protection.
Hepatitis C Procedure The following chart outlines the CDC recommendations for hepatitis C post-exposure prophylaxis following percutaneous exposure. Exposed Individual Perform baseline testing for anti-HCV and alanine aminotransferase (ALT) activity
Source Client Perform testing for anti-HCV
Perform follow-up testing at 4-6 months for antiHCV and ALT activity
Additional Information For additional information related to management of exposure incidents refer to: http://www.cdc.gov/oralhealth/InfectionControl/faq/bloodborne_exposures.htm National Clinicians’ Post-exposure Prophylaxis Hotline: http://nccc.ucsf.edu/clinician-consultation/pep-post-exposure-prophylaxis/ Needlestick Reference: http://www.cdc.gov/niosh/topics/bbp/emergnedl.html Immunization Action Coalition: http://www.immunize.org/ http://www.cdc.gov/vaccines/ Morbidity and Mortality Weekly Report: http://www.cdc.gov/mmwr/index.html
Methods of Reducing Potential for Exposure to Pathogens Standard Precautions Standard precautions refer to the prevention of contact with blood, all body fluids, secretions, and excretions except sweat, and must be used with every client. Exposure of non-intact skin and mucous membranes to these fluids must be avoided. All body fluids shall be considered potentially infectious materials.
Engineering and Work Practice Controls Engineering and work practice controls shall be used to eliminate or minimize exposure to blood or OPIM. An example of an engineering control would include the use of safer medical devices, such as sharps with engineered sharps injury protection and needleless systems. Where potential exposure remains after institution of these controls, personal protective equipment shall also be used. The following engineering controls will be utilized: Revised 3/18 Page 59 of 71
1. Hand washing is a significant infection control measure which protects both the student and the client. Students will wash their hands before donning gloves and immediately or as soon as feasible after removal of gloves or other personal protective equipment. Students will wash hands and any other skin with soap and water or flush mucous membranes with water immediately or as soon as feasible following contact with blood or OPIM. No nail polish or artificial fingernails are allowed during clinical activities. Jewelry has the potential to harbor microorganisms. Refer to individual program handbooks for specific guidelines regarding wearing jewelry during clinical activities. Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. Antiseptic soaps and detergents are the next most effective and nonantimicrobial soaps are the least effective. When hands are not visibly dirty, alcohol-based hand sanitizers are the preferred method for cleaning your hands in the healthcare setting. Soap and water are recommended for cleaning visibly dirty hands
During Routine Patient Care: Wash with soap and water
When hands are visibly dirty After known or suspected exposure to Clostridium difficile if your facility is experiencing an outbreak or higher endemic rates After known or suspected exposure to patients with infectious diarrhea during norovirus outbreaks If exposure to Bacillus anthracis is suspected or proven Before eating After using a restroom
Use an Alcohol-Based Hand Sanitizer
For everything else
http://www.cdc.gov/handhygiene/index.html 2. Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in treatment areas or any other area where there is a reasonable likelihood of exposure to blood or OPIM. 3. Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on counter tops or bench tops where blood or OPIM are present. 4. All procedures involving blood or OPIM shall be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances. 5. Mouth pipetting/suctioning of blood or OPIM is prohibited. 6. Sharps Management Sharps are items that can penetrate skin and include injection needles, scalpel blades, suture needles, irrigation cannulas, instruments, and broken glass. It is recommended that the clinician select the safest medical device and/or technique available to help reduce needlesticks and other sharps injuries. The use of needles should be avoided where safe and effective alternatives are available.
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All disposable contaminated sharps shall be disposed of immediately or as soon as feasible in closable, puncture resistant, leak proof on sides and bottom, and labeled containers. The container must be maintained in an upright position and must not be overfilled. Sharps disposal containers must be readily accessible and located in reasonable proximity to the use of sharps. Containers containing disposable contaminated sharps are not to be opened, emptied, or cleaned manually or in any other manner which could create a risk of percutaneous injury. Contaminated needles and other contaminated sharps shall not be bent, sheared, recapped or removed unless no alternative is feasible or is required by a specific procedure. If recapping is necessary, a one handed technique or mechanical recapping device must be used. Reusable contaminated sharps shall be placed in leak proof, puncture resistant, labeled containers while waiting to be processed. Sharps containers must be closed before they are moved. HCP are not to reach by hand into containers of contaminated sharps. Contaminated broken glass should be picked up using mechanical means such as a brush and dust pan, tongs, or forceps. Whenever possible, sharps with engineered sharps injury protection or needleless systems should be used.
7. Specimens of blood or OPIM shall be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping. The container must be closed before being stored, transported, or shipped. If outside contamination of the primary container occurs, or if the specimen could puncture the primary container, the primary container shall be placed within a secondary container which prevents leakage, and/or resists puncture during handling, processing, storage, transport, or shipping.
8. Equipment Sterilization
a. Reusable heat stable instruments are to be sterilized by acceptable methods. b. Heat sterilization equipment will be monitored for effectiveness and records will be maintained.
9. Equipment which may be contaminated with blood or OPIM shall be examined prior to servicing or shipping and shall be decontaminated as necessary. Equipment which has not been fully decontaminated must have a label attached with information about which parts remain contaminated.
Personal Protective Equipment 1. Personal protective equipment including gloves, gowns, laboratory coats, face masks, eye protection or face shields, resuscitation bags, pocket masks or other ventilation devices shall be used whenever there is the potential for exposure to blood or OPIM.
2. Personal protective equipment must not permit blood or OPIM to pass through to or reach the student's clothes, skin, eyes, mouth, or other mucous membranes.
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3. All personal protective equipment must be removed prior to leaving the treatment area. When personal protective equipment is removed it shall be placed in an appropriately designated area or container for storage, washing, decontamination, or disposal.
Gloves Gloves shall be worn in the following situations:
when it can be reasonably anticipated that hands may contact blood, OPIM, mucous membranes, or non-intact skin. when performing vascular access. when handling or touching contaminated items or surfaces.
Disposable gloves
shall be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised. shall be replaced if excessive moisture develops beneath the glove. shall not be washed or decontaminated for re-use. if contaminated, must be covered by over gloves when handling non-contaminated items (e.g. client charts)
Utility gloves
may be decontaminated for re-use if the integrity of the glove is not compromised. must be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised.
Masks
Masks shall be changed between clients. Masks shall be changed when excessive moisture develops beneath the surface.
Eye Protection
goggles or glasses with solid side shields, or chin length face shields, shall be worn whenever splashes, spray, spatter, aerosols, or droplets of blood or OPIM may be generated and eye, nose or mouth contamination can be reasonably anticipated.
Protective Body Clothing
Appropriate protective clothing such as gowns, aprons, lab coats, clinic jackets, or similar outer garments shall be worn in potential exposure situations. Surgical caps or hoods and/or shoe covers or boots shall be worn in instances when gross contamination can reasonably be anticipated. Protective body clothing must be changed when visibly contaminated with blood or OPIM or if they become torn or punctured.
Housekeeping Equipment and Environmental and Working Surfaces
Contaminated work surfaces shall be decontaminated after completion of procedures using a tuberculocidal chemical disinfectant having an Environmental Protection Agency (EPA) registration number. Decontamination must occur between clients, immediately or as soon as feasible when surfaces are contaminated, or after any spill of blood or OPIM.
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Protective coverings, such as plastic wrap, aluminum foil, or imperviously-backed absorbent paper used to cover equipment and surfaces are to be removed and replaced as soon as feasible when they become contaminated. Protective coverings do not replace decontamination with tuberculocidal chemical disinfectant.
Reusable bins, pails, cans, and similar receptacles are to be regularly inspected for contamination with blood or OPIM and decontaminated as needed.
Infectious Waste Management 1. Infectious waste is defined as: contaminated disposable sharps or contaminated objects that could potentially become contaminated sharps infectious biological cultures, infectious associated biologicals, and infectious agent stock pathological waste blood and blood products in liquid and semi-liquid form carcasses, body parts, blood and body fluids in liquid and semi-liquid form, and bedding of laboratory animals other waste that has been intermingled with infectious waste 2. Infectious waste must be placed in labeled containers which are closable, constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping. 3. Containers must be closed prior to moving/removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping. If the outside of the container becomes contaminated it is to be placed in a second container which must have the same characteristics as the primary container.
Definitions of Terms/Abbreviations AIDS
Acquired Immune Deficiency Syndrome A disabling or life threatening illness caused by HIV (human immunodeficiency virus). It is the last stage on the long continuum of HIV infection and is characterized by opportunistic infections and/or cancers.
Anti-HBs - Hepatitis B Surface Antibody
The presence of anti-HBs (hepatitis B surface antibodies) in an individual's blood indicates immunity to hepatitis B disease. This is the test used to indicate that a person has had a serologic response to hepatitis B immunization and has developed antibodies to the infection.
Anti-HCV – Hepatitis C antibody virus
Indicates past or present infection with hepatitis C
CDC
Centers for Disease Control and Prevention The branch of the U.S. Public Health Service whose primary responsibility is to propose, coordinate and evaluate changes in the surveillance of disease in the United States.
Delayed Report
Not reporting an exposure incident until 24 hours or more hours following the exposure.
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Exposure Incident
A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties.
HBIG Hepatitis B Immune Globulin
A type of vaccine administered in the event of an exposure to hepatitis B disease. The administration of this preparation confers a temporary (passive) immunity or raises the person's resistance to hepatitis B disease.
HBsAg - Hepatitis B Surface Antigen
A surface antigen of the hepatitis B virus. Indicates potential infectivity.
HCP
Health Care Personnel / Professional
HIV - Human Immunodeficiency Virus
The organism that causes AIDS.
LTBI
Latent Tuberculosis Infection
OPIM - Other Potentially Infectious Materials
Materials other than human blood that carry the potential for transmitting pathogens.
PEP
Post Exposure Prophylaxis
Standard Precautions
Treating all clients as if they are infected with a transmissible disease.
Universal Precautions
Treating all clients as if they are infected with a transmissible bloodborne disease.
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College of Nursing and Health Professions Management of Exposure Incidents Any percutaneous (needle stick, cut, human bite, splash to non-intact skin, etc.) or mucous membrane (splash to eyes, lips, or mouth) exposure to blood, blood products, other body fluids, or air borne exposures must be reported immediately by the student to the clinical faculty so that appropriate post-exposure procedures can be initiated. The Public Health Services (PHS) recommends that treatment should be recommended to healthcare workers who experience occupational high-risk exposures. Please see the College of Nursing and Health Profession’s Infection Control Manual for further information.
Management of Exposure Incidents Checklist
For exposures other than air-borne exposures: The affected area was cleansed with antimicrobial soap. Water was run through glove if puncture was suspected. Eyes: The eyes were irrigated for one minute. Mouth: The mouth cleansed with tap water for fifteen minutes. Injury or Illness Report completed. Student Exposure Incident Report completed. Clinical Facility’s Incident Report completed. Exposed student provided a copy of the Student Exposure Incident Report and sent by clinical faculty for treatment. (Refer to clinical site policy for exposure incident treatment.) [For TB exposures, students will receive notice of exposure to suspected or active cases of TB through either the employee health department of the clinical facility where they were exposed or, in cases of active TB, through the county health department. Instructions for follow-up are provided by the notifying department. Source Patient Management: The source client, if known, should be serologically tested for evidence of HIV, HbsAg, and anti-HCV. Please circle one:
Source patient known and tested
Source patient known and refused testing Source patient unknown
Not applicable
Clinical Faculty Signature: ____________________________________________Date: ____________________
The completed Injury or Illness Report, Student Exposure Incident Report and exposure check list returned to Clinical Coordinator within 24 hours or as soon as possible.
Clinical Coordinator Signature: _______________________________________ Date: _____________________
Postexposure management/counseling completed. Students have the right to be counseled about exposure by university faculty if desired. Please Circle One: Counseling completed
Counseling denied
University Faculty Signature: _________________________________________ Date: ____________________
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College of Nursing and Health Professions Acknowledgement of Refusal to Seek Management of Exposure Incident Any percutaneous (needlestick, cut, human bite, splash to non-intact skin, etc.) or mucous membrane (splash to eye, lips, or mouth) exposure to blood, blood products, body fluids, or airborne pathogens is to be reported immediately by the student to the clinical faculty so that appropriate post-exposure procedures can be initiated. The Public Health Services, (PHS), recommends that treatment should be recommended to healthcare workers who experience occupational high-risk exposures. Please refer to the College of Nursing and Health Professions Infection Control Policy.
I understand that I have been advised to seek prompt management of an exposure incident. At this time, I am refusing referral to a healthcare professional for recommendation regarding the need for evaluation and the need for chemoprophylaxis. Date of Exposure Incident: ________________ Time of Exposure Incident: ________________ Institution where incident took place: _______________________________________________ Summary of incident: ____________________________________________________________ _____________________________________________________________________________ ____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Student Name: _________________________________________________________________ Student Signature: _____________________________________Date/Time:________________ Advising Faculty:___________________________________________Date:________________
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College of Nursing and Health Professions Student Exposure Incident Report Exposed Student Information: Program: ______________________________________________________________________ Student Name: ___________________________________________DOB:__________________ Date Incident Occurred: _________ Time Incident Occurred: _______ Time Reported: _______ Does the student have a positive hepatitis B titer? [ ] yes
[ ] no
Post-vaccination HBV antibody status, if known: [ ] positive [ ] negative [ ] unknown Date of Last Tetanus Vaccination: ____________ Date of Last Tuberculin Test: ______________ Exposure Incident Information: Agency/site where incident occurred (include specific unit): _____________________________ Type of incident: [ [ [ [ [ [ [
] needle stick ] instrument puncture ] bur laceration ] injury from other sharp object: ____________________________________________ ] blood/other body fluid splash or spray ] human bite ] other ________________________________________________________________
Area of body exposed: ___________________________________________________________ Type of body fluid/tissue/airborne pathogen exposed to: _______________________________ Describe incident in detail: ________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ What barriers were being used by the student when the incident occurred? [ ] gloves
[ ] mask
[ ] eye wear
[ ] gown
[ ] other ___________________
Source Patient Information: Review of source patient medical history:
[ ] yes [ ] no
Verbally questioned regarding: History of hepatitis B, hepatitis C, or HIV infection Revised 3/18
[ ] yes [ ] no Page 67 of 71
High risk history associated with these diseases
[ ] yes [ ] no
Patient consents to be tested for HBV, HCV, and HIV
[ ] yes [ ] no
Referred to (name of evaluating healthcare professional/facility): ________________________ Incident report completed by: _____________________________________________________ Student Signature: __________________________________________ Date: _______________ Post-exposure management/counseling: Date: ______________________________ Time: ____________ Comments: ____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Counselor Signature: ____________________________________________________________ University Injury of Illness Report Completed: Signature: __________________________________________________ Date: ______________ Clinical Instructor Signature: ___________________________________ Date: ______________ Student Acknowledgment: I have reviewed and confirm the accuracy of the information contained in this report. I acknowledge that I have been referred for medical evaluation and may need to receive additional medical evaluation as prescribed by the physician. I authorize the release of the information related to this exposure incident for treatment, payment activities, and healthcare operations. Student Signature: ___________________________________________ Date: ______________ TO BE COMPLETED BY THE COLLEGE OF NURSING AND HEALTH PROFESSIONS INFECTION CONTROL COMMITTEE
Corrective action needed: _______________________________________________________ _____________________________________________________________________________ Has this action been taken?
[ ] yes
[ ] no
Is further investigation needed?
[ ] yes [ ] no
Comments: ____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Signature: _________________________________________________Date _______________ Revised 3/18
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Instructions for Completing the Injury or Illness Report Print off the document below OR Proceed to electronic version to complete and print for your USI Department Chair http://www.usi.edu/riskmanagement/forms/accidentinjury-forms 1. Completion of Forms
a. Employee and Student Worker injury or illness will be completed by security and or student health services if first aid or medical treatment is needed. If first aid or additional medical treatment is not needed, this form is completed by the department head or supervisor and forwarded to human resources. The form should be completed and returned to Human Resources within 24 hours of occurrence. b. Student and Visitor (non-employee) injury or illness reports will always be completed by security and or Student Health Services. c. Acknowledgement of refusal to seek management of exposure incident must be completed if the person in question refuses to seek management of exposure incident.
2. Timeliness of Reporting Any accidents or injuries which are reported late, i.e., not within a few hours of the occurrence, should be reported directly to the department head or supervisor, whom will then be responsible for completing the entire injury or illness report. The form should then be sent to Human Resources within 24 hours of the occurrence. 3. Distribution of Field Injury or Illness Reports a. Employee and Student Worker reports with sections A and B completed are to be sent (in whole) to Human Resources. Human Resources will then distribute copies to Security, Purchasing, Student Health Services, the Department Head or Supervisor, and the Vice President for business Affairs, while retaining a copy in Human Resources. After the Department Head/ Supervisor receives the report from Human Resources with sections A and B completed, the Department Head/Supervisor should review the injury/accident situation, complete section C on the report, and return it to human resources. b. Student and Visitor reports retained in Student Health Services (if not Originating in this department, the report should be sent there.) Copies are distributed by Student Health Services to the Security and Purchasing departments.
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