Faculty Clinical Compliance Policy
The purpose of the UIC College of Nursing Faculty Clinical Compliance Policy is to protect the health and safety of our faculty, patients and clinical site staff.
In addition, the many clinical agencies with which UIC Nursing contracts for teaching and research have policies that must be adhered to, per legal contractual agreement.
Scope of Applicability Heading link
Faculty employed by the College of Nursing who have direct interaction with patients or research subjects must achieve compliance with all health, safety, and legal requirements at the time of hire and prior to any contact with patients or research subjects.
Continuing faculty must maintain full compliance with all renewable requirements annually. Please consult the flowchart to the right to determine. Faculty adherence to these compliance requirements is expected.
New faculty/staff must be in compliance with this policy at the time of their hiring. Current faculty/staff must follow this policy by the beginning of the semester they are hired for.
A list of UIC Nursing faculty/staff to whom this policy applies must be provided by each department head or associate department head before the beginning of every semester and as needed.
Procedures
This policy covers requirements for:
- Immunization titers or vaccine series for Measles, Mumps, Rubella, and Varicella Zoster (MMRV)
- Positive hepatitis B surface antibody (anti-HBs) titer or vaccine series for Hepatitis B
- Tuberculosis test
- Annual influenza vaccine (Due November 30 annually)
- Current “Basic Life Support (BLS) Healthcare Provider” CPR Card
- Professional licenses
- Annual HIPAA training certification
- Tetanus, Diphtheria and Pertussis
UIC Nursing faculty/staff who interact with patients are at risk of exposure to and possible transmission of vaccine-preventable diseases. Immunizations and other health requirements protect faculty/staff, students, and patients from the risk of vaccine-preventable diseases.
In addition, required current “BLS Healthcare Provider” CPR card and professional licenses equip faculty/staff with basic skills to be qualified healthcare professionals. These requirements help to ensure provision of safe care to patients and allow faculty to fulfill their educational responsibilities to students.
Mandatory HIPAA training helps to ensure compliance with minimum federal standards for safeguarding the privacy of individually identifiable health information. As covered entities, UIC Nursing faculty/staff must comply with HIPAA privacy rules.
New-Current Employees Heading link
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New Employees
All newly employed faculty/staff whose work requires their presence in patient care settings will complete a health screening which includes health questionnaire, immunity review and drug screen.
To complete this process, new employees must make an appointment with University Health Services (UHS) by calling 312.996.7420.
For each new employee, the HR Team compiles the (1) Request for Pre-placement Health Evaluation form and (2) Miscellaneous Stores/Service/ Requisition/Voucher form and sends them to UHS.
This allows the new employee’s health record to be generated before the employee visits UHS. For assistance, contact Human Resources at nurs-HR@uic.edu.
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Current Employees
Among the current faculty/staff whose work involves visits to patient care settings, those who do not meet the immunization or other health requirements covered by this policy must demonstrate and document compliance.
New and current faculty can schedule an appointment with UHS by calling 312.996.7420.
They must print a copy of their health records regarding serology testing and immunization and a completed UIC Nursing Faculty/Staff registration form (Appendix A), which must include their name and UIN.
They must take those documents to their UHS appointment.
Immunization Sites - Regional Campuses Heading link
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Rockford
Faculty may utilize their clinical employers (non-UIC) or their own healthcare providers.
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Springfield & Peoria
Springfield Clinic MOHA
775 Engineering Avenue, Springfield, IL 62703
springfieldclinic.com
Phone: 217.522.4300 -
Urbana
SafeWorks Illinois (For titers, TB tests, and drug screens)
1806 N. Market Street, Champaign IL 61822
safeworksillinois.com
Phone: 217.356.6150For immunization and boosters, please contact your primary care physician.
UIC University Health Service (UHS) - Chicago Campus Heading link
E-144 Medical Sciences Building (MSB)
835 S. Wolcott Ave.
Chicago, IL 60612
Required immunizations and health documents for faculty/staff whose work requires their presence in clinical settings Heading link
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Hepatitis B
Individuals must undergo testing for Hepatitis B antibodies.
- Titers will be evaluated by UHS in accordance with the Centers for Disease Control and Prevention (CDC) guidelines.
- Hepatitis B vaccinations will be offered by UHS in accordance with CDC recommendations and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard.
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Tuberculosis
Tuberculosis (TB) screening test must be performed on hire and annually thereafter.
The preferred method of TB screening is the QuantiFERON TB Gold In-tube (QTBG) blood assay.
- The results of the test will be evaluated by UHS.
- If the test result is positive, documentation of treatment plan needs to be submitted to UHS.
- An individual with a new positive QTBG test result must be evaluated by UHS. A chest x-ray will be required. The employee will be provided with documentation of their test results, may be instructed to consult with a personal physician, regarding further evaluation and/or therapy.
- A positive tuberculosis screening test will not affect their employment status unless active TB disease is present.
- An annual TB Signs and Symptoms Questionnaire must be completed by each individual having either a positive QTBG test result or a positive purified protein derivative (PPD) skin test result.
- Individuals may submit current QTBG test results from outside institutions.
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Measles-Mumps-Rubella-Varicella
Each individual must submit documentation of immunity to measles, mumps, rubella and varicella based on vaccinations or serology testing for each disease.
UHS will follow CDC guidelines for healthcare workers. UHS will evaluate the serology results. If results show lack of immunity, UHS will determine the immunization treatment plan in accordance with CDC guidelines.
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Tetanus, Diphtheria & Pertussis
Tetanus, Diphtheria and Pertussis (Tdap) vaccination is required. The CDC recommends a single dose of Tdap for healthcare personnel who have never received Tdap regardless of the time since their most recent Td vaccination. After receiving 1 dose of Tdap, healthcare personnel should receive a dose of Td or Tdap every 10 years.
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Influenza
Individuals must be immunized during the fall season each year with the current influenza vaccine. The influenza vaccination compliance due date is November 30 each year, which is consistent with UI Health policy.
Faculty/staff who decline to have influenza vaccination for medical or religious reasons must submit a completed Influenza Vaccination Exemption Request Form (Appendix B) to UHS. The exemption request will be reviewed. The faculty/staff will receive an exemption approval notification if the exemption has been approved.
Any healthcare personnel declining annual flu vaccine must have one of the valid contraindications, as listed below.
- A history of Guillain-Barre Syndrome within six weeks following a previous dose of influenza vaccine is considered to be a precaution for use of influenza vaccines by the CDC. Verifiable documentation is required from a licensed healthcare provider.
- Other medical contraindications will be reviewed on a case-by-case basis. Verifiable documentation is required from a licensed healthcare provider.
- An Influenza Vaccination Declination Committee approved exemption: An employee may be granted an exemption for Reasons of Religion if receiving the vaccination would violate the employees sincerely held religious beliefs.
- If a person has a contraindication but still desires to get the influenza vaccine, they should discuss it with their primary healthcare provider. If the primary healthcare provider administers the influenza vaccination, the staff member must provide documentation of vaccination to UHS.
Documentation requirement
- Documentation of vaccine acquired outside of the UHS:
- Will be reviewed by UHS.
- Must be verifiable and include date, place, and signature of the provider who gave the vaccine.
- Documentation will be required annually.
- Medical contraindications:
- Written verification of the contraindication to influenza vaccination from the healthcare worker’s personal physician or primary healthcare provider must be provided to the UHS as part of a work ability visit to evaluate for a work accommodation.
- Religious exemption:
- Sufficient documentation expressing a personal belief regarding the disallowing of vaccination must be submitted to the Influenza Vaccination Declination Committee in care of UHS leadership.
Exemption process
- An employee requesting a religious exemption must write a personal statement that reflects a sincerely held religious conviction in strong opposition to the vaccination to UHS no later than Sept. 1.
- The written statement will be reviewed by the Influenza Vaccination Declination Committee.
- Notification of approval or the need for further conversation between the employee and an Influenza Vaccination Declination Committee member will occur within 15 days of receipt of the religious exemption request by the University Health Service leadership. An employee asked to have further conversation with the Committee shall be entitled to union representation during any such conversation.
- If the employee’s exemption is denied, the employee has 7 days from the date of the denial notice to appeal to Hospital Administration for review. Appeal request must be submitted to uihhrcompliance@uic.edu.
- Hospital Administration will respond in writing within 7 days of receipt of the appeal.
- Documentation must be submitted and approved by the influenza Vaccination Declination Committee no later than 4 p.m. on the last business day of September, in accordance with procedures established by UHS. Staff who do not have an approved declination confirmation will be considered to be non-compliant with hospital policy if healthcare personnel fail to receive the influenza vaccine no later than Nov. 30.
- Healthcare personnel can exercise their option to receive the influenza vaccination and withdraw an exemption request at any time during this process.
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Drug Screening Test
A drug screening test is not required but can be provided by UHS. In particular, during encounters with new employees, UHS provides a drug screening test.
The drug screening test includes the following panel: Amphetamines, PCP, Cocaine, Methamphetamine, Barbiturates, Benzodiazepines, Opiates, Propoxyphene, and Methadone.
Current “BLS Healthcare Provider” CPR Certification Heading link
Faculty whose UIC Nursing work involves their presence in patient settings for clinical practice, teaching, and/or research must submit their current American Heart Association (AHA) “BLS Healthcare Provider” CPR certification to the UIC Nursing Director of Compliance. Based on AHA policy, this certification must be renewed and submitted every 2 years.
CPR certifications issued by organizations other than AHA will be accepted if the associated training is administered in accordance with AHA guidelines.
Current Professional Licenses
Professional licenses include active registered nurse (RN) and/or advanced practice registered nurse (APRN) licenses. Illinois RN and APRN licenses must be renewed by May 30 every even year (e.g., next renewal due date is May 31, 2024). Professional licensing is a requirement for all employees whose role includes teaching nursing students.
The Director of Compliance and or designee will review current professional licenses in Illinois Department of Financial & Professional Regulation’s (IDFPR) electronic database.
Each department HR officer reviews the current professional license of each new employee as one of the employment requirements and uploads into the Banner system.
The UIC Nursing Director of Compliance maintains licensure database and obtains updated licensure information from faculty every other year.
Annual HIPAA Training Certification
Faculty/staff compliance with the HIPAA training requirement is confirmed by the HIPAA and Security Officer’s department upon electronic receipt of notification of HIPAA training completion. All new employees of UIC Nursing whose work involves their presence in patient settings for clinical practice, teaching, and/or research must complete HIPAA training at the time of hiring.
If a faculty/staff member is an employee of UI Health, the individual must complete the HIPAA training course via the UI Health learning management system (LMS). UI Health will assign the individual to the course. If the faculty/staff member has any difficulties accessing or completing the course via the UI Health LMS, the individual should place a ticket using the LMS support request online form.
If a faculty/staff member is not an employee of UI Health, the required HIPAA training course will be provided by training.knowbe4.com. If you are not able to log into the site, request training using the tool below. The Security Officer will enroll the faculty/staff member in the HIPAA training course. The College of Nursing Director of Compliance will provide the list of faculty/staff required to complete HIPAA training to the HIPAA and Security Officer, which will allow the officer to assign them to the HIPAA training course.
The UIC Nursing Director of Compliance checks and updates faculty/staff’s HIPAA compliance status and may confirm an individual’s completion of HIPAA training with the HIPAA and Security Officer.
Use the following University of Illinois link, to find general information on HIPAA.
Request HIPAA Training Heading link
Fees Heading link
Fees
Fees for titers and immunizations required under this policy are covered by UIC Nursing when these services are conducted at UHS. If a faculty/staff member is an employee of UI Health, UI Health takes precedence over UIC Nursing as the payment entity. If a faculty/staff member obtains titers and immunizations at outside entity, they are not covered by UIC Nursing.
CastleBranch Heading link
CastleBranch
CastleBranch is the website used to store and screen your compliance documents. CastleBranch is a third-party company and not managed by UIC College of Nursing. Therefore, it is the employee’s responsibility to upload their documentation directly to the site. Directions on how to create an account will be supplied to you either by your Department Head or the Compliance Director. For technical issues contact CastleBranch directly at 888.723.4263. For all other issues, contact the Compliance Director.
