Clinical Compliance (Policy SON-01)
Last Revision Date
School of Nursing Divisional Dean, Chief Nurse Administrator, Program Directors, faculty, staff, and students.
Scope and Audience
All School of Nursing faculty and students.
CHS: Student Background Check (Policy 313), Student Drug and Alcohol Testing (Policy 314)
1. Policy Purpose
To define clinical compliance requirements and measures for the School of Nursing.
2. Policy Statement
Requirements For Attending Clinical Courses
As per contractual agreements with our clinical partners, background checks, drug screens, CPR certification, tests for tuberculosis and certain vaccinations and immunizations are required.
Students are responsible for all costs related to health requirements for the School of Nursing and any partner health systems.
Some, or all, of these requirements may be gathered by an outside company, depending on the program. The company used will be based on contractual agreements in place at the time requirements are due. Students will be notified prior to the beginning of the program-specific Health Requirement cycles of details. For some School of Nursing programs, in addition to an account for background check and drug screens, an account for health requirement tracking may be required. Students may also be required, based on their clinical placement, to have accounts through additional outside vendors in order to meet the requirements of their clinical placement. Should this be necessary, you will be notified by your program and all costs incurred will be the responsibility of the student.
Verification Of Enrollment in Medical Insurance
Neither the College of Health Sciences, the Departments or Divisions within the College, nor the clinical agencies carry health insurance for students. All students enrolled and participating in clinical coursework through the College of Health Sciences must be covered by a medical insurance policy. Documentation of current health insurance coverage must be provided.
Students in the School of Nursing may be required to have and maintain a clean background check. Students are admitted to School of Nursing Programs conditionally, pending completion of a clean background check by the deadline date provided by specific programs.
Students are responsible for following the program-specific account set-up requirements, arranging payment, and directly handling any disputed results with the vendor at the time of check or recheck. Please note School of Nursing designated staff have access to all results but will not initiate or process appeals or corrections through the vendor. Decisions regarding program eligibility will be made based on background results in accordance with College of Health Science Policy: CHS-314.0. Background checks performed for previous employment or licensing cannot be used, per contractual agreements with our partnering health care agencies. Students will be required to maintain a clear criminal record during their time in the Program and will be required to complete subsequent background checks every six months, during the time- period directed by the individual program. “Clear criminal background” is defined as a background meeting the criteria as outlined in COHS Policy: CHS-313.0.
Clinical Health Requirements
Students will submit the following health requirements as directed prior to being accepted fully into their specific program. Students will also be required to complete subsequent health requirements (or “serial” health requirements) and re-submit during the time frame indicated by their specific program and in the manner directed at the time of submission.
Verified negative 2-Step or Baseline TB skin test or blood test, such as T-spot or Quantiferon Gold
- The Baseline or 2-Step test OR blood test are required prior to the beginning of the student’s first semester in their specific program. An annual TB skin test or blood test is then required annually, as directed by their specific Baseline tests are only required at the beginning of the program.
- Tine Tests are not accepted
- If student has a positive TB test –\
- A chest X-ray report indicating the absence of TB obtained within six months prior to admission must be submitted and an annual TB Questionnaire, provided by your program, must be submitted every year thereafter in lieu of the annual test. The questionnaire must be completed by a provider and will be completed annually until the end of the program. The questionnaire must state that the student has no symptoms of TB.
- The School of Nursing will not interpret these or any other results
Mumps, Rubeola, Rubella
- Documentation of positive titers for each (OR verification of 2 MMR vaccinations) must be submitted prior to admission unless a severe allergy is documented–
- Rubeola (“hard measles”)
- Rubella (German Measles)
These are three separate and distinct tests
- If any of the titers are “equivocal” or indicate that the student is not protected, immunization and follow-up titers are Follow-ups may be in progress but must follow standard immunization/follow-up titer timeline protocols, as recommended by the CDC.
Varicella (chicken pox)
- Documentation of a positive antibody A statement of history of illness, even from a provider, will not be accepted in lieu of titer or shot series.
Documentation of a positive Hepatitis B
- If no history of vaccination, documentation that vaccination series is in progress must be submitted but positive titer must be submitted or provider statement of care in the event of a negative first titer within 7 months. Some students may be “non- converters,” despite following proper protocol. In order to demonstrate “non-converter” status, the student must provide verification of 2 complete series with 2 negative titers, 1 at the end of each series. Series must be done within the CDC recommended timeframe in order to qualify.
Management of Hepatitis B Virus-infected student
- Students must show validation that they are under the care and guidance of a physician with regard to management of the Hepatitis-B viral infection. This can be found in the form of a signed physician note, stating that viral load testing and other appropriate assessments, will occur every 6 This note should be uploaded into the mCE platform before the beginning of the first semester of the pre-licensure program.
- All students should receive hepatitis B vaccine according to current CDC recommendations. Vaccination (3-dose series) should be followed by assessment of hepatitis B surface antibody to determine vaccination immunogenicity and, if necessary, revaccination. Students who do not have protective concentration of anti-HBs (>10 mIU/ml) after revaccination (i.e., after receiving a total of 6 doses) should be tested for HBsAg and anti-HBc to determine their infection status (Holmberg, Suryaprasad & Ward, 2012).
Hepatitis B vaccinations
- HBV-infected students can conduct exposure prone procedures if a low or undetectable HBV viral load is documents by regular testing at least every 6 months (Holmberg et al., 2012).
- Students with active HBV infection (i.e., those who are HBsAg-positive) who do not perform exposure-prone procedures but who practice non or minimally invasive procedure should not be subject to any restriction of their activities or study (Holmberg et al., 2012).
- Students with a positive HBeAg or circulating HBV burden of greater than or equal to 10(4) genome equivalents (GE) per mL of blood will be prohibited from performing certain pre-defined high-risk (Category III) exposure-prone procedures (EPP) (Lewis, Enfield & Sifri, 2015). The list of Category III exposure-prone procedures is found in Table 3 of the following reference:
- Students will use double-gloving for all invasive procedures, for all contact with mucous membranes or non-intact skin, and for all instances in patient care for which gloving is recommended (Lewis et al., 2015).
Please see relevant tables and charts, found in the following link to summarize the recommendations, guidelines, screening, vaccination, viral load threshold and restrictions for students:
Tdap (tetanus, diphtheria, and pertussis) vaccination
- Documentation of Tdap vaccination received as an adult within the past 10 years.
Current CPR Certification
- Students entering the Program must have Health Care Provider CPR certification. Class content should include CPR for clients of all ages; ventilation with a barrier device, a bag- mask device, and oxygen; relief of foreign-body airway, and use of an automatic external defibrillator. Certification cannot expire at any time during participation in program.
Seasonal Flu Vaccination
- Proof of seasonal flu vaccination received by October 31 for prelicensure students and by October 1 for AGNP students. Exemptions may be requested for the annual influenza vaccine under the following circumstances:
- Medical Exemption – Requires the signature of a licensed healthcare provider
- Religious Exemption
- Proof of COVID-19 vaccination compliance may be required by participating healthcare agencies. Exemptions may be requested for the COVID-19 vaccination under the following circumstances:
- Medical Exemption – Requires the signature of a licensed healthcare provider
- Religious Exemption
Exemptions may result in clinical sites refusing to accept the exempted student and may limit clinical placement options. If no other placement option is available, the student may be delayed or prevented from meeting the requirements for progression within the program and graduation from the program. For information on the exemption process, please contact the Student Services Compliance team at firstname.lastname@example.org.
Serial health requirements are to be satisfied by deadlines as determined by the individual program in collaboration with the Clinical Compliance. Any student not in compliance past the program specific deadline dates may not attend class or clinical rotations until all requirements are satisfied.
All Clinical Health requirements, processes, and procedures are subject to change based on contractual agreements with clinical partners. Should changes occur after normal Health Requirement cycles, students will be informed by the Student Services Compliance team and given clear directions, to include deadlines for compliance, in order to remain eligible for program participation. Continuous compliance with clinical health requirements is mandatory for all school of nursing programs. Failure to maintain continuous health requirements is grounds for dismissal from the program.
For assistance and questions contact the Student Services compliance team at email@example.com.
Additional AGNP Program Requirements and Information
Clinical Health Requirements, Background Checks, and Drug Screens
Students must complete, submit, and always maintain clinical health requirements from admission until completion of the program. You will receive reminders from Castlebranch—please make sure to respond quickly to these. Students out of compliance (having any expired or incomplete clinical compliance requirements) are subject to the following actions:
- Written warning sent via email: The student must resolve the out-of-compliance item and email the program director and clinical coordinator of the date and action taken to comply within 72 hours. Course faculty will be notified.
- If any/all outstanding items are not corrected within 72 hours, a letter of suspension will be sent by email. During suspension, respective faculty will be notified and students will not receive credit for any course assignments or clinical hours until the compliance issue is resolved. Once suspension occurs, the student must petition the program director to request to remain in the AGNP program and resolve compliance issues within 72 hours. If this deadline is not met, or if compliance issues are not resolved, then the student is subject to program dismissal. The School of Nursing Dismissal Policy will be initiated.
If students are unable to have required vaccinations due to pregnancy or other health related issue, students must provide a letter from their health care provider to confirm the reason for declination and, if pregnant, a date when the vaccination can be received. Students must also make an appointment with the Program Director to review the issue and provide all requested documentation.
Upon admission to the AGNP program, all students are required to complete both an Idaho State background check as well as a national background check through Castlebranch. Students may be required to complete additional background checks depending on their state of residence. Castlebranch background checks must be completed every 6 months.
Additional RN-BS Online Completion Program and DNP Program Requirements and Information
The RN-BS Completion Program and DNP in Leadership Program are non-direct care programs. The programs serve students in multiple states who work with organizations that have specific, varied clinical compliance documentation requirements, which may change for a variety of reasons including patient and employee safety.
- RN-BS: Lab hours for the community and leadership project-based courses comprise the experiential learning components for the program. Lab hours are accomplished with community and clinical partners.
- DNP: Hours for Scholarly Project and policy application courses comprise the experiential, “clinical” practicum components for the These are accomplished with community and clinical partners.
Due to contractual and/or organizational requirements of these partners and School of Nursing (SON) and College of Health Science (COHS) policies, DNP students may be asked to document certain health requirements (such as tests for tuberculosis, titers, and immunizations) upon entry and at other required points in the program. In addition, DNP students may be required to submit documentation for background checks, drug screens, and/or specified health, CPR, and/or other requirements to their community or clinical partner to meet their specific requirements in order to conduct their Scholarly Project work in that organization.
Due to contractual and/or organizational requirements of these partners and the School of Nursing (SON) and College of Health Science (COHS) policies, RN-BS students may be required to submit documentation of criminal background checks and drug screens and may be asked to document certain health requirements (such as tests for tuberculosis, titers, and immunizations) upon program entry and at other required points in the program. In addition, RN-BS students may be required to submit similar and/or specified health, CPR, and/or other requirements to their community or clinical partner/s in order to conduct their project-based work in that organization.
Many RN-BS and DNP students accepted into their respective program have identified a community or clinical partner site in which to conduct their community and leadership projects (RN-BS) or doctoral Scholarly Project (DNP). In most cases, students are employees in these sites, which facilitates approval by the sites for doing their projects and in many cases, may reduce the amount of documentation for clinical compliance documentation that is needed.
In rare cases, RN-BS or DNP students who need to change community or clinical partner sites from one site to a different site, may be required to provide clinical compliance documentation for that site or to be retained by the SON on behalf of the site. (Example: a faith community site may not collect student compliance documentation but wish the SoN to collect and retain it.)
This policy and CHS Policy 313.0 further describe components of this documentation and rationale in detail. These will be followed in the event the community or clinical partner policy does not have specific compliance requirements.
There are costs associated with background checks and clinical education accounts that may be required by the SON and by partner organizations. These vary between organizations and/or states depending on their requirements. These costs are borne by the student.
RN-BS and DNP Program Health Requirement Documentation
At the current time, there is no health requirement documentation required for the RN-BS or DNP programs, however health requirement needs for the SON and clinical partners are
dynamic and subject to change. Students will be notified of any changes and/or new requirements, procedures, and deadlines in a timely manner. RN-BS and DNP students may be asked to document certain health requirements upon program entry and/or at other required points in the program. Examples include but are not limited to drug screens, tests for tuberculosis, or certain immunizations.
If warranted, university, COHS, and SON protocols for COVID-19 precautions must be followed. (Example: On-campus Executive Sessions for DNP students.) Precautions are updated on the university website. If specific precautions are necessary, students will be informed in a timely manner.
RN-BS and DNP students may also be required by their community or clinical partner to submit documentation for specified health, CPR, COVID-19, and/or other requirements to their community or clinical partner in order to conduct their project work in that organization. For DNP students this will vary by site, with some students being asked to submit documentation as early as semester 1 and others not having to submit until semester 4.
- Students will submit health requirements as directed by their community or clinical partner prior to beginning work on their projects.
- Students will also be required to complete subsequent health requirements (or “serial” health requirements) and re-submit during the time frame indicated by their specific community or clinical partner and in the manner directed at the time of submission.
- Delay or failure to submit required documentation by deadlines for program and/or community or clinical partners may jeopardize progression in the RN-BS and DNP programs and/or prohibit starting or performing on-going work on projects.
- If a student has a pre-existing medical condition that conflicts with a program and/or a community or clinical partner health requirement, the student is responsible to communicate well in advance of deadlines for compliance with the appropriate person.
For the RN-BS program, the student should contact the RN-BS Program Director. For the DNP program, the student should contact the DNP program director. Documentation of pre- existing medical conditions will be reviewed on a case by case basis.
For the community or clinical partner, the student should contact organizational clinical education personnel.
Clinical compliance documentation is a dynamic, fluid process that changes frequently in health care settings and as clinical contracts are updated. When changes occur in RN-BS or DNP program requirements, students will be informed by the program. It is the student’s responsibility to stay informed about these, to monitor the community and clinical partner requirements, and to submit documentation of compliance with requirements by deadlines.
Delay or failure to submit required documentation by deadlines for program and/or community or clinical partners may jeopardize development or completion of projects and progression in the RN-BS or DNP programs.
Requirements for RN-BS and DNP Clinical Compliance Documentation
RN-BS student may be required to submit a background check prior to enrolling in lab courses.
It is the student’s responsibility to check with the site in which they plan to do their project to determine if that is required.
DNP students may need to complete a background check before Scholarly Project Implementation (approximately semester 4). It is the student’s responsibility to check with the site in which they plan to do their project to determine if that is required.
- If required by the partner organization where their project will be completed, the drug screens must meet acceptable requirements of the community or clinical partner or CHS Policy 314.0.
- Students are required to maintain a clear criminal record during their time in the “Clear criminal background” is defined as a background meeting the criteria as outlined in CHS Policy 314.0.
- If applicable, students are responsible for following the program-specific account set-up requirements, arranging payment, and directly handling any disputed results with the vendor at the time of check or recheck.
- RN-BS program-designated staff and DNP program-designated staff have access to all results but will not initiate or process appeals or corrections through the Decisions regarding program eligibility will be made based on background results in accordance with CHS Policy 313.0.
- Background checks performed for previous employment or licensing cannot be used, per contractual agreements with our partnering health care agencies.
Some, or all, of these requirements may be gathered by an outside vendor. Students will need to establish an account with the vendor used by the SON and/or the specific community or clinical partner.
Students may also be required, based on the requirements of the community or clinical partner, to have accounts through additional outside vendors (examples are my Clinical Exchange, ACEMAPP) in order to meet the requirements of the partner to conduct their project work.
All costs incurred will be the responsibility of the student.
Delay or failure to submit required documentation by deadlines for program and/or community or clinical partners may jeopardize progression in the RN-BS or DNP programs and/or prohibit starting or conducting on-going work on projects.
4. Related Information
Last Review Date
August 2013, Spring 2015, Summer 2017, Fall 2019, October 2021, April 1st 2022, Fall 2022, Summer 2023
Holmberg, S. D., Suryaprasad, A., & Ward, J. W. (2012). Updated CDC recommendations for the management of hepatitis B virus-infected health-care providers and students. Centers for Disease Control and Prevent Morbidity and Mortality Weekly Report, 61(3), 1–12.
Lewis, J. D., Sifri, C. D., & Enfield, K. B. (2015). Hepatitis B in healthcare workers: transmission events and guidance for management. World Journal of Hepatology, 7(3), 488–497. https://doi.org/10.4254/wjh.v7.i3.488