UNIVERSITY OF KENTUCKY HOSPITAL POLICY NUMBER: PH-15-01

CHANDLER MEDICAL CENTER FIRST ISSUED: 8/82

CURRENT AS OF: 12/08
Department of Pharmacy Policy
Subject: Employee Handbook

Purpose: To provide a handbook reference for Pharmacy employees.

Introduction

As an employee of the Department of Pharmacy Services, you are a member of a department that serves all
areas of the Hospital, both inpatient and outpatient. The Pharmacy is made up of Inpatient Pharmacy
(Central and Satellites), and the Kentucky Clinic Pharmacy (KCP).

While you are an employee in Pharmacy Services, you will attend orientation and training sessions to learn
how to properly perform your assigned tasks. You will come in contact with nurses, physicians, and other
support staff.

Please read this departmental manual carefully. We ask your cooperation in abiding by these established
policies and procedures. These policies and procedures will be enforced throughout the department.

All Pharmacy and Hospital policies cited in this handbook are available for your review on-line on the
Pharmacy Web page http://www.hosp.uky.edu/pharmacy/. Copies of these policies are also available for
your review in the Second Floor Pharmacy Manager’s Office.

YOUR EMPLOYMENT IN PHARMACY /HOSPITAL

1) EMPLOYEE CLASSSIFICATION

Pharmacy has several classifications of employees. Professional/Administrative fulltime regular or

temporary employees are the group of employees that consists mostly of pharmacists and managers. The
remainder of the staff is classified as technical or support.

2) PROBATIONARY PERIOD

The probationary period for all new employees is ninety (90) days. This period gives the department an
opportunity to evaluate you as a new employee as well as giving you an opportunity to evaluate your fit
within the department and University Hospital.

Should your work be considered unsatisfactory during your probationary period, your probationary period
may be extended up to an additional ninety (90) days. There are many reasons why you might not pass
probation such as excessive absenteeism and tardiness, not following directions properly and/or completing
assigned tasks.

3) PROMOTIONAL OPPORTUNITIES
The Department of Pharmacy prefers to promote our present employees to more advanced positions.
Present employees will be considered when filling vacancies. Supervisors will review present employee’s
files for related experience, dependability, the ability to work with others, and the willingness and ability to
take on greater responsibilities.

All university job vacancies, as well as those in Pharmacy, are posted on the first floor over the water
fountain near Elevator C. If you are interested in applying for a vacant position, you must fill out a transfer
application in Human Resources, Scovell Hall. The UK Human Resources Services Website
http://www.uky.edu/FiscalAffairs/HR/ has the job postings as well as CATSkills Connection for
application, transfer and self-nomination forms.

4) TRANSFERS

If you wish to transfer from Pharmacy to another department within the University, you may do so after six
(6) months of satisfactory work performance. Transfer within pharmacy should be infrequent (i.e., after a
three (3) months period) to allow for stable operations; however, this may be waived based on the
departmental needs. Internal pharmacy positions are selected according to policy PH15-07, Internal
Selection Process.

No employee on any type of disciplinary or work performance probation may be transferred without special
permission of your supervisor, department director or associate director, and/or Medical Center Personnel
Director.

No loss of vacation or sick leave benefits will occur as a result of transferring, unless the transfer is to a less
than half-time position. All vacation and sick leave benefits accumulated will be continued in the new area
or department.

5) PERFORMANCE REVIEWS

In order to support and guide you in personal growth on the job and to keep you informed of how you are
doing on the job, your Supervisor will review your performance at the end of your probationary period and
at least once a year. Reviews may also be made when deemed necessary.

6) ASSIGNMENT

Your duties and shift hours will be assigned by your immediate supervisor. The demands of our
department may necessitate reassigning you to other duties and even supervisors depending on
departmental/staffing needs.

7) WORK HOURS
The hours you are scheduled to work depend upon your work area assignment. Professional/Administrative
fulltime regular or temporary employees are scheduled to work forty (40) hours per week. The remainder
of the staff are non-exempt, e.g., technicians, staff support is scheduled to work thirty-seven and half (37.5)
hours per week.
Overtime hours shall be compensated in one of two ways, as follows:

a. Each hour of work in excess of 40 is compensated by one and one-half hours of time off in the
same pay period, or

b. One and one-half times the rate of pay is given for hours worked in excess of 40 in the same week.

8) REST PERIODS

It is important that most areas of Pharmacy Department be covered at all times. Rest periods of 15 minutes
may be scheduled by your supervisor for each four hour work period. Rest period may be changed by the
supervisor to meet the needs of the department at any time.

Rest periods are not cumulative nor may they be used to shorten the scheduled work period. These rest
periods should be taken away from your assigned area. Employees are asked not to take breaks in the main
lobby of the Hospital. Prior to leaving for your break, notify the pharmacist in your assigned area that you
are leaving for your break.

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Since the hospital and parts of the Department of Pharmacy must be open for 24 hours a day, everyday in
the year, employees, although their specific shift is assigned, may be asked to work another shift,
weekends, and holidays at various times of the year.

9) WORK SCHEDULES

Work schedules will be posted by your supervisor and are considered final. All changes in the work
schedule must be authorized by your immediate supervisor. Employees may trade shifts or change hours
provided the following criteria are observed:
a) Both employees are in agreement,
b) The trade occurs within the same scheduled work week, Sunday through Saturday,
c) Both employees have the same job description or have been trained in the respective work area,
d) The exchange does not compromise the staffing in the work area (e.g., two new employees
working together is not advisable),
e) The exchange does not result in overtime.

The changes must be submitted to your immediate Supervisor at least two scheduled work days in advance
of the exchange in writing and, if approved, makes the appropriate changes on the posted schedule.

Doctor’s appointments and personal business should be scheduled on your days off, but if this cannot be
done, a special request should be made to your Supervisor and must be approved in advance. Vacation and
personal business should be requested according to department scheduling guidelines. Sick leave for
doctor’s appointments must be requested two (2) days in advance and time absent from work will need to
be verified by a doctor’s note.

10) PAYROLL

The University of Kentucky Chandler Medical Center uses the KRONOS system for timekeeping. Each
employee must clock in and out at their designated time clock by using your employee ID badge. It is the
responsibility of each employee to make sure that they clock in and out according to their work schedules.
If you forget to clock in or out, you may not be paid for time worked unless a Payroll Verification Form is
filled out completely and turned into your supervisor. You must have prior permission from your
supervisor to receive extra time. Employees should not clock in more than 7 minutes before their shift
begins. If you leave 7 minutes before the end of your shift, you will receive a “no pay” for time not
worked.

Failing to clock in and out will initiate the disciplinary guidelines as outlined below:

• Failing to clock in 3 times in a 4 month period will result in a WRITTEN WARNING.

• Failing to clock in 4 times in a 4 month period will result in PROBATION.
• After 4 unexcused occurrences in a 4 month period will result in the employee being suspended
for one day with NO PAY.
• Further occurrences would result in additional suspension or termination.

Discrepancies in the computerized payroll system must be reviewed for appropriateness and if necessary
manually adjusted by supervisors only. The KRONOS system does not calculate time worked on a per
minute basis. The shortest amount of time for which KRONOS can calculate pay is 15 minutes (quarter
hour). Therefore, individual minutes are rounded up or down to the next quarter hour. You must have
permission from your supervisor to receive extra time. Employees should not clock in more than 7 minutes
prior to beginning of the shift, doing so will cause KRONOS to calculate pay for a quarter hour that was
not approved. The same is true at the end of a shift. Employees should not clock out prior to the end of
your shift. Clocking out 7 minutes prior to the end of your shift will allow KRONOS to incorrectly

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calculate pay for the entire last quarter hour. When this happens, KRONOS will be manually adjusted to
reflect actual time worked. Leaving early without prior approval from your supervisor (Lead Technician
for technicians and an Associate Director for Pharmacists) will result in a No Pay.

Consult HP09-30 Biometric Time & Attendance Guidelines for details.

11) PAY PERIODS

You will be paid on a bi-weekly schedule, every other Friday. This covers the preceding two weeks period
of work, but does not include the immediate week in which the paycheck is issued. Direct deposit of
paychecks is mandatory for all UK employees. Rather than receive a paycheck for each pay period, all UK
employees are required to participate in direct deposit. This simply means that employee pay is deposited
directly in a designated bank account each bi-weekly or monthly pay period. However, employees receive
documentation for every pay period, including salary and deductions.

Should there be any questions about your payroll records, please contact the administrative secretary, Terri
Dawson (3-6289) or Sheila Ghrayib (3-8153). Errors in reporting time will not result in salary adjustment
until the following pay period. A Payroll Verification Form (located on the pharmacy website) must be
filled out and submitted to your supervisor for any missed punches or errors in time.

Final submission of the pay-period is on the Sunday of the pay week by 11am. Prior authorization must be
on file in the Pharmacy Personnel Office to allow another individual to pick up an employee’s check in
Pharmacy, only during the pay distribution hours.
Consult HP07-19 Employee Payroll Time Reporting for details.

12) Call-in Policy

If you are unable to report for work, you must report in by telephone to your supervisor, or appropriate on-
call supervisor, at least one hour prior to your scheduled shift (or according to established procedure for
your particular work area) and provide the reason for your absence.

In order to receive sick pay in the Hospital Pharmacy, a call-in must be at least:
f) One hour before, but not before 6 a.m., for first shift
g) Three hours before or by 11 am for second shift
h) Four hours before or by 7 p.m. for third shift.

EXCEPTION: Positions where substitute or alternative employee coverage is not routine. For the
Kentucky Clinic and Administrative Support Personnel, a call-in must be received by one (1) hour before
the start of the scheduled shift.

a) Hospital Pharmacy and Kentucky Clinic Pharmacy staff member should contact their immediate
supervisor. Technicians in the Inpatient Pharmacy should contact the lead technician via pager
323-3000 / #6448; Pharmacists in the inpatient pharmacy should contact the on-call pharmacist via
pager, 323-3000 / 6415 (decentral positions) or 6447(central positions). The employee must leave
a numeric page so the supervisor can return the page received.
b) It is unacceptable for someone other than the employee to call-in.
c) It is unacceptable to leave the call-in message on the VMX system since the information may not
be retrieved in a timely manner.
d) If the supervisor cannot be reached, call the Central Pharmacy, 323-5641 or 323-6153; Kentucky
Clinic Pharmacy, 257-3499 and ask for their assistance. The shift pharmacist may log in the call
but must obtain the number at which the employee can be reached. The shift manager must notify
the supervisor with the information and phone number. The supervisor may then call the
employee back for specific reason and other needed information.

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IF PROPER ADVANCE NOTIFICATION IS NOT GIVEN TO A SUPERVISOR IN ANY AREA THE
EMPLOYEE WILL RECEIVE “NO PAY” FOR THAT SHIFT

WEEKEND/HOLIDAY CALL-IN PROCEDURES

If a staff member calls in sick on a weekend, they are automatically required to work an equivalent number
of additional weekend shifts within the next six weeks. For the purpose of this policy, a weekend time
period is shifts falling between 3pm Friday through 7am Monday.

This requirement is waived if the staff member has not called in on a weekend during the previous six-
month period. The requirement is not waived until this perfect attendance is confirmed. It is the
responsibility of the employee to contact the pharmacy administrative assistant, to document their
attendance for this period of time.

If an employee calls in on a holiday, the employee will be automatically required to work an equivalent
shift on the next holiday not already assigned. This requirement is not waived regardless of perfect
attendance.

13) SEPARATION FROM EMPLOYMENT

a) VOLUNTARY

In order to separate in good standing, you must have a satisfactory work record and give an adequate
notice, two (2) weeks for support staff and one (1) month for professional and administrative staff, so
the job may be posted for a replacement. A written notice should be given to your immediate
supervisor with the date of termination.

b) INVOLUNTARY
Involuntary separation can be the result of:
i) Misconduct
ii) Job performance
iii) Misuse or theft of hospital resources
iv) Communication
v) Attitude
vi) Confidentiality
vii) Temporary disability leave
viii) Tardiness

When an employee is terminated from Pharmacy, an exit interview may be conducted with Hospital
Administration.

i) Misconduct:
You may be separated from employment if you conduct yourself in a manner which reflects
unfavorably upon the University, the Hospital, the Department, and /or yourself. You may be
subject to immediate discharge without advance notice and without further pay depending on
the seriousness of the offense. Each occurrence will be handled by progressive disciplinary
action which may include (1) an oral warning; (2) written warning, (3) probation, which may
be concurrent with a written warning; (4) suspension; (5) termination. Once an employee has
received a written warning for misconduct, further misconduct, acts or problems may result in
progression to the next step, probation, suspension, or termination depending on the severity
and nature of the problem or act. A letter documenting successful completion of probation
shall be placed in the employee’s file. Grounds for dismissal for misconduct include, but are
not limited to:

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 (1) Insubordination, which includes, but is not limited to unwillingness to perform assigned
duties or follow verbal or written instructions.

(2) Violation of University or Department rules.

(3) Falsification of employment application or records.

(4) Reporting time falsely.

(5) Any act which has a negative effect on the reputation of the University or Hospital.

(6) Dishonesty on the job including but not limited to theft of drugs, food (e.g., staff
refrigerator), supplies, and cash.

(7) Endangering the safety of employees, the public and patients.

(8) Possession of a firearm on the University property.

(9) Gambling on the University property.

(10) Destructive negligence of University property.

(11) Alcohol abuse while on the job or while on University property.

(12) Drug abuse while on the job on the University property.

(13) Acts which are violations of local, state or federal law on University property.

(14) A jail sentence following conviction, which results in missing five or more days of work.

ii) Job Performance

If your job performance is unsatisfactory, appropriate action will be taken toward involuntary
separation from the department. Poor job performance is defined as an inability to perform a job
in a satisfactory manner, excessive absence or tardiness without adequate justification, or
exhibiting a lack of interest, carelessness, or other unacceptable position. Progressive warning, (1)
an oral warning, (2) a written warning, (3) a disciplinary probation to improve performance, (4)
suspension, and (5) termination. Employees on disciplinary probation for poor job performance
will receive a written statement and counseling which outlines steps for correcting deficiencies.

iii) TARDINESS
Information:
You must clock in to the Kronos system to be considered on the job and to be paid. Professional
staff are exempt, salaried personnel and are expected to clock in at the beginning of their shift.
The work hours for pharmacist may vary to meet their service and/or position assignment, but
must adhere to the established hours of their position. Technical support staff are non-exempt and
paid hourly. Technical support staff are expected to clock in at the beginning and end of the
scheduled shift.
Tardiness
Being tardy for an assigned shift negatively affects your coworkers as well as the overall ability of
the department to provide Pharmacy Services to our patients. It is our expectation that all
employees will be present and ready to work at the defined starting time of their shift. The
department recognizes that on rare occasions, circumstances beyond your control may impact your
ability to arrive at work on time.

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Employees will be considered tardy if they are one minute or 60 minutes late. The following point
system has been designed to allow for those rare occasions while also encouraging punctuality and
accountability. In addition to the point system outlined below, each employee will receive one
non-transferable, one-time use only amnesty card for each 6 month period (July 1 thru December
31 and January 1 thru June 30) The amnesty card may be used to avoid the points associated with
one tardy occurrence and must be declared prior to the end of the pay period in which that tardy
occurs.

Minutes Late Prior Notification Required Points

0 – 5 minutes No 0
6 – 10 minutes No 1
11 – 15 minutes No 2
16 – 30 minutes Yes* 3
> 31 minutes Yes* 4
* Double points if Supervisor not notified PRIOR to the beginning of shift

Less than 15 minutes tardy, does not require prior notification. However, it is the employee’s
responsibility to communicate with his/her supervisor whether or not time will be made up on that
day or if V/L should be used to fulfill the time requirement of that shift. Being tardy >15 minutes
absolutely requires prior notification; failing to notify your supervisor prior to the beginning of
your shift for tardies of > 15 minutes will be result in double points for that occurrence.

Habitual tardiness will lead to disciplinary action as follows for total number of points
accumulated in a 4-month period:

Total Points in 4-months Disciplinary action

6 Verbal coaching
8 Written warning
10 3-month probation (not V/L permitted)
12 1 day suspension without pay
14 Termination

Overall trends in punctuality will be noted during annual performance assessment and will be
reflected on the employee’s Performance Evaluation. For example, one of UKH core values is
accountability; tardiness and attendance would be reflected within the accountability portion of
your annual performance evaluation.

If an employee fails to clock in, they will need to verify their time of arrival by filling out a payroll
verification form. The supervisor or Shift Manager Pharmacist will document the current time on
the payroll verification form as they sign.
This time will be entered into KRONOS are your time of arrival.

iv) MISUSE OR MIS-APPROPRIATION OF HOSPITAL RESOURCES

Unauthorized or misuse of hospital or departmental resources (such as unauthorized use of

telephones, internet for non UK HealthCare business, equipment, supplies, etc) by any
employee may result in disciplinary action such as probation, suspension or dismissal.

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 Staffing resources are a critical hospital resource. Nonproductive activities such as surfing
the internet for non UK HealthCare business, excessive socializing, doing homework or being
missing from the workplace is inappropriate and will result in disciplinary action. If you are
done with your assigned tasks, assist others or seek additional tasks.

Personal business should not be conducted during work hours. Telephone usage should be
used within the Hospital to relay messages concerned with Pharmacy business.

Personal calls should not be made or received during work hours unless it is an emergency or
approved. For any calls coming into the Pharmacy Administrative Offices, a message will be
taken and forwarded to the appropriate supervisor. Employees’ work numbers will not be
given out.

Employees consistently violating the three minutes or long distance rule on personal calls will
be subject to disciplinary action.

Repair costs resulting from employee negligence to equipment will be billed to the employee
for reimbursement of the Department.

v) COMMUNICATION
Communication is an important fact o affecting the overall efficiency of Pharmacy Services.
Employees are expected to
a) Initiate and maintain communication as needed to ensure tasks are successfully
completed/problems are satisfactorily resolved.
b) Use the phone, intercom and email according to communication protocols.
c) Act in accordance with the UK Hospital Behavioral Standards and policies.

Mutual Respect and Collaboration/Cultural Diversity

Employees are expected to act in a courteous and appropriate manner toward the public or
University employees. Employees are expected to
a) Contribute to department/unit teamwork by accepting assignments without resistance,
take the initiative to help others when in need, and asking for help when in need
b) Act in accordance with the UK Hospital Behavioral Standards and Policies
c) Offer own and accepts other’s skills, experience, and knowledge in order to accomplish
departmental/unit goals or resolve problems
d) Share pertinent organizational information with staff that may have an impact on their
ability to do their job. Serve as resource by providing reliable, correct
information/assistance to colleagues/co-workers/customers/etc.
e) In communication with University faculty and staff, always maintain their self esteem
f) Always cooperate with coworkers (including staff in other units) to constructively resolve
problems and accomplish work goals
g) Develop and maintain positive and productive working relationships with all coworkers,
regardless of age, gender, race, national origin, religion, etc.

vii) Initiative/Commitment
Attitude toward your job and the Hospital should demonstrate a willingness to learn, work
with fellow employees and a desire to improve your skills. Your attitude toward patients,
visitors, and other staff members should show honesty, respect, and courtesy. Employees are
expected to:
a) Identify work needs and perform additional work without being told
b) Make themselves available when unexpected work demands occur and own workload is
light
c) Anticipate problems and voluntarily take correct actions

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 d) Take (or recommend) appropriate corrective actions to resolve problems
e) Always follow up to ensure problems are actually corrected
f) Always keep appropriate people involved and informed of problems/issues
g) Always advise (relevant persons) about situations, decisions made, or actions taken
h) Develop and/or implement new and improved ways of doing work

i) CONFIDENTIALITY

• All information pertaining to patients, treatment or hospitalization should be limited to only those
people that “need to know” to provide patient care. Our patients are often our co-workers/family.
The same level of protection of privacy must be observed. All confidential information is
maintained in secured locations according to established policies; never discuss confidential
information in public or disclose confidential information to unauthorized persons. All such
information should be released, only after receiving permission form the Medical Center Public
Affairs Office. There are visual, auditory, information challenges to providing patient care while
protecting the patient’s privacy. Specific actions that can be taken to safeguard the patient’
privacy include:

(1) Discuss patient information only in private areas. Don't discuss patients in hallways,
elevators, the cafeteria, outside, or on shuttles. This is particularly important if using
a cell phone in an atypical setting.
(2) Speak as quietly as possible in semi-private rooms.
(3) Ask visitors to leave the room before discussing private medical
(4) Information with patients.
(5) Discuss patient information only with people with a "need to know" to provide patient
care.
(6) Find private areas to discuss sensitive issues with patients and families.
(7) Logoff computer screens when you are finished.
(8) Turn monitors so that patient information cannot be casually viewed by people
passing by.
(9) Reset your screen saver so that patient information is not visible when you are not at
the monitor. Access only the information you need to do your job.
(10) If you use wall boxes outside patient rooms, turn charts toward the wall.
(11) Do not use patient-specific information on white boards that are visible to the public.
(12) Don't let others use your passwords.
(13) Return charts to chart racks. Store charts in secure locations.

ii) TEMPORARY DISABILITY LEAVE (SICK LEAVE) GUIDELINES

See Also: HR 82.0 Temporary Disability Leave

University Hospital recognizes that employees may occasionally suffer illness or injury, which
temporarily renders them incapable of performing assigned duties. The policy outlines the
employee entitlements for such instances. It does not guarantee or provide entitlement for any
employee who is absent from work on a frequent or regular basis or whose absences affect job
accomplishments. Consult University of Kentucky Handbook policy 82.0, Temporary Disability
Leave.
(1)
(a) Employees must phone in according to their area’s call-in policy and provide the
reason for any unexpected absence. If this policy is not followed, the employee
will receive a no pay for that day. This no-pay will count as an occasion of
absence and subject to progression of disciplinary guidelines.

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 (b) If an employee has used up all sick leave, the employee must then use accrued
vacation and /or bonus days. These will be considered an occasion of absence and
will be subject to progression of disciplinary guidelines.

(c) Sick leave is not considered as time worked when computing overtime payment.

(2) Physician’s statement

(a) University Hospital reserves the right to require a signed physician’s statement to
justify an employee’s absence or to ensure that an employee is permitted to return to
work. The physician’s statement does not “excuse the absence”. The absence,
defined by policy as any absence of 50% or more of normal scheduled working
hours, is still counted as an occasion and the employee is subject to progression of
the disciplinary guidelines.

(b) If an employee is off for five consecutive days, the employee must automatically
provide their supervisor with a doctor’s excuse.

(c) Medical appointments that require an absence of 50% or more (i.e. for a procedure)
that the employee coordinates with the supervisor seven days or more in advance
will count as an occasion but will NOT be subject to progression of the disciplinary
guidelines. A physician’s statement is required.

(d) Physician’s statements must be on printed letterhead, indicating the date and nature
of the treatment and the date the employee can return to work. The statement must
be issued at the time of treatment. Employees on disciplinary or initial probation
must bring in a physician’s statement.

(e) Retroactive physician’s statements will not be accepted.

(f) If a physician’s statement is requested and not provided, the supervisor may deny
sick leave pay resulting in a “No-pay”, and/or take disciplinary action after
consulting with the Personnel Officer.

(3) Frequency of Absences

If a regular employee has an unreasonable or excessive number of absences, he/she will
be subject to disciplinary action. Disciplinary action may include:

(a) A written warning informing the employee that a doctor’s excuse is now required for
any further illnesses will be issued when the employee is absent on THREE
Occasions in a four-month period. THE EMPLOYEE MUST BRING A
DOCTOR’S EXCUSE FOR ANY ABSENCES (EVEN THOSE OF LESS THAN
50% OF THEIR SHIFT.

(b) PROBATION (Three months): If the employee is absent on a fourth occasion within
a four-month period, the employee will be placed on a three-month probation. The
employee may not take any vacation while on absentee probation.

(c) SUSPENSION: IF an employee has another absentee occurrence while on absentee

probation (3-month) or if an employee is absent FOUR times in a FOUR-month
period after having been on absentee probation (3-month) during the previous 12
months, the employee will be placed on a one-day nonpaid suspension.

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 (d) TERMINATION, if the employee is absent on a second occasion while on
(ABSENTEE) probation (3-month) or FIFTH occasion within a four-month period
within 12 months of having completed 3-month probation for absenteeism, the
employee will be terminated.

14) GRIEVANCE PROCEDURE POLICY

It is the intention of the department and the university to deal fairly with all employees. In working
together on a day-to-day basis, problems in connection with the working relationship can be expected
to arise. In most cases, the problem can, and should be settled with your supervisor. However, when a
mutually satisfactory solution cannot be worked out at the first level, the employee will be given an
opportunity to appeal the decision through the Department Director and the Personnel Office without
fear of prejudice. There are time deadlines in the grievance procedure that must be followed (refer to
UK Staff Personnel Policy and Procedures 7.2).

15) SECURITY
Employees are expected to exercise common sense in promoting personal safety and the security of
their personal belongings. Check with your supervisor as to areas in which to keep your property.
Security Officers are available 24 hours each day for assistance whenever needed. For any emergency
they can be reached by calling telephone number 333. For less urgent needs, a dispatcher can be
reached by calling 7-1616. Entering the building is restricted from 9 p.m. to 6 a.m. Staff ID badges
must be presented to the security guard on duty.

16) WORKERS’ COMPENSATION

When an employee sustains an on-the-job injury or suspects an illness is work-related this must be
reported to the shift manager or on-call supervisor. A reportable occurrence form should be filled out
and forwarded within 24 hours to Risk Management. In addition, the injury must be reported to the
UK Managed Care. UK Managed Care will instruct you what providers are covered. UK Workers
Care operates in accordance with the University of Kentucky Staff Personnel Policy and Procedure
96.0 as well as with state and federal worker’s compensation regulations. [HP-09-25, Worker’
Compensation/ UK Workers’ Care]

17) NO-PAY STATUS

a) Unauthorized Leave Status “No Pay” – An unauthorized absence that will lead to disciplinary
action of the employee.
b) Authorized Leave Status that results in No-Pay – an authorized absence that does not adversely
affect the quality of service provided must be approved by the Director of Pharmacy. Approval of
Authorized No Pay must be documented and kept in the employee file.
c) Unauthorized absences adversely affect the quality of service which we provide and results in an
unfair burden which must be carried by our loyal employees.
d) There are many reasons an employee could receive a no-pay. For example: improper call in,
improper clocking in and out; no accumulation of vacation or sick leave hours; suspension;
deliberate absence from work; or unauthorized departure from work area. If you receive a no-pay
of equal to or greater than half a shift, it will be counted as one (1) occasion of absence on your
record. Please discuss the reason for the no-pay directly with your supervisor.

18) LEAVES

a) Family Medical Leave

i) Recognizing the occurrence(s) of serious health conditions, which involve either the
University employee or a qualified family member, the University provides unpaid family or
medical leave of up to twelve (12) weeks in a twelve (12) month period.

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 ii) Any employee who has been a University employee for twelve (12) months and has worked at
least one thousand two hundred fifty (1250) hours during the previous twelve (12) month
period may take up to twelve (12) weeks of unpaid leave for a serious health condition
involving the employee or a qualified family member during any twelve (12) month period
for any or all of the following reasons:

(1) Because of the birth of a child of the employee and in order to care for such son or
daughter;

(2) Because of the placement of a child with the employee for adoption or foster care;

(3) In order to care for the spouse, or child, or parent, of the employee, if such spouse, son,
daughter, or parent has a serious health condition; or

(4) Because of a serious health condition that makes the employee unable to perform the
functions of the position of such employee.

(5) NOTE: The twelve (12) weeks of leave under 88.1.1 is leave which is consistent with
(not an additional leave) and will run concurrently with the ninety (90) days temporary
disability leave that is provided for specific employees under HRP&P 82.1.1 or the thirty
(30) working days childbearing leave that is provided for employees under HRP&P
82.1.18

(6) Consult University of Kentucky Staff Handbook Policy 88.0. Family Medical Leave Act
for details.
iii) Family medical leave request form should be completed and submitted as soon as absence is
anticipated. Without the FML approval, temporary sick leave will be applied and frequency
of absences will result in progression of discipline.

b) Maternity Leave

i) Consult University of Kentucky Staff Handbook Policy 82.1.16.

ii) This is a 30 working day leave that starts the day your baby is born. If you need time before
or after the baby is born a doctor’s excuse is required.

iii) Family medical leave form should be completed and submitted as soon as absence is
anticipated.

c) Funeral Leave

Funeral leave with pay is allowable to regular employees and is subject to the following University
guidelines:

i) In the event of a death of a member of the immediate family (husband, wife mother, father,
brother, sister or child) a maximum of three work days will be granted without loss of pay. If
extensive travel is involved, funeral attendance leave shall not exceed five work days.
ii) In the event of a grandparent, grandchild, mother-in-law, father-in-law, brother-in-law, or
sister-in-law, absence with pay will be granted up to one day for funeral matters. The total
funeral attendance leave with pay, where extensive travel is involved shall not exceed three
work days.
iii) In the event of the death of other relatives or close friends, absence may be granted up to one
half day for funeral attendance if staffing and department activity permit.

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b) Military Leave
A regular employee shall be paid for annual training. A 10 day annual Leave of Absence for extended
active military service is granted to eligible employees a year. Employees requesting this leave must
place a copy of their orders or call to duty in their Pharmacy personnel file. Consult University of
Kentucky Handbook policy 75.0, Uniformed Services Leave. Leaves greater than the above shall be
without pay unless the employee requests use of accrued vacation time.

c) Leave Without Pay

Requests for special leave of absence without pay are considered on an individual basis after
satisfactory completion of probationary period. The leave must be requested in writing with the exact
dates of the request, based on staffing, is approved by the supervisor, it will then be sent to the
Department Director and on to Personnel, the Hospital Director and the Chancellor. Consult
University of Kentucky Handbook policy 85.0, Special Leaves.

d) Vacation Leave

i) Vacation allowance with pay is considered an earned benefit that employees in a 0.50 FTE or
above receive. Vacations may be requested anytime during the year, although, specific
deadlines for preparation of the schedule is required. Requests must be made on the
Pharmacy Vacation Request Form available form supervisors. It must be approved by your
immediate supervisor.
ii) The 7/7 scheduling pattern is designed to manage paid time off (vacation, bonus days and
holidays). Paid time off (vacation bonus and holidays) are assigned according to the 7/7
pattern. Employees with vacation leave in excess of the 7/7 scheduling requirement may make
additional vacation requests. If additional vacation is desired by 7/7 employees that do not
have any vacation hours in excess of that which is required by the 7/7 scheduling pattern,
these employees should arrange a scheduling trade.
iii) An employee must have passed initial probation to be eligible for vacation leave and only the
amount of vacation accumulated may be taken at the time requested. Vacation requests will
be granted based on staffing.
iv) If you transfer from one department to another, the amount of vacation credit earned will
carry over into the new department.

e) TERMINAL VACATION

Vacation leave earned but not taken at the time of resignation may be granted to those employees
who have given sufficient notice to their Supervisor of their intent to leave. (Note: If an employee
terminates in good standing: by giving at least 2 weeks notice for regular employees and 4 weeks
notice for professional and administrative employees).

i) Terminal vacation cannot exceed the annual allowance.

ii) If termination results from dismissal for cause or termination without notice, there shall be no
terminal vacation granted.

f) HOLIDAYS

i) The following days and any other days as the University may designate, are considered
holidays:
(1) New Year’s Day
(2) Martin Luther King Jr Day
(3) Memorial Day
(4) Independence Day
(5) Labor Day

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 (6) Thanksgiving Day
(7) Christmas Day

ii) If you are required to work on any of these holidays, an equivalent time off will be given.

iii) Holidays are scheduled by your immediate supervisor. Holiday time must be taken during the
period of two weeks prior to the holiday to two week following the holiday or the hours are
lost.

iv) If a holiday occurs during an authorized vacation period, the holiday will not be charged as a
day of vacation.

v) An employee who is in a no-pay status on a scheduled work day. The day before and/or the
day after the scheduled holiday shall not be paid for the holiday. The holiday is considered
taken, and it cannot be scheduled later.

g) 7/7 Technician Holiday Assignments

The holiday rotation assignment recommended by the Scheduling Committee was implemented to
avoid the same staff having to work an unfair number of significant holidays, or the same
holidays for consecutive years. The details of the holiday rotation are outlined below.

i) Holiday Coverage
Holidays are divided into two groups. Notice, the holiday assignments may vary depending on
the shift). Each year, the 7/7 group will switch to avoid having to work the same holidays for
multiple years in a row. The entire 7/7 group will be assigned the same holiday group. The staff
are responsible for working the assigned "traditional" holiday regardless of how the 7/7 pattern
falls (this is different than in years past). If you have the holiday "off" during your natural work
week, it will require coming in during the natural "off" week to cover for the staff that had to work
the holiday. If the holiday assignment requires staff to work during their "off" week, a day will be
scheduled off. The technician scheduled off for the holiday covers the day off. Only the holiday
day will be covered. If the holiday falls within the 7-days the person is scheduled to work, it is the
working technicians first choice to work it. IF alternative holiday requests are desired, staff is
encouraged to trade with other staff members. This holiday coverage applies primarily to the 7/7,
4/3 and 5/2 scheduled positions.

2008
Blue Team will work: White Team: will work
New Year’s Eve ’07 (2nd shift)
New Year’s Day (1st shift)
Martin Luther King Jr. Day Memorial Day
4th of July Labor Day
Thanksgiving Christmas Eve (2nd shift)
Christmas Day (1st shift)

2009
Blue Team will work: White Team: will work
New Year’s Eve ’08 (2nd shift)
New Year’s Day (1st shift) Martin Luther King Jr. Day
Memorial Day 4th of July
Labor Day Thanksgiving
Christmas Eve (2nd Shift)
Christmas Day (1st Shift)
2010
Blue Team will work: White Team: will work

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 New Year’s Eve ’09 (2nd shift)
New Year’s Day (1st shift)
Martin Luther King Jr. Day Memorial Day
4th of July Labor Day
Thanksgiving Christmas Eve (2nd shift)
Christmas Day (1st shift)

A great deal of discussion has been involved in developing this holiday rotation. Since pharmacy
is critical to providing excellent patient care, staffing during holidays is required, though not
popular. Our hope is that this rotation is fair to all.

h) Bonus Days

Five (5) special bonus days are given to all full-time employees hired before early December
(specific date announced annually). Regular employees earn bonus days based on percentage of
time worked before the cut off date. These days must be arranged in accordance with an annual
timetable from Hospital Administration and scheduled at times convenient with the department.
(Less than full-time employees receive bonus hours based on their FTE).

19) EMERGENCY UNIVERSITY CLOSING

On rare occasions, the operation of the University may be adversely affected be severe weather, fuel
shortages, or other external factors. Since essential patient care services of the University Hospital
cannot be interrupted, the Hospital is excluded from the University closing policy.

i) All Pharmacy employees and supervisory personnel are deemed essential; therefore, you are
expected to report to work regardless of weather or other external factors. Employees are
expected to take proactive measures to allow them to report to work on time. It is the
employee’s responsibility to obtain transportation to and from the Hospital.

In the event of external factors, Pharmacy employees who cannot report for their assigned shift will be
paid under the following guidelines:

b) When a call-in occurs, if the employee must be replaced and a replacement is not found, the
employee who called in will receive a no-pay for the shift.

i) If an employee calls in and a replacement is available, and the employee has followed proper
call-in procedures for their designated area, call-in is treated as a “trade” with the employee
who is replacing them and an alternative shift is identified to work.

ii) If an employee reports to work late, the employee may be compensated only for time worked.
At the discretion of the supervisor, if proper call-in procedures was followed and the area did
not have to pay another employee to cover the time, the hours missed due to late arrival for
this situation only maybe made up or vacation and bonus leave may be taken.

iii) Under no circumstances will an employee be permitted to take sick leave for time missed due
to inclement weather or other external factors. If an employee reports illness as the factor for
not reporting to work, a physician’s statement verifying illness will be required.

iv) Following the weather related event, appeals for utilizing vacation time for the employee who
was unable to work their scheduled shift may be considered. Approvals will be based on
individual circumstances and the department’s ability to meet all patient care needs.

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20) EMPLOYEE EDUCATION PROGRAM

a) Regular, full-time employees are allowed to register for a maximum of six credit hours per
semester at the main campus or a community college. To receive a tuition waiver, an employee
must complete an Employee Education Program Form and turn it into Employee Benefits on or
before the deadline established by the official academic calendar.
b) The employee may not take courses during work hours. Special permission is required if any
deviation is needed to accommodate the employee’s request to take a course during the normally
scheduled hours. The schedule deviation should not compromise the operations of the department.
Any time away form the job as a result of the provisions of this policy (staff Personnel 51.0;
Hospital 09-17) must be made up within that workweek.

21) ID BADGES
a) An ID badge will be provided. The first badge is paid for by Pharmacy Department and is to be
worn at all times while at work. If an employee is without their ID badge, they must obtain a
temporary badge from Hospital Security. To have a new one made the cost is $11.00.
b) The ID badge should be on your front upper torso while working. If you wear a badge holder
(lanyard, clip) that causes it to flip over, your name and picture should be visible, not another type
of information card.
c) The badge should not be defaced with stickers/pins, etc.
d) If you forget your badge on a given day, you MUST go to Security to obtain a temporary paper
badge (it will cost you $1 for the day). Note - Do NOT try to make it through your shift without a
badge.
e) If you need a temporary plastic badge with a proximity card access, you MUST give Security $11;
$10 of which is returned when the badge is returned.
f) You should not allow unauthorized or unescorted access to any of the pharmacy locations.

22) SMOKING

The Department of Pharmacy and the Hospital have developed a very strict smoking policy (Hospital
Policy 10-31). Smoking is not permitted in any work area of the Hospital. You may smoke only in
areas specifically designed as “Smoking Areas”- check with your supervisor for the area. Smoking is
prohibited in all patient care areas, all elevators, corridors and stairways. If violation of this policy is
reported, necessary disciplinary action will be taken.

23) PERSONAL MESSAGES

a) Personal business should not be conducted during work hours. If a personal telephone call is
received in Pharmacy Administration, a message will be taken and relayed to the Supervisor.
Employees work numbers will not be given out.

b) If a personal call is received or made, it must be held to an absolute maximum of three minutes.

c) An employee consistently violating the three minute or long distance rule of not making personal
calls on Pharmacy telephones will be subject to disciplinary action. Pharmacy receives a printout
of all long distance calls made from their telephones.

24) ELEVATORS

a) Patient Elevator- The patient elevator is never to be used by Pharmacy personnel except for
delivery of the “500 Cart”.

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 b) Main Elevator Numbers 1,2,3,9, and 10- these elevators are general use, and are to be used by
Pharmacy personnel to move all drugs, supplies, and equipment from second floor to other areas
within the Hospital that cannot be delivered via the Pharmacy conveyor system. These are not to
be used to deliver warehouse orders or stores orders to the second floor.

c) Elevator #11- Located in 2ICU is to be used by Pharmacy personnel to move all drugs and
supplies to the second floor or vice versa.

d) Service elevator in the Critical Care Complex Transportation Tower is to be utilized for all
deliveries from the receiving dock to all other areas of the Hospital.

25) CHANGE OF ADDRESS OR OTHER PERSONAL DATA

If there is a change in your address, name, marital status, or number of dependants you wish to claim it
is very important that you report this at once to the Pharmacy Administrative Office and fill out the
proper forms to keep your personnel record accurate. If your telephone number changes, let your
immediate supervisor know of the change immediately.

26) INTOXICANTS AND DRUGS

No employee will be permitted to start work if, in the opinion of their supervisor, they are under the
influence of intoxicants or drugs to the extent that they are unable to perform in a safe and efficient
manner.

The Federal Drug-Free Workplace Act if 1988 (Section515) requires that all employees receive a copy
of UK’s statement which certifies that UK is a drug –free workplace. According to a letter of April 28,
1989 form Dr. David Roselle, then UK President, “The University of Kentucky is committed to
providing a drug-free workplace for its employees. Accordingly, it is a violation of University policy
(ARII-1.1-10 and Staff Personnel policy 13.0: Drug Abuse Policy) for an employee to unlawfully
manufacture, distribute, dispense, or use a controlled substance while in the workplace or on
University business. It is University policy that violation of the above shall result in appropriate action
which may include referral to an employee assistance program/rehabilitation program and/or
disciplinary action up to and including suspension or dismissal…Further, in accordance with the
federal law and University policy, a UK employee is required to notify the immediate supervisor
within 5 days of conviction of any criminal drug statute violation which occurred in the workplace or
while on University business…The University is required to take appropriate action, as outlined in
policies within 30 days of receiving notice of the conviction.”

27) POLICE CHECKS

All applicants and transfer applicants for Pharmacy jobs will be police checked. Medical Center
Personnel will conduct this. This is not a reflection on any employee personally.

28) DEPARTMENTAL FIRE PLAN

a) State and County laws dictate that fire plan must be known by all Hospital personnel. A fire drill
requires the same response as a real fire.

b) Manual “pull box” alarms and hose cabinets are located throughout the Hospital at the end of each
wing, at major intersections of corridors, and across form the nursing station on patient care units.
This detection system is monitored 24hours/day by Physical Plant Division and TheLexington-
Fayette County Fire Department.

c) If you discover a fire in a non-patient area, activate the nearest manual “pull box’ alarm and close
the doors.

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 d) Call University Emergency 333; give your name, telephone number, building and room where the
fire exists, and a brief description of the circumstances. Remain on the phone until the officer
dismisses you.

e) The hospital has established a Fire Response Team, composed Environmental Services, Physical
Plant, and Security personnel. These employees are trained to fight minor fires and to assist in
transporting patients to safety.

29) BOMB THREAT PLAN

If you should receive a bomb threat:

a) Remain calm and try and prolong the conversation as long as possible.
b) Record the date and time the call is received, sex and estimate age of the caller, the exact words of
the caller, any distinguishing voice characteristics, and any unusual background or phone line
noises. Attempt to determine if the caller has knowledge of the Medical Center and the caller the
exact location of bomb, description of the explosive, when it timed to explode, and the kind of
explosives involved.
c) Call University Emergency 333; call paging at 3-5200
d) Follow evacuation procedures if requested to do so
e) Paging will activate chimes and announce :Blue Sky”, and will announce “All Clear”

30) HOSPITAL EVACUATION PLAN

Evacuating patients from the hospital is an extreme measure, warranted only when the patients are
endangered because of damage or danger to the Hospital. If it becomes necessary to evacuate patients,
a Hospital Administrator, in consultation with the Fire Marshall, will issue the order. The evacuation
order will be communicated to PCS by the general alarm system is inoperable, by messenger.

Pharmacy personnel will secure the drug area and report to the main lobby for assignment.

31) EXTERNAL DISASTER PLAN

In the event of a Disaster, the paging operator will announce over the voice paging system:

a. “ALERT ONE” meaning a real disaster has occurred and that a heavy influx of injured people
can be expected.
b. “ALERT ONE DRILL “ meaning a mock disaster has been initiated and affected Pharmacy
personnel are expected to respond to their assigned functions.

Supervisors will instruct new employees of their duties during a disaster. A command Center will be
established in the Central Pharmacy. A pharmacy team will be sent to the Emergency Department with
code cart and appropriate supplies. They are to provide code 500 assistance, provide supplies to restock
incoming ambulances and to communicate needs to the Pharmacy Command Center. Pharmacy staff
should call into the Central Pharmacy to report their availability and to obtain their assignment. (See
Department Disaster Plan)

32) SEVERE THUNDERSTORM AND TORNADO PLAN

This plan was developed to protect patients, visitors, and employees if a tornado does occur. The plan
goes as follows:
a. When a severe thunderstorm warning or tornado watch is issued for Fayette county,
University Hospital will automatically initiate Phase I of the plan (alerting Hospital

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 Administration, Security, paging, and ER personnel that the storm warning or tornado has
been issued).
b. When the National Weather Service issues a tornado warning or that a severe thunderstorm
poses immediate danger to the Hospital, Hospital Administration will upgrade the plan to
Phase II. “Yellow Sky” proceeded by chimes will be paged to signal employees that Phase
II has been implemented.
c. Pharmacy employees should leave any area that has a window and close the doors within
their areas.

33) OTHER PAGING CODES

a. Code names which will be voice or radio paged to alert key personnel that an emergency
situation exists. All codes will be preceded by warning chimes.

b. ASSITANCE PLEASE (combative patient urgent) – help is needed to control a patient.

c. 500 (CODE) –summon medical personnel to treat a patient who has suffered cardiac arrest.
NOTE: This page is usually radio paged. Voice paging only occurs when a second code is in
progress or radio system is inoperable.

d. URGENT (chimes) – staff or service is needed at certain location to help in critical manner.

34) SAFETY

a. All employees have a primary responsibility for the safety, health and well

b. Being of all patients, visitors, and fellow employees. This responsibility can

c. Be met only by working together continuously to promote safer work practices, observing all
rules and regulations, and consistently maintaining property and equipment in a safe working
condition.

d. Supervisors will regularly enforce all rules and regulations, be constantly alert for unsafe
practices, unsafe conditions, and take appropriate actions to correct any observed
irregularities. Supervisors will investigate and complete accident/incident report forms on all
accidents in their area involving PCS personnel, no matter how minor the situation may be.
They will make recommendations on how to avoid similar situations in the future on the
form. Always remember, safety is an essential part of the Hospital’s service and the
employee’s responsibility. Violations of safety rules and regulations constitute grounds for
disciplinary action.

e. The Hospital requires that each department conduct a safety inspection at least every 30 days
in accordance with the criteria established by the OSHA (Occupational Safety and Health Act of
1972).

Other safety related policies include:

Hospital 03-13 Antineoplastic Agent Utilization

Hospital 10-27 OSHA Safety Inspection

35) UNIVERSAL PRECAUTIONS

a. Each new employee is shown the Universal Precautions film and given a handout within the
first few of weeks of employment. According to the Infection Control Policy, personnel will

19
 use blood and body fluid precautions when there is any risk of exposure to the blood or other
body fluids of any patient. The universal blood and body fluid precautions must be taken by
Pharmacy personnel to protect themselves from potential infections.

b. Pharmacy and the Hospital have developed policies related to Universal Precautions. They
are:

i. PCS-053 Infection Control

ii. Hospital 03-05 Reporting communicable Diseases
iii. Hospital 03-07 Control of Varicella-Zoster (chickenpox)
iv. Hospital 03-09 Hepatitis B infection in Patients
v. Hospital 03-11 Disposal of Used Needles and syringes
vi. Hospital 03-13 Antineoplastic Agent Utilization
vii. Hospital 03-17 Monitoring Employee Exposure to Transmissible agents
viii. Hospital 03-19 Management of Employees with Communicable diseases
ix. Hospital 03-21 Universal Blood and Body Fluid Precautions

36) HAZARDOUS COMMUNICATIONS PROGRAM

a. After I-9 process each employee is shown and tested on the OSHA film (Hazardous
Communications). The Pharmacy Department maintains manual in Inpatient Pharmacy’s
Supervisor’s Office which contains Material Safety Data Sheets (MSDS) and other
information which relate to the safe handling and use of chemicals in the workplace.

If a biological, chemical or radiation emergency occurs, DO NOT handle or dispose of any of

these materials unless qualified and authorized. Call between 8 a.m. and 5 p.m.*3-6247 to
report radiation emergencies, *3-5728 to report biological and chemical emergencies, after
hours, call 3-5200 to report all such emergencies

b. Report any electrical shocks, frayed cords, damaged plus or strange smells from equipment
to your supervisor.

Related policies are:

Hospital 10-11 Hazard Communication

Hospital 10-29 Chemical waste Disposal

37) HEPATITIS B VACCINE

i. The Pharmacy Department will provide each employee with written information
about Hepatitis B vaccine and the opportunity to participate in a voluntary
vaccination program. The vaccine is administered free to Pharmacists and
Technicians as identified in Pharmacy Infection Control Policy. Employees in
these areas must pick up a form from C114.

ii. Hospital Policy 03-03 Hepatitis B employee Immunization Policy 03-05 Reporting
communicable Diseases and 10-33 Accident/Incident Reports are policies that detail
procedures related to Hepatitis B.

iii. If an employee is exposed to a patient’s blood, the supervisor should be notified

immediately and an Accident/Incident report and first report of Injury forms filled
out. The supervisor will report the injury to the nurse epidemiologist and send the
employee to General Medicine Outpatient Clinic for testing, treatment, and follow-
up. If the injury occurs when the clinic is closed, the employee should report to the
Emergency Department.

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 38) TB Policy

Each employee must be screened at least once per year after the initial employment
screening (some employees are required to be screened more often). The due date for the
annual screening is one day prior to the anniversary of the last screening. If an employee
is not screened by the anniversary date, the employee will receive a written warning,
then move through the progressive disciplinary process including probation/suspension
and termination of employment, as appropriate.

Approved:_______________________ Authorized:____________________________
Rebecca Reagan, PharmD John Armitstead, MS
Associate Director, Pharmacy Services Director of Pharmacy Services

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