drug/alcohol testing programs a testing site perspective jorge bujanda, md

DRUG/ALCOHOL TESTING PROGRAMS

A Testing Site PerspectiveJorge Bujanda, MD

1. Importance of stakeholders in drug/alcohol testing programs.2. US HealthWorks as a multiple collection site service agent.3. Inside the Mind of a Collector:

A. Collection site.B. Preparation for testing.C. Routine collection procedures.D. Problem collection procedures.E. Documentation errors and fatal flaws.

4. Impact of Other Stakeholder Deficiencies on Collection Site Performance. 5. Recommendations for Program Revision and Improvement. (Handout)

OBJECTIVES

2

• Department of Transportation

Representatives

• Employers

• Collectors / Technicians

• Program Managers / Administrators

• Consultants

• Substance Abuse Professionals

• Medical Review Officers

• Public

• Donors

STAKEHOLDERS IN THE DEPARTMENT OF TRANSPORTATION DRUG AND ALCOHOL TESTING PROGRAM

3

• All stakeholders are important elements of the program.

• Stakeholders’ expectations drive the program.

• Stakeholders must not shift responsibilities.

• Stakeholders’ expectations must be reasonable.

Encourage perfection, but don’t expect it.

4

IMPORTANCE OF STAKEHOLDERS IN DRUG AND ALCOHOL TESTING PROGRAMS

COLLECTORS AND TECHNICIANS

• Key to success of drug/alcohol testing programs.

• Represent employer and operating agency in the process.

• Interact with Donors and shoulder the consequences.

• Responsible for collection/testing procedural compliance.

• Responsible for integrity of process and specimens.

• Require the contribution of all other stakeholders.

5

IMPORTANCE OF THE COLLECTION / TESTING SITE IN DRUG AND ALCOHOL TESTING PROGRAMS

SIMILARITIES• Training requirements.• Procedures.• Problems.• Proper participation of other stakeholders.

DIFFERENCES• Experience.• Training resources.• Knowledge resource network.• Type and/or number of agencies or employers served.

6

SINGLE vs. MULTIPLE COLLECTION / TESTING SITES

INSIDE THE MIND OF A COLLECTOR/TECHNICIAN

7

DRUG/ALCOHOL TESTING PROGRAMSA Testing Site Perspective

COLLECTION SITE

• A place where Donors provide urine specimens for testing.

• Source of water for washing hands secured during the collection process. Towelettes when not available.

• Single lavatory or multi-stall restroom that provides privacy for specimen collection.

• No access to running or clear water.

• Clean surface for processing the specimen and to complete the documentation.

8

INSIDE THE MIND OF A COLLECTOR / TECHNICIAN

COLLECTION SITE

• Security requirements:○ Prevent unauthorized access to site

during collection.○ Prevent unauthorized access to

collection materials and supplies.

○ Prevent Donor’s access to potential specimen adulterating or diluting substances (e.g., soap, disinfectants, etc.).

○ Ensure supervision by Collector or authorized site personnel of any person authorized to enter site.

○ Provide secure handling and storage of specimens.

9


COLLECTION SUPPLIES

• Necessary to conduct proper collections.• Include:

○ DOT-compliant drug test collection kit.

○ Federal Drug Testing Custody and Control Form (CCF).

○ Coloring agent for water in toilet bowl or tank to prevent specimen dilution.

○ Tamper-evident tape available to secure faucets, water tanks, etc.

○ Disposable gloves recommended for Collectors.

10


PREPARATION FOR TESTING

• Ensure compliance of collection site.

• Ensure availability of collection supplies.

• EBT Calibration Checks performed every 30 days.

(Daily before use at USHW centers).

11



Determine Test Type:

• Drug Tests: Regulated urine drug test, non-

regulated urine lab-based test, instant urine tests, hair tests, etc.

• Alcohol Tests:Regulated breath alcohol test, non-

regulated breath alcohol test, screening saliva alcohol tests, etc.

12



Determine reason for Test:

• Regulated:Pre-employment, random, post-

accident, reasonable suspicion, return to duty and follow up.

• Non-Regulated:Pre-employment, reasonable

suspicion, post-accident, post-injury, random, return to duty, follow up.

13



• Identify employer policy to follow:Single policy vs. multiple policies.

• Determine applicable rules:HHS, NRC, FMCSA, FAA, FRA, FTA,

PHMSA, USCG, FBI, DOD, etc.

• Identify governing agency:California Public Utilities Commission,

State of Florida Drug Free Workplace, etc.

14


PREPARATION FOR TESTINGAssuming DOT/FTA Rules apply:

• Collector ideally has access to an updated CCF (9/30/2011).

Copies:1. Testing Facility (lab) Copy sent

with specimen. 2. Medical Review Officer Copy sent to the MRO.

3. Collector Copy retained by Collector.

4. Employer Copy sent to employer.

5. Employee Copy given to employee.

• Collector needs to complete CCF orderly and thoroughly.

15


INFORMATION REQUIRED FROM

EMPLOYERS/SERVICE AGENTS

• Donor’s full name, SSN or ID number.

• Laboratory name and address.

• Employer name, address, telephone and

fax numbers.

• MRO name, address, telephone and fax

numbers.

• DER name and telephone number (C/TPA

when applicable).

• Agency governing the employee’s safety-

sensitive duties.

• Reason for test.

• Whether the test is to be observed or not.

16


ENSURING A SECURE SITE TO DETER SPECIMEN TAMPERING

• Secure any water sources available to Donors. • Use coloring agent in toilet water/tank. • Secure toilet tank cover. • Inspect for possible adulterants or substances. • Inspect and securing areas/items that appear suitable for concealing contaminants. • Ensure undetected access to site is not possible. • Recheck items above following each collection to ensure site’s continued integrity.

17


OTHER COLLECTOR/TECHNICIAN CONSIDERATIONS

• If breath alcohol test applies, it must be performed before the urine collection, to the greatest extent practicable. • Only one collection at a time per Collector (except during a shy bladder period).• Donor’s scheduled test time. Employer responsibility. • Pre-employment unique characteristics before starting a collection.• Collection should begin without undue “delay”.• Before the collection, employer must provide DER, laboratory and governing agency information.

18


ROUTINE COLLECTION PROCEDURES

Donor identification:

• Acceptable forms include:○ Government or employer-issued

photo identification.○ Identification by representative of

higher hierarchy.○ Other form of identification allowed

by operating agency.

• If not provided, Collector must contact DER.

19



• Explanation of procedures to Donor, including back of CCF.

• Laboratory name and address.

• Correctly enters Step 1 information: ○ Employer name, address, telephone/fax numbers. ○ MRO name, address, telephone/fax numbers. ○ I.D. number. ○ Testing authority. ○ Reason for test. ○ Type of test. ○ Collection site information.

20



• Donor must remove outer clothing and leave with Collector, together with belongings. Donor may retain wallet. No

additional request of clothing removal or exam gown, with exceptions.

• Donor may keep head covering if refused based on religious practice, unless indication of specimen tampering intent.

21



• Collector asks Donor to empty pockets for possible presence of adulterating substances/devices. If no substances

present, Donor returns items to pockets.

• Collector encourages Donor to leave all belongings outside.

• Ideally, Donor belongings are locked.

• Collector provides receipt for belongings, if asked.

• All belongings are returned to Donor after collection.

22



• Donor instructed to wash and dry hands in Collector’s presence.

No further access to water or other materials allowed.

• Donor selects sealed collection kit/container from supply.

• Collector or Donor, unwraps it.

• Donor takes collection container into the collection room.

• Sealed specimen bottles remain with Collector.

23



• Collector directs Donor:○ To collect a specimen of at least 45

mL. ○ Not to flush the toilet.○ Return as soon as possible after the

void. ▪ Collector should set and explain

a reasonable time limit for Donor to stay in the collection room.

▪ Collector should explain Donor the importance of specimen temperature determination and

possible requirement of an observed collection.

24



• After receiving the specimen, Collector:○ Determines temperature within 4

minutes. ○ Inspects specimen for tampering

signs. ○ Determines specimen volume.

• Donor’s admission of specimen tampering, refusal to follow directives or disruptive behavior are refusals to test. Collector discards specimens and notifies DER.

25



• If specimen is acceptable, Collector proceeds with collection:

○ Unwrapping specimen bottles and pouring a minimum of 30 and 15 mL in bottles A and B, respectively.

○ Placing caps on bottles A and B.○ Placing seals over bottles A and B,

and dating them.○ Having Donor initial the seals.○ Allowing Donor to wash hands.

26



• Collector directs Donor to Step 5 on Copy 2 of the CCF and:

○ Read the certification statement. ○ Enter personal contact information.○ Sign. ○ If Donor refuses to any of it, Collector

ensures that:▪ Donor’s name is entered; and▪ Notation is made on the

Remarks section.

• Collector signs Step 4 on Copy 1 after entering personal and collection information, including courier service to lab.

27



• Collector:○ Ensures all copies of the CCF are

legible and complete. ○ Removes Copy 5 and gives to

employee.○ Places bottles and Copy 1 inside

plastic bag and seals.○ Places sealed plastic bag in

appropriate shipping container, when applicable.

○ Informs Donor collection is finished and may leave site.

○ Discards any left over urine specimen in the collection container.

28



• Collector:○ Sends Copy 2 to MRO and Copy 4 to

DER (or designee) within 24 hours or during the next business day.

○ Keeps Copy 3 of CCF.○ Ships specimen to laboratory within

24 hours or during next business day.

○ Ensures integrity and security of specimen, while on site, until given to a courier.

29


PROBLEM COLLECTION PROCEDURES

Donor identification problems:

• Unacceptable forms of include: ○ Identification by a co-worker or

safety-sensitive employee.○ Non-photo identification card (SS

card, credit card, etc.).○ Photocopies of an acceptable

identification document.

• Collection must not proceed until positive identification.

30



Insufficient Specimens (Shy Bladder):

• If the specimen provided is insufficient (<45 mL), a Shy Bladder process is started. Collector:

○ Discards specimen and notes the events and time in CCF.

○ Explains process to Donor, including inability to leave the designated area.

○ Facilitates a maximum of 40 ounces of drinking fluids within 3 hours.

○ Continues to document time and amount of each attempt.

31




• If no acceptable specimen is provided within the three hours, the Collector:

○ Discontinues the collection, notes the fact on the Remarks line and completes documentation.

○ Immediately notifies the DER. ○ Distributes Copies 2 and 4 to MRO and

DER respectively.

• Employer arranges a Shy Bladder medical evaluation together with MRO.32




• If any insufficient specimen is out of temperature range, Collector must consider it as evidence of tampering and

must proceed with an observed collection.

• If Donor refuses to provide another specimen or leaves the collection site for any reason, before doing so, it is considered a refusal to test.

33



Directly Observed Collections:

• It is a routine collection except with use of an observer.

• Apply after a routine collection when:○ Specimen temperature is outside

acceptable range.○ Donor is found to have possible

tampering materials. A Memorandum for Record (MFR) describing devices substances found suspected of use for specimen

tampering is sent to MRO and employer.

34




• Apply after a routine collection when: ○ Donor’s conduct is indicative of

possible tampering.○ Collector believes specimen has been

adulterated (e.g., specimen is green, exhibits excessive foaming when

shaken, bleach smell, etc.).

• Apply to all Return-To-Duty and Follow-Up tests.

35




• Apply when a previous drug test was reported as:

○ Positive○ Diluted○ Adulterated○ Substituted○ Unsuitable for testing○ Canceled due to split specimen not

available for testing.36




• If Collector observes clear behavior of tampering attempt:

○ Collector documents on Remarks line that it is first of two collections, the specimen numbers of both

CCFs, the reason for observed second collection; and completes first collection.

○ Completes second collection under observation, entering similar information on second CCF.

○ Informs site supervisor and DER.

37




• Observer:○ Must be same gender as Donor,

without exception.○ May be the Collector or another

person.○ Must accompany Donor into

restroom.○ Must direct Donor to raise clothing

above navel, lower it to mid-thigh and turn in a circle for possible presence of

tampering devices/substances.○ Must watch Donor void in the

collection container.

38



Refusals to test:

• It is considered a refusal to test when Donor:

○ Refuses to display pocket contents.○ Refuses to wash hands.○ Refuses to follow any other

mandatory directives. ○ Displays disruptive behavior. ○ Admits to specimen tampering.

• Collector must then stop the collection process, discard any specimens and notify the DER of the refusal to test.

39


MONITORED COLLECTIONS

• Collection procedure performed in a multi-stall restroom during which a person (Monitor) is present inside the

restroom during the collection.

• Allows specimen collection in private.

• Monitor must be of the same sex, unless a medical professional.

40


DOCUMENTATION ERRORS / FATAL FLAWS

Upon receiving a specimen, the laboratory ensures that:

• Specimen ID number on CCF and labels/seals match.

• Specimen bottle seals are intact.

• CCF is properly completed.

• There are no discrepancies and/or errors of omission in CCF (e.g., Collector’s signature missing, unchecked specimen temperature boxes, etc.) in the CCF.41



• When documentation errors are found, the laboratory must:

○ Determine if the error/omission can be corrected.

○ Request a MFR from the Collector, stating that the required action took place but its documentation

inadvertently missed in the CCF.

• Once a MFR is requested, Collector must respond immediately, indicating whether it can be issued.

• If a MFR is not issued, laboratory reports the specimen as "Rejected for Testing" to MRO and provides reasons.

42



• MROs may also request a MFR to correct collection or documentation flaws.

• Collector must undergo Error Correction Training within 30 days of a cancelled test.

• Donors can only be recalled for a repeat collection when a directly observed collection was required and was not

performed. Collectors must contact the DER for arrangement.43


REGULATED vs. NON-REGULATED COLLECTIONS

• Regulated (DOT) collections must be done on Federal CCFs and employers are prohibited from using Federal CCFs for

non-regulated collections.• Using a non-regulated form for a regulated collection is not grounds for test cancellation. However, the laboratory

and/or MRO must ensure that :○ Regulatory collection process

was followed.○ Specimen was tested in

accordance with regulations.○ Ensure that all documentation

required exists. ○ A compliant MFR from the

Collector is obtained.

44


2013

SERVICES TOTAL CANCELLED

DOT Drug Tests: 67,200

DOT Drug Test Collections: 189,700 Non-DOT Drug Tests: 138,800

Non-DOT Drug Test Collections: 280,000

Non-DOT Instant Drug Tests: 368,800 Breath Alcohol Tests: 134,000

Saliva Screening Alcohol Tests: 7,900 Medical Review Officer Reviews: 131,700

45

U.S. HEALTHWORKS EXPERIENCE

2013

SERVICES TOTAL CANCELLED

DOT Drug Tests: 67,200 (12) (1/5,600) 0.018 %

DOT Drug Test Collections: 189,700 Non-DOT Drug Tests: 138,800

(13) (1/10,676) 0.009 % Non-DOT Drug Test Collections: 280,000

Non-DOT Instant Drug Tests: 368,800 Breath Alcohol Tests: 134,000

Saliva Screening Alcohol Tests: 7,900 Medical Review Officer Reviews: 131,700

46

U.S. HEALTHWORKS EXPERIENCE

IMPACT OF OTHER STAKEHOLDERS’ DEFICIENCIES ON COLLECTION SITE PERFORMANCE

47


• Missing or incorrect DOT agency selection.

• Missing or incorrect test reason:Pre-Employment vs. Return To

Duty/Follow Up , Post- Accident DOT vs. non-DOT, Return To Duty or Random vs.

Follow Up.

• Missing or incorrect test type:DOT, non-DOT and instant testing,

urine drug test vs. breath alcohol test, urine, breath, saliva, blood.

• Discrepancy between request and Donor-provided information.

• Donors unaware of reason to be at the collection site.

48

FREQUENT PROBLEMS WITH SERVICE REQUEST FORMS

• Missing or incorrect employer policy selection.

• Discrepancy between request, protocol and CCF provided.

• Incomplete information and no name/signature on request.

• Contradictive instructions between employer and TPA.

(TPA reimbursement problems with altered CCFs.)

• Multiple divisions with multiple DERs.

• Incorrect or no instructions to Donors on testing time limits and restrictions (e.g., Post-Accident, Random).

• Donors sent for testing without their knowledge.

49

FREQUENT PROBLEMS WITH SERVICE REQUEST FORMS

• The need to contact the DER /Sender, for any reason, is among the most frequent source of testing delays and problems.

○ Correct DER contact information not available for problems or reports.

○ Alternate DER contact information almost never provided.

○ Corporate DER in another time zone.○ Clinic or sender unable to reach DER,

especially after hours. ○ Senders do not know who their DER

is. ○ DER changes not reported to

Collectors or Technicians.

50

FREQUENT PROBLEMS WHEN CONTACTING THE DER

• Only the DER knows testing policy and cannot be located.

• DER/sender almost never provides date and time on

time-sensitive test requests.

• DER number does not allow to leave voice messages.

• DER/sender is reached but lacks program knowledge.

• Process is more difficult when a TPA is involved.

• Unaccompanied Donors dropped or sent for Reasonable Suspicion testing.

51

FREQUENT PROBLEMS WHEN CONTACTING THE DER

• Incorrect, outdated or expired CCFs provided by employers, laboratories and/or TPAs.

• Donor sent for testing with only one CCF or kit.

• Employer/Donor not aware of operating agency for test.

• Different CCFs coming from employer and TPA.

• Donor sent for testing without service request form, CCF or kit and Collector expected to alter one and use another

employer’s kit.

52

FREQUENT PROBLEMS WHEN COMPLETING THE CCF

• CCF alterations:○ Some employers “demand” CCF

alteration and use of someone else’s kit.

○ Some TPAs do not allow CCF alteration.

○ Laboratory kit, CCF or account information for alteration not available.

○ Employer’s faxed information to alter a CCF is unreadable.

○ TPA reimbursement problems.○ Altering a CCF leads to delays and

triggers problems all throughout the process.

○ Unavailable information to alter or hand-print CCF.

53


• Discrepancy between type of test requested and CCF provided.

• Unusable CCFs sent with excessive information or signature.

• MRO information on file conflicts with service request or CCF.

54


• Although paper trail proves they were picked up and received; laboratories:

○ Misplace specimens. ○ Lose specimens.

• Constantly report:○ Insufficient specimens.

○ Leaks in transit.

55

FREQUENT PROBLEMS WITH LABORATORIES

• Employers’ deficient knowledge of regulations and/or their own testing program.

○ More prevalent after-hours and with subcontractors.

○ Donors allowed by employers to leave premises and return later.

○ Employer requests DOT testing when not applicable or incorrect test:

▪ DOT post-accident test when accident does not apply.

▪ DOT Post-injury test or incorrect Return To Duty test.

56

FREQUENT PROBLEMS DUE TO DIRECTIVES FROM STAKEHOLDERS THAT ARE INCORRECT OR IN CONFLICT WITH REGULATIONS

• Employers’ deficient knowledge of regulations and/or of their own testing program.

○ Employer requests usually do not address alcohol tests when accompanying a drug test.

○ Employer’s lack of knowledge about testing time limitations and not addressing on request (random, post-accident, drug and alcohol).

○ Employer requests random drug test and assumes alcohol test applies automatically.

○ Employer instructs Collector to accept photocopies or faxes as valid forms of identification.

57


• Employers’ deficient knowledge of regulations and/or of their own testing program.

○ Employer requests observed collections when not applicable.

○ Employer requests a retest after a shy bladder or a refusal, sometimes demanding disposal of original specimen.

○ Employer’s lack of understanding of the laboratory analysis, medical review and reporting process.

(Request results from Collector, want Collector to contact MRO to expedite results, etc.).

• TPA protocol contradicts CCF presented by Donor (MRO, lab).• Barcode and lab automation problems when altering another employer’s CCF.

58


• Others:○ Donor statement contradicting

employer’s request. ○ Employer directs Collector to TPA for

questions and TPA is usually not available.

59


• Unable to contact DER to: ○ Discuss collection problems. ○ Report breath alcohol test results.

• DER/Sender: ○ Asks technician what to do with a positive result. ○ Asks what is a shy bladder process. ○ Wants to allow Donors to leave after collection has started.

• DER has been changed without notification to collection site.

• Busy or incorrect MRO and fax numbers.

• Employers requiring faxing of CCF to multiple parties.

60

FREQUENT PROBLEMS WITH ADVERSE EVENTS AND REPORTS

• Misplaced/lost MRO copy with Collector’s proof of delivery.

• Conflict between employer corporate instructions and field branches.

• MRO Office: ○ Collector name or signature missing.○ Occasional CCF number and seals’

number discrepancy. ○ Wrong reason for testing checked on the CCF. ○ Wrong DOT agency checked on the CCF.

○ Reporting problems when using another employer’s CCF. ○ Not getting the MRO copy of the CCF on time.

61

FREQUENT PROBLEMS WITH ADVERSE EVENTS AND REPORTS

• Most frequent employer questions to Sales Associates: ○ “Do I need to have a written drug/alcohol testing policy before testing my employees?”

○ “Can I choose who is “randomly” selected or who to include in the random pool?”

(Usually by owners or senior management)

○ “We believe we have a drug use problem in one of our departments. I want to arrange for testing everyone in that department.”62

OTHER FREQUENT PROBLEMS

• Most frequent employer questions to Sales Associates:

○ “Can I send my employees for testing after their shift?” ○ ”How much time after notification can I give my random- selected employees to give the specimen; 24 hours?”

• Lack of knowledge of drug and alcohol testing, as far as what they want or need, and how to do it.

• Lack knowledge of the program by subcontractors that need

to implement regulated drug and alcohol testing are a frequent source of delays and problems.

63

OTHER FREQUENT PROBLEMS

Do not blame Collectors/Technicians without looking at all the factors, including all other

stakeholders involved.

64

FINAL OBSERVATIONS



When you, or your consultant, visit them for a review, ask them about possible problems with

your program and ideas on how to improve it. They can give you better feedback

than most, in certain aspects of your program.

65

FINAL OBSERVATIONS



When you, or your consultant, visit them for a review, ask them about possible problems with

your program and ideas on how to improve it. They can give you better feedback

than most, in certain aspects of your program.

Consider that Collectors/Technicians may be your best allies to assist in correcting a problem and giving you feedback about your programs when

everyone else is unavailable, or not doing all they should to ensure its success.

66

FINAL OBSERVATIONS

RECOMMENDATIONSFOR PROGRAM REVISION

AND IMPROVEMENT

HANDOUT

67


QUESTIONS

68


drug/alcohol testing programs a testing site perspective jorge bujanda, md

Documents

md slide

laboratories slide

ccf slide

testing site perspective

collector technician

healthworks experience

service request forms

frequent problems