Part of the Board of Registered Nursing Disciplinary Process is mandated random drug testing. It is the intention of this website to provide accurate information to nurses in order to increase knowledge and reduce the air of mystery surrounding many aspects of discipline. Drug testing can be the subject of great debate, as well as anxiety to nurses undergoing this process. A large amount of data is given here. An effort has been made to provide accurate information by quoting the Board and updating information as rules change, thereby giving the nurse an idea of what to expect.
One of the things that are helpful for a nurse undergoing Intervention (Diversion) or Enforcement (Probation) to learn is to remain in the present moment, focus on what they have control over at this moment in time. Do not drag along a stressful incident into the following hours, days, or even years but instead, learn to release and let go so that life is not given over to the emotional control of another person or entity.
The nurse can make a decision to accept the challenge placed before them. Empowerment begins in their choice.
Honest and successful participation in the challenge placed before the nurse empowers them to control their own lives and reclaim their right to work in their chosen profession.
The following is information based upon Board Regulations and Meeting Minutes, Maximus, as well as upon the experiences of RNs in Intervention (Diversion) and Enforcement (Probation) Programs.
Random drug testing begins immediately upon acceptance into either the Intervention (Diversion) or Enforcement (Probation) programs. The first clean drug test is considered the nurse’s first clean date in the program.
Samples required may be urine, blood, or hair follicle specimens. A nurse can expect 1-8 random drug tests per month; urine, possibly a blood draw, rarely but possible hair follicle samples, weekend, and holiday testing. Nurses can expect mandated drug testing while on vacation and while out of the state.
Please research and review Department of Consumer Affairs Contract and Performance Audit of the DCA Diversion Program provided by Maximus Health Services February 18, 2016
The following are excerpts taken from the BRN minutes regarding Intervention (Diversion) and Enforcement (Probation) Regulations and Standard Summaries.
www.rn.ca.gov/pdfs/meetings/brd/brd_jun15_item9.pdf
B&P Code Section 315(c)(4) Standards governing all aspects of required testing, including but not limited to, frequency of testing, randomity, method of notice to the licensee, number of hours between the provision of notice and the test, standards for specimen collectors, procedures used by specimen collectors, the permissible locations of testing, whether the collection process must be observed by the collector, back up testing requirements when the licensee is on vacation or otherwise unavailable for local testing, requirements for the laboratory that analyzes the specimens, and the required maximum time frame from the test to the receipt of the result of the test.
www.rn.ca.gov/pdfs/enforcement/discguide.pdf
(17) SUBMIT TO TESTS AND SAMPLES – Respondent, at his/her expense, shall participate in a random, biological fluid testing or a drug screening program that the Board approves. The length of time and frequency will be subject to approval by the Board. The respondent is responsible for keeping the Board informed of the respondent’s current telephone number at all times. Respondent shall also ensure that messages may be left at the telephone number when he/she is not available and ensure that reports are submitted directly by the testing agency to the Board, as directed. Any confirmed positive finding shall be reported immediately to the Board by the program and the respondent shall be considered in violation of probation.
In addition, respondent, at any time during the period of probation, shall fully cooperate with the Board or any of its representatives, and shall, when requested, submit to such tests and samples as the Board or its representatives may require for the detection of alcohol, narcotics, hypnotics, dangerous drugs, or other controlled substances.
If the respondent has a positive drug screen for any substance not legally authorized and not reported to the coordinating physician, nurse practitioner, or physician assistant, and the Board files a petition to revoke probation or an accusation, the Board may suspend respondent from practice pending the final decision on the petition to revoke probation or the accusation. This period of suspension will not apply to the reduction of this probationary time period. If respondent fails to participate in a random, biological fluid testing or drug screening program within the specified time frame, the respondent shall immediately cease practice and shall not resume practice until notified by the Board. After taking into account documented evidence of mitigation, if the Board files a petition to revoke probation or an accusation, the Board may suspend respondent from practice pending the final decision on the petition to revoke probation or the accusation. This period of suspension will not apply to the reduction of this probationary time period.
RATIONALE: This condition provides documentation that the respondent is substance or chemical free. It provides the Board with a mechanism through which to require additional laboratory analyses for the presence of narcotics, alcohol, and/or dangerous drugs when the respondent appears to be in violation of the conditions of probation or appears to be under the influence of mood altering substances. This condition protects the public by giving the Board the discretion to suspend respondent from practice based on the use of any substance that is not legally authorized. This condition further protects the public by immediately suspending the respondent’s practice if he or she fails to comply with the drug screening requirement.
BOARD’S VIEWPOINT
1. The Board of Registered Nursing must be able to document a nurse’s abstinence from drugs and alcohol.
2. A nurse has the burden of proof to show the Board of Registered Nursing they are safe to work under their license.
3. The Board of Registered Nursing has a burden of proof to show the Department of Consumer Affairs and the public that they have taken every measure to ensure an individual is safe to work under their license.
4. This forced period of abstinence from drugs and alcohol theoretically gives the nurse time to break a potentially destructive cycle long enough to find recovery.
5. If random drug test frequency and dates can be predicted, there is a degree of risk that a nurse, who is not being honest in their recovery, could use drugs or alcohol while undergoing Intervention (Diversion) or Enforcement (Probation).
NURSE’S VIEWPOINT
Increased frequency of random drug testing can cause great duress to individuals in recovery:
1. Exorbitant costs are placed upon the shoulders of nurses who are often unemployed and struggling to support their families. Every time a nurse is required to provide one witnessed urine sample it costs approximately $100. Up to 8 urine samples can be required in any given month. Minimum wage cannot begin to pay for these costs that are difficult for even an RN working full time to bear.
2. Not every nurse in Intervention (Diversion) or Enforcement (Probation) is there because of misuse of drugs or alcohol yet, in many circumstances, are also required to provide random drug tests and their frequency of testing is increasing to a minimum standard of 36 per year.
3. If testing is required on a weekend or Holiday, the nurse may have to drive many miles in the opposite direction of work to an alternative testing site that has same-sex technicians because their usual testing site is closed.
4. Frequent drug testing, especially cutting someone’s hair to obtain hair follicle samples and venipunctures, is perceived as punitive treatment. The question arises as to what right a State governmental agency has to perform painful invasive procedures, thereby penalizing a citizen on an ongoing basis for something that occurred years ago, for an infraction that may have had nothing to do with drugs or alcohol, and for something which the nurse has already been penalized by the State of California for.
There is an impasse’ between the two mindsets, each having its own important and valid points.
Testing frequency is outlined in the BRN Committee Meeting Jun 4. 2015
BOARD OF REGISTERED NURSING Diversion/Discipline Committee Agenda Item Summary
“Establishes two levels of testing: Level 1 (Year 1) 52 – 104 tests per year; Level 2 (Years 2 -5) 36 – 104 tests per year. After year 5, testing is 1 time per month if there have been no positive tests in the previous 5 consecutive years of probation or diversion. The board may increase frequency for any reason. Testing frequency exceptions are: 1) licensee has participated in treatment or monitoring program that required testing, 2) violation was outside of employment, 3) not employed in healthcare field, 4) licensee is on tolled status, and 5) substance abuse disorder is not diagnosed. The Standard also specifies drug testing standards and requires collection of specified data for 2 years prior to implementation, if available, and for 3 years postimplementation.”
It is important the nurse observe chain of command for their specimen and that the lab slip is properly filled out. All procedures must be properly followed by the technician. If a nurse feels uncomfortable with the technician, they have the right to ask for another one or find an alternative site for testing.
Bring picture ID, chain of command lab slip, and lab ID # with you to the testing site.
If a nurse has an out of range test or raises suspicion of non-compliance to the Board, frequency and type of test can increase dramatically. An increase or decrease in the frequency of testing can occur with or without provocation. Variation in frequency is never without great speculation as to why and is always up to the Board’s discretion. It has been observed by nurses that the frequency of testing has increased after life events such as job changes, the birth of children, marriage, and the death of loved ones.
TRAVELING
Call the Lab 14 days in advance of travel to notify them of your destination and times. The lab will provide testing sites in the location you are traveling to. It is the nurse’s responsibility to ensure test site hours, same-sex technician availability, provide own chain of command lab slip, and the proper specimen kit is available at the site.
Do not forget to pack lab Forensic Drug Testing Forms. If the nurse does not have the proper form with them, if they are unable to locate a lab that has the correct forms on-site, they may be required to return home in order to obtain the lab form and test at their local testing site. If they do not follow proper procedure, the nurse will have a Missed Test. Forms are obtained through the lab testing company and are delivered by mail to the nurse’s home. Make certain the testing site has the correct lab kits and the ability to send the specimen to the lab processing company. In some areas of certain states, such as Hawaii, testing sites are scarce and nurses have had to fly to a testing site while on vacation, all costs to the nurse. It is the nurse’s responsibility to ensure compliance with every mandate.
The nurse will have an increase in testing frequency upon return from traveling and can expect a hair and PETH test, as well.
Random picture in Northern Ca. Just for fun.
Lab testing check-in time begins at 0500 and ends at the time designated by the Board stipulations. If a nurse checks in past that designated time it considered a Missed Test. If a nurse misses a urine test they should contact their monitor, the Intervention nurse consultant, and the lab immediately upon discovery. Testing the following morning is a good idea. This may or may not influence the Board’s decision regarding noncompliance but wouldn’t hurt.
FEES
TESTING SITES
Urine site testing fees vary and can range from $25 to $100 for each urine collection fee. They are due at the time of testing.
There are mobile sites that are open after lab offices are closed. These have been utilized by nurses who work 12-hour shifts and are not able to test until after 8 pm when many labs are closed. The costs of these services vary and can be $100-$250 or more for each test, also due at the time of the test. Keep a list of drug testing sites to share with other nurses in need.
PROCESSING FEES AND PAYMENTS
FirstLab bills each participant monthly for each drug test performed. Participants are responsible for paying the specimen processing fees each month. These fees can range up to $125. (CA Department of Consumer Affairs Maximus Diversion Program Audit Final Report. Feb 18,2016)
Urine lab processing fees are $62.50 per test. Because testing frequencies vary from 1-8 tests a month, it can be challenging to budget for payments every month. The testing website posts how much the nurse will be charged that month. Make sure there is enough in the account to cover the direct withdrawal payment each month.
As of 2020, nurses must pay increased flat fees to drug test within Maximus provider groups. If the nurse does not have a testing site within their region they pay higher fees. The rationale is the nurses will see a decreased rate over a year but in reality, the costs are higher for the nurses who are already struggling to pay many required program fees.
If there is not enough money in the account to cover the fees, the account is immediately suspended and attempt to check in that day will be considered a “missed test”. This is a moment of great panic to a nurse. This can be corrected online within minutes by changing payment method and if done immediately before check in time ends, will not cause compliance concerns. It has been recommended that an exclusive form of payment, eg. a separate credit card, or Pay Pal be used so the only payment coming out of that account is to cover lab fees.
If a urine test is missed, some nurses have chosen to have a random drug test done that same day anyway, whether or not they knew if they were selected. Whether this helps their case or not is up to speculation but certainly couldn’t hurt when questioned by the Board.
“Missed tests” are considered non-compliance and will be cause for discipline by the Board.
It is important to document every time a nurse checks into the lab. Develop a method of keeping track of every check-in and keep every lab slip on file. There have been incidences when the nurse is notified months later that a random urine drug screen was missed. If the nurse has a record of the drug screen, lab slip, and checking in, this can be disputed. If there is no record, the Board or Lab records will stand indicating non-compliance and discipline will follow. The lab testing site recommends printing out every record. If a nurse chooses to follow this procedure, they can keep a notebook containing all lab records. Some nurses maintain their own written records in a notebook. Some nurses take a computer screenshot as proof of the lab check-in. It is highly recommended that some form of documentation that works for the nurse be maintained. Unfortunately, when life is busy, when children are running through the house, when an individual is late for work, when working nights or PM hours and sleeping during the day when trying to relax on vacation, it is not difficult to forget to check into the lab every morning without fail. The nurse needs a backup system to protect themselves.
It is highly recommended that nurses have a buddy system to text or call every morning to ensure each nurse has checked into the lab that day. This avoids Missed Tests which result in extreme duress to the nurse.
Urine samples must be witnessed. Ensure there is a same-sex witness at the testing site.
Some testing sites get nurses in and out quickly while other offices require nurses to wait for other appointments to be seen first. In order to reduce the stress of time constraints, leave ample time for testing, and bring a book. If a nurse does not fill the specimen container they may not leave the testing site until they are able to.
Urine specimens that measure low creatinine are considered Missed Tests.
Urine can measure low creatinine for multiple reasons: glomerulonephritis, kidney disease, pregnancy, exercise, UTI, drinking large amounts of fluid, vegetarian diet, liver disease, aging, thyroid disorders such as Graves Disease. Drinking coffee or tea prior to a test causes diuresis which can dilute urine. If a nurse has a medical reason for low urine creatinines, provide written documentation from a Physician to the Board.
Blood samples are called PETH tests: PETH tests are specific for Alcohol and are sensitive to 3 weeks past consumption. The PETH is able to differentiate between alcohol consumption and food or product additives.
A PETH test can be obtained by a finger-prick blood droplet that detects mid to long term biomarkers for alcohol (phosphatidyl ethanol) or by venipuncture into vials. Venipuncture blood draws detect alcohol and multiple types of drugs within the system. www.dopl.utah.gov/programs/urap/forms/MedGuide.pdf
Blood draw fees vary according to lab testing sites and can be $50-$100 or more per test.
Blood lab processing fees billed to the nurse the following month for that sample are $110 or more for each test.
The Board states PETH Testing or blood draws are ordered to rule out a false-positive urine test. “It provides the Board with a mechanism through which to require additional laboratory analyses for the presence of narcotics, alcohol, and/or dangerous drugs when the respondent appears to be in violation of the conditions of probation or appears to be under the influence of mood-altering substances.” BRN Guidelines For Disciplinary Orders. ww.rn.ca.gov/pdfs/enforcement/discguide.pdf)
In an effort to monitor complete abstinence of drugs or alcohol, the power of the State extends to the body, with or without justified suspicion of non-compliance. PETH Testing has frequently been ordered without provocation or suspicion of abuse, leaving no plausible explanation for the necessity of mandating invasive, painful, and expensive procedures such as blood draws. Unfortunately, not all lab technicians are proficient in venipuncture technique and not all nurses have large veins. Both of these circumstances have resulted in multiple needle sticks. As many as 9 needle sticks have been reported to obtain one blood test. The lab sends one blood specimen kit for each nurse to their preferred testing site a month prior to the BRN mandating the random blood specimen for suspicion of violation the nurse may or may not in the future provoke. If the specimen kit is damaged or the venipuncture failed, there is no other kit available to obtain another sample for that nurse.
Hair follicle samples may be required if a urine sample has low creatinine, or if there is suspicion of non-compliance, of drug or alcohol use. A hair follicle sample can detect drug use up to one year past.
Hair samples are taken from the head where a chunk of hair is cut at the roots approximately the size of a dime circle for testing. This causes emotional duress for nurses. Hair dye reportedly does not affect the test.
COST TO NURSES
- Cost of urine drug test processing fees for each nurse in Intervention (Diversion) or Enforcement (Probation) is $2,400 to $9,600 annually
- Cost of random hair tests is $236.30 each. These tests are ordered randomly, without provocation or suspicion of drug or alcohol use.
- Collection site fees paid by the nurse to lab testing sites on top of lab processing fees are $600 to $2,400 annually.
- The cost of urine drug test processing fees paid by all nurses throughout California in Intervention (Diversion) or Enforcement (Probation) is $2,400,000 can potentially exceed $9,600,000 annually.
- Urine collection fees paid by all Enforcement (Probation) and Intervention (Diversion) nurses throughout California to testing sites on top of lab processing fees is $600,000 and can exceed $2,400,000 annually
These are conservative numbers and do not include hair follicles and PETH (blood) tests. (Numbers were obtained with the use of a calculator, the reader is encouraged to do the math themselves.) - “Cost to the licensee – loss of wages during cease practice – undetermined. Average RN annual income in 2012 was $89,940 (BRN 2012 Survey of RNs)” Multiply $89,940 by how many years the nurse is forced into unemployment or minimum wage employment = hundreds of thousands of dollars in lost wages.
- “Cost to licensee for drug testing – approximately $800; $100/test x 8 tests)” per month. (www.rn.ca.gov/pdfs/meetings/brd/brd_nov14_item9.pdf )
If any of the Board mandates are not met or are “out of compliance”, the threat is a nurse’s license will be sent to the Attorney General’s office and license revocation will occur.
Non-compliance can mean:
Drug test “out of range” ie. Low Creatinine or Positive for substances such as drug or alcohol metabolites.
Missed Tests.
Inability to pay lab fees.
LINK TO LIST OF MEDICATIONS THAT WILL SHOW POSITIVE ON DRUG SCREENS
www.dopl.utah.gov/programs/urap/forms/MedGuide.pdf
The following are potential causes for urine testing Positive for Alcohol or Drugs:
- Alcohol does not “cook-off” and the metabolites are found in urine.
- Hand Sanitizers
- Kombucha
- Non-alcoholic beverages such as O’Douls
- Do not accept drinks or food that you are not sure of ingredients.
- Perfumes, although some nurses reportedly use perfumes without testing Positive. It is advised to err on the side of caution.
- Mouth wash such as Listerine can cause false positive for alcohol consumption. “Safe” Mouthwash is Act but always check all ingredients prior to use.
- It is rumored Soy Sauce can cause an Alcohol Positive urine because it is fermented. Some Soy Sauces contain alcohol. Check the Soy Sauce to ensure Alcohol is not an ingredient. Gluten-Free Soy Sauces have sometimes been found to be alcohol-free. This is a highly debated topic among nurses.
- Sauces cooked with wine or beer. Be cautious when ordering from the menu in restaurants. Nurses have suddenly found themselves spitting food out in front of guests when discovering the food they are eating was cooked with an ingredient that will cause urine to test positive. This is highly embarrassing and quite unfortunate.
- Foods cooked with poppy seeds will test positive for opiates.
- Maximus has an exhaustive list of things that can cause altered urine screens. It is never a mistake to call the lab and double-check acceptability for products or food.
- Ask your lab testing facility to send you a list of acceptable and unacceptable foods and products.
- Being in an environment where second-hand cannabis smoke can be inhaled is not an excuse for positive drug tests. They will be treated as non-compliance. Be wise regarding environments you place yourself in.
- This is your Life, your Nursing License, and your career. Take every precaution to protect them.
WHEN IN DOUBT, DON’T.
If prescription medication is required, report it to the Board with a letter from the Physician. Report all medications used to the Board including medications used in dental and surgical procedures. One negative drug test is required before a nurse can return to work after a medical procedure.
If a nurse tests positive for a suspicious substance or has low urine creatinine (please see above for causes of low creatinine)
- Drug testing frequency will increase.
- PETH testing and or hair follicle samples may also be required.
- The nurse may be required to keep a 3-month diary of everything they ingest.
- Enforcement (Probation) may be extended or early discharge from Enforcement (Probation) denied. Intervention (Diversion) may be extended or Transition be denied.
- At worse, the nurse’s license can be sent to the Attorney General’s office and revoked for noncompliance. Please see the link provided under “Additional Information” page. Department of Consumer Affairs Contract and Performance Audit of the DCA Diversion Program provided by Maximus Health Services February 18, 2016.
The most common picture is that every morning upon awakening a nurse reaches for the phone or computer to check in with the lab. It takes 60 seconds of their day to check-in and finds out whether or not they have been selected for testing. Next the nurse texts a “buddy” in the program to verify that both have checked in on that day. This is another 60-second task. If they are not testing that day, the nurse can forget about it for the rest of the day. Focusing on it any longer than that is giving power and energy away for nothing.
Assume a test will be ordered any given day and make plans accordingly that will be incorporated into your routine. Doing this reduces the stress of having to rearrange your schedule because you have planned ahead. You have taken control and there are no surprises. When you don’t have to test, you can go about your day unencumbered.
If a nurse is selected for testing, test first thing in the morning before drinking coffee or test later in the afternoon when your body is done diuresing. Increase protein intake by eating peanut butter, granola, nuts, or meat. There are many methods each nurse has found effective in avoiding low creatinines and everyone’s body is different. Talk to nurses in your support group for advice. The witnessed urine test does take time out of the day, depending upon the location of test sites. It can be a 4-hour block of time to drive, wait, and test. Some nurses meet for coffee or lunch with other nurses afterward. Some have a testing site near their worksite and test before, during, or after work.
Do not focus on the negative aspect but defy the negative by creating something positive.
The intention of this website is to make nurses more informed during the process of their BRN Intervention (Diversion) or Enforcement (Probation) disciplines. It is not intended to evoke fear but rather to reduce it and help the nurse find their own power in their lives.
If a nurse has information that can shed light on this subject, please contact this site to share it. If the information has been misspoken or needs to be accurately updated, again, please share correct information or insight so rumors and fears can be dispelled. Hopefully, the shroud of mystery is lifted so the nurse knows more fully what can be expected and the emotions evoked secondary to fear of the unknown can be mollified.
You are not without control over your life. You are empowered to make healthy choices, to succeed, to grow, to become everything you were intended to become. Remember, there are approximately 1,500 nurses in the State of California facing some of the same things you are facing every day. You are not alone!
Photo by Vivian Lowe. Hearst Castle San Simeon, California