Substance Abuse and Drug Free Workplace Policy

I. Purpose of policy

In the interest of promoting health and safety and preventing liability, this policy establishes Dartmouth- Hitchcock’s (D-H) expectations for all employees to maintain a drug-free workplace and outlines the means for addressing any violation of those expectations.

II. Policy scope

This policy applies to the following persons (hereafter referred to as “employee” or “employees”) at all D-H locations unless a person is covered by a separate agreement:


  • Physicians, fellows, and residents
  • Associate providers
  • Non-provider staff
  • Temporary taff
  • Per diem/PRN staff
  • Geisel (credentialed/privileged)
  • Dartmouth College (credentialed/privileged)

Covered individuals

  • Volunteers
  • Travelers
  • Students
  • Externs
  • Vendors
  • Geisel (non-credentialed/non-privileged)
  • Dartmouth College (non-credentialed/non-privileged)

This policy applies to any individual who conducts business for or represents D-H, applies for a position with D-H, or conducts any business or provides services on D-H property.

Nothing in this policy provides any person with any contractual rights regarding D-H’s implementation or waiver of any provisions of this policy, nor does anything in this policy alter or modify the employment-at-will relationship between D-H and its employees.

III. Definitions

Drug and/or Alcohol Testing: Any and all testing for drugs and/or alcohol by Occupational Health or its designee.

Drug and/or Alcohol Testing Failure: A Blood Alcohol Level (BAC) of 0.02 or higher or the presence of a drug at a level previously established by Occupational Health according to regulatory standards.

Fitness (or Fit) For Duty: An employee’s ability to perform safely and/or appropriately all job functions of his/her position from the time the employee reports to work and throughout the entirety of the employee’s work shift, as determined by D-H in its sole discretion. See also: Fitness for Duty Policy (Policy ID 511).

Human Resources (HR): Employee Relations or other local D-H Human Resources office.

Occupational Health: Occupational & Environmental Medicine, Employee Health, or other employee health entity designated by D-H.

Under the Influence: An employee who is not fit for duty and/or has undergone drug and/or alcohol testing and has had a drug and/or alcohol testing failure.

Work or Work time: Whenever any employee reports to work, represents D-H, or conducts business for D-H, regardless of whether or not at a D-H location. Work or work time shall include but not be limited to attendance at any D-H sponsored event, and/or when reporting to work from on-call or standby status.

IV. Policy statement

In compliance with the federal Drug-Free Workplace Act of 1988 and the New Hampshire Drug-Free Workplace for Licensed Health Care Facilities and Providers Act (NH RSA 151:41), D-H has a longstanding commitment to provide a safe, quality-oriented, and productive work environment consistent with the standards of the communities in which we operate. Alcohol and drug diversion, use, and abuse pose a threat to the health and safety of D-H patients, employees, and the public. For these reasons, D-H is committed to the elimination of drug and/or alcohol diversion, use, and abuse in and affecting the workplace, including but not limited to work time, and educating employees about the importance of a drug-free workplace.

  1. Prohibited Conduct Concerning Alcohol and Drugs
    Except as stated below, D-H employees are prohibited from coming to work and/or performing work while under the influence of alcohol and/or other controlled substances.

    Prescription and over-the-counter medications are not prohibited when taken according to the medication directions and/or according to the provider’s prescription and provided the employee remains fit for duty.

    D-H employees are prohibited, during work and off duty, from engaging in unlawful manufacture, distribution, dispensation, solicitation, sale, transfer or possession of illicit drugs, controlled substances, inhalants or drug paraphernalia. D-H employees are prohibited from illegal or unauthorized use of controlled substances, including prescription medications, illicit drugs or inhalants at any time.

    With respect to medical marijuana, the possession, distribution, and/or use of marijuana, including medical marijuana, is prohibited under federal law. D-H understands that some employees may consider using medical marijuana to treat their own injuries or illnesses. However, D-H prohibits employees from using, possessing, or being under the influence of marijuana, including medical marijuana, while at work or during work time. Any employee who tests positive for marijuana, regardless of whether the marijuana consumed was for medicinal purpose and/or with a prescription, will be considered to have violated this policy, and may be subject to disciplinary action. As such, D-H encourages employees to discuss with their providers alternative treatments to the use of medical marijuana.

    Employees are prohibited from diverting any amount or type of medication intended for patient use. In addition to disciplinary action, theft of medications from D-H inventories may result in reporting to appropriate governmental agencies and criminal prosecution.

    Patients, family members, vendors, contractors, agents, and visitors on D-H property are expected to comply with all appropriate state and federal laws pertaining to controlled substances, illegal drugs, and alcohol. Persons suspected of being in violation of these laws may be asked to leave D-H property and may be reported to local law enforcement.

    Questions regarding the meaning or application of this policy should be addressed to Employee Relations at 603-653-1570 or to Occupational Health.
  2. D-H Social Event
    D-H occasionally sponsors events where alcohol may be available. D-H does not require or encourage anyone to consume alcohol at such events. D-H expects that employees who decide to drink at such events will do so consistent with this policy and only if it will not affect their fitness for duty for work. All employees at D-H social events remain subject to all D-H policies, including all policies related to professional behavior. Any employees who drink at such social events are responsible for doing so in adherence with all laws regarding the operation of motor vehicles.
  3. Self-Reporting of a Substance Abuse Problem or Violation of this Policy
    D-H endeavors to assist individuals in recovery from addiction to drugs and/or alcohol, with medical conditions requiring treatment with mood-altering or controlled drugs, or with a medical history of treatment for substance abuse. Employees are encouraged to seek assistance before their drug and/or alcohol use renders them not fit for duty. If an employee self-reports, every effort will be made to treat this matter as discreetly as possible. The employee’s fitness for duty will be determined according to the Fitness for Duty Policy.
  4. Consequences for Violation of this Policy
    Consequences for any violation of this policy, even when self-reporting, may include but are not limited to:
    • Due process for professional staff covered by the By-Laws
    • Corrective action up to and including immediate termination of employment
    • Fitness for Duty evaluation
    • Removal from work
    • Referral to treatment, rehabilitation, or counseling program
    • Return to work contracting
    • Return to work drug testing
    • Ongoing follow-up drug testing
    • Reporting to professional boards
    • Notification to federal contracting agencies
    Nothing in this policy prohibits an employee from being disciplined or terminated for violations of other policies and/or performance deficiencies.
  5. Employee Responsibilities
    Providers shall not prescribe controlled medications to themselves or to immediate family members.

    All employees who handle, dispense, or administer controlled substances are required to be aware of and follow all applicable laws and D-H policies and procedures regarding administration, disposal, and documentation.

    An employee who is arrested for and/or charged with a drug or alcohol-related offense must inform their supervisor, Employee Relations, or Occupational Health as soon as he or she is able to do so, which generally means within 48 hours, but no later than the commencement of his or her next regularly scheduled shift. An employee who is convicted of a criminal drug or alcohol-related violation must inform their supervisor within 48 hours and no later than the commencement of his or her next regularly scheduled shift.

    An employee taking prescription or over-the-counter medications is responsible for consulting with the prescribing provider and/or pharmacist to ascertain whether the medication may impair safe performance of their job. If the use of the medication could compromise the safety of the employee, fellow employees, or patients or impair his or her ability to perform safely the employee’s essential job functions, it is the employee’s responsibility to notify their supervisor, to call in sick, use Earned Time, or request a temporary change of duties.

    Any employee who has actual knowledge or reasonable concern that another employee is impaired or has engaged in or is engaging in conduct prohibited by this policy shall report their concerns to an appropriate supervisor or to Human Resources at the earliest opportunity. Information communicated under the terms of this policy is limited to those who have a legitimate need to know in compliance with relevant laws.
  6. Supervisor Responsibilities
    Any supervisor who receives a report of employee substance abuse, or has actual knowledge or reasonable concern that an employee has engaged in or is engaging in conduct prohibited by this policy, shall not permit the employee to work until the matter has been thoroughly assessed and resolved through consultation with Occupational Health, Human Resources, and/or the Employee Assistance Program (see the Fitness for Duty Policy). The investigation is based on D-H’s assessment of the facts and circumstances, which may include an interview, drug audit, pharmacy audit, and up to a full fitness for duty evaluation.
  7. Drug Testing
    D-H conducts post-offer/pre-employment, reasonable concern, return-to-work, and follow-up drug and/or alcohol testing per drug testing protocols at the request of management and with the consent of Occupational Health. Compliance with this testing is a condition of employment. An employee who refuses timely drug or alcohol testing, adulterates or dilutes their specimen, substitutes their specimen with that from another person, sends an imposter for testing, will not sign the required forms, or refuses to cooperate in the testing process in such a way that prevents timely completion of the test, is subject to disciplinary action up to and including termination.

    The Fitness for Duty Policy establishes the terms for drug testing of employees for whom D-H has reasonable concerns about the employees’ fitness for duty due to drug or alcohol impairment or who are reasonably suspected of drug diversion and establishes consequences for failure of a drug test.

    The terms for drug screening of non-employees who work at D-H are established in the contract or agreement between D-H and the relevant school, agency, or other organization.

    To ensure accuracy and fairness of testing, D-H conducts drug testing in accordance with federal law and Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines.
  8. Reporting to Professional Licensing Board or Federal Contracting Agency
    D-H shall report violations of this policy to the appropriate authorities, boards, and/or agencies as required by applicable state and/or federal law and, if appropriate, according to the terms of the Mary Hitchcock Memorial Hospital Professional Staff Bylaws and Rules and Regulations. If permitted by the applicable law, D-H, in its sole discretion, may allow an employee to self-report the violation, provided such self-reporting is timely done and verified to D-H’s satisfaction. Regardless of the reporting mechanism, if the employee wishes to remain eligible for employment at D-H, the employee is solely responsible to satisfy all requirements to retain or reinstate his/her license and to remove any sanctions. However, the retention or reinstatement of the license(s) does not guarantee continued employment at D-H; D-H has sole discretion to determine the employee’s employment status.

    Licensing boards may implement programs to support license holders which include formal contracts, support groups, and/or peer reviews. When appropriate, Occupational Health, the Chief Medical Officer, the Chief Nursing Officer, Human Resources, and the supervisor support and participate in such contracts.

V. References

Substance Abuse and Mental Health Service Administration Guidelines

D-H Policy ID: 476