Compliance

Nursing Student Compliance Program

The School of Nursing is committed to ensuring all nursing students are compliant with national and state for personnel providing nursing care, as well as additional/specific requirements mandated by the school’s clinical affiliates. All nursing students are required to be in full adherence to the school’s compliance program while enrolled in the nursing program as an essential part of their professional responsibility for patient safety.  These requirements include immunizations (MMR, Varicella, Hepatitis B, Tetanus, influenza), trainings (CPR, HIPAA, OSHA), contracts (Confidentiality and Social Media), as well as a tuberculosis test and a background check.  We utilize CastleBranch to track student compliance.  When accepted to the program, you will receive further information about signing up for an account.

The School of Nursing partners with CastleBranch to manage student health compliance documents. This management system allows students to order their own background checks online and store all required documentation. There is a one-time Castle Branch subscription fee ($35) that is paid by the student, as well as a cost for the background check ($58).  Once the subscription fee is paid, students will have permanent access to their account.  Background checks expire after four years.  If there is any change in the individual’s background while enrolled in the program that results in a change of the caregiver report, it is the responsibility of the student to notify the School of Nursing and another full background check is required.

For more information, please click on the tab for the specific requirement.  If you have any questions or concerns, please contact our compliance staff at compliance@nursing.wisc.edu.

New incoming students-one of the following is required with NEGATIVE results:

  • Documentation of a two-step PPD skin test. The two-step test requires an initial injection and reading by a healthcare professional and a second injection and reading by a healthcare professional within 1–3 weeks of the first; OR
  • Documentation of a negative QuantiFERON Gold -TB blood test

Current Students:

The renewal will be set for 1 year for negative results. Students with negative two-steps or QuantiFERON Gold -TB blood test must submit documentation of annual testing yearly after initial screening to maintain compliance. The renewal options are:

  • A negative one-step skin test, OR
  • A negative two-step skin test, OR
  • A negative QuantiFERON Gold -TB blood test

If POSITIVE results, a QuantiFERON Gold -TB test is required.

  • If the QuantiFERON Gold -TB test is negative, submit both of the following:
  • If the QuantiFERON Gold -TB test is positive, submit all of the following:
    • positive QuantiFERON Gold test AND
    • a post-positive chest x-ray report AND
    • physician clearance documented on letterhead OR
    • a symptom risk assessment form reviewed and signed by a healthcare professional/clinician.

The renewal will be set for 1 year for positive results. Upon renewal, a new TB Symptom Risk Assessment form reviewed and signed by a healthcare professional/clinician is required.

All documentation must be from a verifiable source such as MyChart, Wisconsin immunization registry, or be on a physician letterhead. Documentation must also include student’s name on at least the first page of the document.

Submit documentation:

  • Three vaccination series OR
  • Serological laboratory evidence of immunity to Hepatitis B (positive antibody titer)

Students must have at least one dose administered prior to the compliance deadline. The second and third doses must follow, with the second dose 1 month after the first dose and the third dose 4 months after the second dose.

All documentation must be from a verifiable source such as MyChart, Wisconsin immunization registry, or be on a physician letterhead. Documentation must also include student’s name on at least the first page of the document.

One of the following is required:

  • 2 vaccines OR
  • a positive antibody titer for all 3 components (lab report or physician verification of results required)

If titer is negative or equivocal and you have documentation of 2 vaccinations, no further action is required. If titer is negative or equivocal and you do NOT have documentation of 2 vaccines, additional alerts will be created for you to complete the vaccination series. If series is in process, submit where you are and additional alerts will be created for you to complete the series.

All documentation must be from a verifiable source such as MyChart, Wisconsin immunization registry, or be on a physician letterhead. Documentation must also include student’s name on at least the first page of the document.

One of the following is required:

  • 2 vaccines OR
  • a positive antibody titer (lab report or physician verification of results required)

If titer is negative or equivocal and you have documentation of 2 vaccinations, no further action is required. If titer is negative or equivocal and you do NOT have documentation of 2 vaccines, additional alerts will be created for you to complete the vaccination series. If series is in process, submit where you are and additional alerts will be created for you to complete the series.

All documentation must be from a verifiable source such as MyChart, Wisconsin immunization registry, or be on a physician letterhead. Documentation must also include student’s name on at least the first page of the document.

Submit a Tdap administered within the past 10 years. The date of renewal will be set 10 years from the administered date of the vaccine at which time a TD booster is required every 10 years.

All documentation must be from a verifiable source such as MyChart, Wisconsin immunization registry, or be on a physician letterhead. Documentation must also include student’s name on at least the first page of the document.

Submit documentation of one of the following:

  • a flu shot administered during the current flu season (09/01 – 11/01) OR
  • declination on the Flu Declination Form available for download from this requirement.

Documentation does not need to include batch information.  The renewal will be set for 11/01 of the following flu season.

All documentation must be from a verifiable source such as MyChart, Wisconsin immunization registry, or be on a physician letterhead. Documentation must also include student’s name on at least the first page of the document.

Submit your CPR certification. Must be for one of the following courses:

Advanced Professional Healthcare Education provides acceptable American Heart Association courses.

The UW-Madison Police Department offers CPR classes for BLS Healthcare Providers.  Below are some dates for BLS CPR Hands on skills classes.  This could be the hands on skills portion of the blended learning.

Click date below to register:

July 22nd – BLS Skills Testing – 2pm to 4pm – SSCH

July 29th – BLS Skills Testing – 2pm to 4pm – SSCH

The University of Wisconsin Madison Recreational Sports offers American Red Cross CPR/FA/AED for Professional Rescuer Courses throughout the school year that satisfy the School of Nursing requirement. Click here to register through Rec Sports.

Blended Online + Classroom (hands on) courses are acceptable from either American Red Cross or American Heart Association. (Also, see dates above.)

Required documentation is a copy of the final CPR certification card or certificate.

OSHA training is done through UW Health.  To complete the training, click here to access the training website, create an account, select the Safety and Infection Control course, and select “Direct Patient Care.”  If you have difficulty with the training, contact the UWHC Help Desk at 265-7777 or ehealth@uwhealth.org.  Please be sure to carefully follow the instructions when uploading your certificate to CastleBranch. Click here for step-by-step instructions.

The UW-Madison Office of Compliance is developing a new on-line HIPAA training course that is expected to roll out by the end of the summer.  Specific instructions on how to access the course will be sent to you via email when you need to complete the training.

If you are a returning student and it has been more than a year since you last completed the HIPAA course (version 2018-19), please rest assured that UW-Madison still considers you to be in compliance with our campus-wide HIPAA training policy. You do not need to re-take last year’s course (version 2018-19) and do not need to upload renewed certification to CastleBranch.  CastleBranch is not being used at this time to track HIPAA training compliance because of its inability to reflect our campus training timelines.

If you are new to the School of Nursing and have heard of the need to take HIPAA training, please note that you do not need to take the training until the new course (version 2019-20) is ready.  The SoN will provide you with a reasonable timeframe for completing the course.

A small SoN program (ABSN) took the 2018-19 course earlier in the summer (prior to beginning clinical rotations) and is expected to take the new training when it becomes available. We apologize in advance for needing you to take a new training course in less than 12 months.  The Office of Compliance shifted the timing of its annual training in an effort to align with the schedules of the majority of the trainees – and this unintentionally created a situation where pockets of students in programs with unique start-dates or clinical schedules need to complete training again despite completing the 2018-19 course less than twelve months ago.  We anticipate that this is a one-time occurrence.  The 2019-20 course will highlight new security-related information and provide examples and quiz questions derived from current federal guidance and recent experience addressing HIPAA compliance at UW-Madison.

You can direct questions to Staci Lowe (slowe@wisc.edu), HIPAA Privacy Coordinator for the SoN or the SoN compliance team (compliance@nursing.wisc.edu).

When entering the School of Nursing, all students are required to access and sign both a Confidentiality Agreement and a Social Media Contract.  This is a one-time step to ensure students are aware of confidentiality procedures and social media rules regarding patient data.

Consequences of Non-Compliance

Students who are not in compliance as of the first day of the semester, or who fall out of compliance during the semester, are not allowed to participate in classroom or clinical experiences, including practicum or research experiences in a clinical or other care setting.  Students may return to classes once they complete the compliance requirement(s) or are able to provide evidence of a future appointment/registration to update the immunization or training requirement. Students may return to clinical settings (including practicum or research experiences) only after the appropriate immunization or training has been completed and the documentation submitted.

Students who are out of compliance will have a hold placed on their university record, which will suspend the student’s ability to add courses; the hold will be lifted once the student is in compliance.

Compliance Support Staff

compliance@nursing.wisc.edu

Ann: 608-263-5329 | Emily: 608-263-5167