UNIVERSITY OF NORTH CAROLINA HEALTH CARE SYSTEM - DRAFT SYSTEM POLICY -

POLICY NAME: Vendor Visitation for Network Entities

RESPONSIBLE FOR CONTENT: UNC HC Supply Chain & Compliance

I. DESCRIPTION

This policy details requirements and expectations for vendor representatives who visit UNC Health Care (HC) Network Entities representing or promoting products or services that could be used by or sold to the UNC HC Network Entity, as well as vendor representatives promoting referrals for patient care or post-hospitalization services (e.g., durable medical equipment providers, home health providers).

II. DEFINITIONS

Vendor – any business that provides or has potential to provide services or products to UNC HC, its Network Entities or its patients.

• Examples of Vendors – medical device/supply company, pharmaceutical company, software and programming service providers, insurance company, post-acute care placement provider.

Vendor Representative – any person representing a vendor to UNC HC or its Network Entities.

Independent Contractor – any individual person classified and approved to provide services to UNC HC or its Network Entities under the terms of a contract or agreement in exchange for payment via IRS Form 1099.

• Examples of Independent Contractors – sole proprietors, window repairperson, caterer, specific clinical care providers.

Business Contractor – any corporation, business, or limited liability corporation classified and approved to provide services to UNC HC or its Network Entities under the terms of a contract or agreement in exchange for payment.

• Examples of Business Contractors – building construction company, paper shredding company, drink and snack vending machine company, landscaping company, window-washing company, contract clinical care teams, operational business consultants, operational fiscal auditors.

Post-Acute Care Service Provider – any business that provides or has potential to provide post-acute services or products to the patients of UNC HC or its Network Entities.

• Examples of Post-Acute Care Service Providers – long-term acute care (LTAC) hospitals, skilled nursing facilities (SNFs), durable medical equipment (DME) providers, home oxygen providers, managed care representatives.

Auxiliary and/or Gift Shop Vendors – any business or person solely providing services to hospital gift shops and in support of approved auxiliary sales events.

• Examples of Gift Shop and Auxiliary Sales Vendors – decorative gift item company, community member donating/selling handmade breast cancer awareness items, annual book sale company.

Visitor Attending a Business Meeting – any person not considered a vendor, independent contractor, business contractor, or post-acute care service provider visiting UNC HC and/or its Network Entities for the purposes of attending a scheduled business meeting with covered personnel.

• Examples of Visitors Attending a Business Meeting – Community leaders, local business persons, health care providers considering employment with UNC HC or its Network Entities, health care industry leaders.

III. RATIONALE

This policy provides regulatory and behavioral guidelines for vendor representatives and others providing, consulting or soliciting services, as well as referrals for patient care services. Vendor representatives are considered guests of UNC HC and, as such, should provide services in accordance with accepted rules of conduct and in a manner that provides the greatest benefit to UNC HC’s patients and Covered Personnel.

IV. POLICY

1. Vendor Registration and Credentialing

   1. Vendor representatives must be credentialed in advance of entering a UNC HC Network Entity. Vendor credentialing should be accomplished using a vendor credentialing system and process adopted by the Network Entity. All vendor credentialing shall include vendor education regarding:

      1. Compliance, including fraud, waste and abuse.

      2. Privacy, including protected health information (PHI) and confidentiality.

      3. Office of Inspector General sanction screening.

      4. UNC HC and/or entity-specific vendor visitation requirements and behavioral expectations.

      5. Immunization and health requirements, including annual influenza vaccination.

   2. Vendor representatives entering a UNC HC Network Entity must have a previously scheduled appointment or arrangement, e.g., involvement in a surgical case. It is unacceptable for vendors to enter the Network Entity for drop-in visits. Vendor representatives should arrive prior to their appointment and depart immediately after. Unsolicited presence in or about patient care areas, medical staff offices, or other public or private areas for the purpose of making an appointment, or of detailing product or product lines without an appointment, is not permitted. The use of any Network Entity’s paging system by vendor representatives is expressly prohibited.

      1. Some Network Entities may have dedicated vendor representative liaisons. Dedicated liaisons may locate themselves in public areas of the facility to accommodate timely assistance to departments and hospital staff. All other requirements outlined in this policy must be followed.

   3. Vendor representatives are required to sign in using the entity’s vendor management software or designated process and receive temporary identification upon arrival at the Network Entity facility. The temporary identification badge must clearly state “Vendor.”

   4. Vendor representatives are required to also sign in to the department(s) the vendor is visiting. These department vendor visitation logs will be retained for seven (7) calendar years for auditing purposes.

   5. The temporary vendor identification shall only allow access for the specific date of visit. All vendors must visibly and prominently display the temporary identification at all times during their visit to the Network Entity. A multiday identification badge may be issued upon approval of entity Supply Chain leadership to vendor representatives working under the supervision of a departmental director on a multiday project.

   6. Security access may be added to vendor representative temporary identification badges only upon approval of entity Supply Chain leadership and designated entity leadership. Annual renewal of temporary identification badges with security access is required. It is the sole responsibility of the vendor to provide timely notification to the applicable UNC HC entity in advance of a specific vendor representative leaving the vendor’s employment. Vendors failing to do so may be denied the privilege of visiting and/or providing products and services to UNC HC and/or the Network Entity, as well as revocation and declination of security access for all the vendor’s representatives.

   7. Vendor management credentialing and completion of education and health requirements outlined above in A.1 must be renewed annually by each vendor representative. Annual completion will be accomplished using a vendor management software or another process as defined by a specific entity. Failure to complete the annual education and health requirements will result in loss of privileges to visit and/or provide products and services to the Network Entity.

   8. It is the sole responsibility of the vendor representative or their company to pay any associated fees for use of a designated vendor management software product.

   9. Upon sole discretion of UNC HC and/or the Network Entity, vendors failing to continually meet and adhere to this policy, including behavioral expectations, may be denied the privilege of visiting and/or providing products and services to UNC HC and/or the Network Entity.

2. Authorized Vendor Representative Access

   Representatives may only access patient care areas (e.g., Emergency Department, off-site clinics, Operating Room areas) for appointments prearranged with a member of the medical staff, the area director or designee or other Network Entity department head. Single invitations are not to be construed as blanket approval for future visits. Vendors must remain in designated areas as specified by a member of the medical staff, the area director or designee at all times, or the staff member must be aware and manage vendors within their areas.

3. Vendor Representative Behavioral Expectations

   All vendor representatives must:

   • Comply with all Network Entity policies and procedures and the Vendor Representative Code of Conduct associated with this policy (Appendix A).^[2]

   • Present only products or services that have been reviewed and approved by Network/Entity Purchasing or the Director of Pharmacy, as applicable.

     • Pharmaceutical vendors visiting hospital departments:

       • Unless modified by local policy, only Formulary medications may be detailed in hospital departments. Nonformulary medication information may be presented to the appropriate Pharmacy employee listed above.

       • If there are restrictions placed on a formulary medication by the system or hospital pharmacy and therapeutics committee, the representative may only detail the product within those restrictions. It is the responsibility of the representative to inquire about any restrictions.

       • Representatives may not detail off-label uses for their products.

   • Provide no product samples to individuals, patients, clinicians, or in departments without prior approval of Purchasing or the director of pharmacy, as applicable.

4. Vendor Representatives Visiting Specific Departments

   Individual departments such as Surgical Services and Pharmacy may have department-specific policies, requirements and behavioral expectations. Department-specific guidelines may not conflict with this policy. It is the responsibility of the vendor representative to ensure department-specific requirements are adhered to at all times.

   Pharmaceutical vendors who wish to discuss hospital formulary contracting shall contact the system sourcing team at formulary@unchealth.unc.edu.

   Pharmaceutical vendors who wish to provide clinical information with the local hospital pharmacy departments may contact the local Director of Pharmacy or designee.

5. Vendor Representative Prior UNC Health Care Employment

   Effective 00/00/2021 (1 year from adoption of this policy), UNC HC employees who choose to leave employment for a position with a vendor may not represent the vendor at the UNC HC entity where the person worked as a UNC HC employee for a period of one year from the date of termination with the UNC HC Network Entity. The vendor representative may represent the vendor at another UNC HC entity where the person was not assigned to work immediately upon leaving UNC HC employment. (For example: A nurse working solely in Caldwell Memorial Hospital’s cardiac cath lab leaves employment on December 12, 2020. The nurse may begin visitation as a vendor representative to all UNC HC entities other than Caldwell on December 13, 2020, and begin visiting Caldwell as a vendor representative on December 13, 2021.)

6. Determination of Business Representative Role

   The nature of business conducted when present at UNC HC or a Network Entity determines if a person is a vendor representative, independent contractor, business contractor representative, representative of a post-acute care service provider, or visitor attending a professional meeting for purposes of this policy. It is possible for a person to at times act as one type of representative, and at other times act as another. For example: A representative of a DME company who makes an appointment with Care Management to market available services the company provides is acting as a vendor representative. This same DME company representative present in a Network Entity solely to deliver an ordered walker for a patient in anticipation of discharge to home is acting as a post-acute care service provider.

7. Service and Manufacturing Product Maintenance, Delivery, and Pick-Up

   Business representatives of companies providing service and manufacturing product maintenance, delivery and pick-up may enter UNC HC facilities only upon coordination with Supply Chain, Bio-Medical Engineering or other applicable department directors. Credentialing of such representatives as a vendor is not required when all requirements are met:

   • Business representatives must wear visible company photo identification at all times.

   • Supervision by appropriate UNC HC personnel is required for such representatives entering patient care areas.

   • Employing company must maintain documentation of employee criminal background check, and compliance with mandatory health requirements and immunizations. This required documentation must be provided to UNC HC upon request. Business representatives may not conduct any type of marketing on behalf of the company while providing service and manufacturing product maintenance, delivery and pick-up.

8. Facility Construction and Maintenance

   Credentialing as a vendor of company representatives providing contracted services related to facility construction and maintenance is not required when all requirements are met:

   • Business representatives must wear visible company photo identification at all times.

   • Business representatives provide service as specified in applicable contract and/or agreement with UNC HC.

   • Business representatives may enter patient care areas and patient rooms only upon direction of UNC HC leadership, departmental director or other appropriate personnel.

   • Employing company must maintain documentation of criminal background check and compliance with mandatory health requirements and immunizations. This required documentation must be provided to UNC HC upon request.

   • Business representatives may not conduct any type of marketing on behalf of the company while providing contracted service.

9. Delivery of Post-Acute Equipment Needed for Patient Discharge

   Representatives of post-acute care providers may assess acute care patients in UNC HC facilities for appropriateness of post-acute care services. In addition, companies providing durable medical equipment and oxygen equipment for patient home use may make such deliveries to acute care patients in anticipation of discharge to home. Credentialing as a vendor of such post-acute care provider representatives is not required when all requirements are met:

   • Representatives must wear visible company photo identification at all times.

   • Representatives must coordinate on-site assessment of acute care patients with Care Management, and schedule this assessment in advance.

   • Representatives from retail and/or specialty pharmacies must have approval from the director of pharmacy before visiting patients or staff within the hospital/clinic setting.

   • Representatives must check in with Care Management or appropriate clinical staff upon arrival, and enter patient care areas and patient rooms only upon their direction.

   • Employing company must maintain documentation of employee criminal background check and compliance with mandatory health requirements and immunizations. This required documentation must be provided to UNC HC upon request.

   • Representatives may not conduct any type of marketing on behalf of the company while delivering equipment.

10. Business Contractor and Independent Contractor Services

    Business and independent contractors provide specified services upon agreement or contract. Credentialing as a vendor of such business and independent contractors is not required when all requirements are met:

    • Contractor must wear visible company photo identification at all times.

    • Contractor must coordinate provision of agreed-upon service with the appropriate departmental director in advance of arrival at a UNC HC facility.

    • Contractor may enter patient care areas and patient rooms only upon direction of UNC HC leadership, departmental director or other appropriate personnel.

    • Contractor must maintain documentation of criminal background check and compliance with mandatory health requirements and immunizations. This required documentation must be provided to UNC HC upon request.

    • Contractor may not conduct any type of marketing on behalf of the company while on-site providing agreed-upon service.

11. Auxiliary and/or Gift Shop Vendors

    Vendors providing sales to hospital/auxiliary gift shops and/or participating in hospital leadership and hospital auxiliary approved events (e.g., book sales, medical uniform sales) are not required to be credentialed as a vendor when all requirements are met:

    • Vendor must wear visible company identification at all times.

    • Vendor must coordinate provision of agreed-upon service with the appropriate departmental director in advance of arrival at a UNC HC facility.

    • Vendor may not enter patient care areas and patient rooms.

    • Vendor must maintain documentation of annual influenza vaccine. UNC HC and/or Network Entity may require documentation of additional immunizations and mandatory health requirements as deemed necessary by applicable UNC HC and/or Network Entity Infection Prevention Director. This required documentation must be provided to UNC HC upon request.

    • All marketing materials advertising hospital/auxiliary sponsored events bearing the vendor’s name, logo or other business identification must be approved by the department director in advance of distribution. All other types of marketing by vendor on any UNC HC property is prohibited.

12. Visitors Attending a Professional Business Meeting

    Visitors attending scheduled business meetings with UNC HC and/or Network Entity covered personnel not considered vendor representatives, business contractor, independent contractors or post-acute care service providers as defined above are not subject to this policy.