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Volunteer Practitioners During a Disaster or Emergency Situation


To establish guidelines and procedures for determining qualification and competence of volunteer personnel (RNs/LPNs) during times of disaster or emergency.

1. Human Resources will be responsible for ensuring proper licensure of nursing personnel working at Sandhills Regional Medical Center.

2. During times of disaster/emergency, the Chief Nursing Officer will determine additional nursing personnel needs and will coordinate with Human Resources to procure such assets.

3. Human Resources will be responsible for obtaining temporary licensures (in accordance with the requirements set forth by the North Carolina Board of Nursing) for all nursing personnel prior to such personnel beginning work at Sandhills Regional Medical Center. 

1. Once the emergency/disaster plan has been implemented, the Chief Nursing Officer will identify additional nursing needs (RN/LPN) and will forward this list to the Director of Human Resources.  If appropriate, the Chief Nursing Officer will provide a list of names and facilities that have volunteered to support our disaster/emergency needs.

2. The Director of Human Resources will be responsible for completing the Disaster/Emergency Application, have the application signed by the incoming personnel and obtain a copy of their state license.  The Human Resources Department will also request a valid government-issued photo identification issued by the state or federal agency and at least one of the following from all incoming personnel:

A current hospital picture identification card that clearly identifies professional designation
A current license, certification or registration
Primary source verification of licensure, certification or registration 
Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), Medical Reserve Corps. (MRC) or the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), or other recognized state or federal organization or groups.
Identification indicating that the volunteer personnel has been granted authority to render patient care, treatment and services in disaster circumstances (ie, granted by state, federal or municipal entity)
Identification by current organization members who possesses personal knowledge regarding the volunteer practitionerís qualifications.  Such identification must be identified in writing by the member attests to the volunteer personnelís qualification.

3. Once all Volunteer Personnel have followed the above process, the Chief Nursing Officer will assign a registered nurse currently licensed to practice in North Carolina, to provide direct supervision to volunteer personnel.  A list of the nurses designated to provide this direct supervision, along with the name of the volunteer personnel being supervised, must be provided to the Director of Human Resources.  (This requirement does not apply to nurses that are licensed in a compact state and have a copy of licensure or primary source verification indicating state of licensure.)
4. The Director of Human Resources will send the following information to the North Carolina Board of Nursing:
The names and license number of supervising nurses
The names and license number of out-of-state nurses

(Note: The requirement for supervision by a Registered Nurse does not apply to the provision of first-aid and emergency services in temporary shelters or emergency stations established by the American Red Cross.)

5. Primary Source verification of licensure, certification or registration will commence as soon as the immediate situation is under control and is completed within 72 hours from the time the volunteer practitioner presents to Sandhills Regional Medical Center.  In the extraordinary circumstance that primary source verification of licensure, certification, or registration cannot be completed within 72 hours, Human Resources will document the following information:

Why primary verification could not be completed within the required time frame
Evidence of demonstrated ability to continue to provide adequate care and treatment to patients

6. The Chief Nursing Officer is responsible for assessing staffing levels and determining the need for continued use of volunteer personnel.  This decision must be made within 72 hours of the disaster/emergency designation and as needed thereafter.

Please fill out, print, and return to Administration or Human Resources. 

Click Here to Fill Out Disaster/Emergency Application