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More Q&A on the New BH Human Resources Management Chapter

As reported in earlier editions of our newsletter, the standards in the new Human Resources Management chapter in the 2015 Behavioral Health Care manual went into effect on January 1. Since then, many behavioral health organizations have been reviewing the new standards and their own HR processes to make sure they are compliant and also to see if they can simplify some of those processes. We’ve received some questions from readers and hope that the following clarifications are helpful:


With the new requirement for a valid picture ID for all staff, do we have to go back and get a picture ID for all of our current staff?
HRM.01.02.01 EP 3 requires that you verify the identity of the job applicant by viewing a valid picture ID issued by a state or federal agency (e.g. a driver’s license or passport.)  Since this requirement refers specifically to the “job applicant,” it applies only to individuals applying for positions in your organization since January 1, 2015 when this requirement went into effect. Thus, you are not required to obtain picture IDs for staff who were in their positions prior to that date. We discussed this issue with the TJC Standards Interpretation Group and they confirmed this understanding.


We have some positions that only require a high school diploma. Do we need to obtain primary source verification for the high school diploma?
At the October 2014 TJC Annual Behavioral Health Care Conference, it was clarified that primary source verification is not required for high school diplomas and that a copy of the diploma is sufficient. For college degrees and above, education does need to be verified with the primary source.


Can primary source verification of licensure suffice for primary source verification of education for licensed independent practitioners?
Yes, primary source verification of licensure can satisfy the requirement for primary source verification of education IF you have confirmed with the state licensing board (for that profession) that they verify the individual’s education prior to granting the license.


Under the new 2015 HRM standards, does the governing body still need to be involved with granting clinical responsibilities to licensed independent practitioners?
Under the previous HR standards, there was a requirement for the governing body to grant clinical responsibilities to LIPs every two years. Under the new 2015 standards, there is no longer a requirement for the governing body to grant clinical responsibilities to LIPs. LIPs can work under a job description (for employed LIPs) or under a contract (for contracted LIPs.) That job description or contract should define all of the duties and clinical responsibilities for that LIP. Also, in the 2015 standards, the term “licensed independent practitioner” is not used. LIPs are now included under the term “staff.” This includes both LIPs who are employed and LIPs who are contractors.


We are a behavioral health program within a hospital setting. Our hospital has a medical staff and a medical staff credentialing and privileging process. Our LIPs are credentialed and privileged under that process. Do we need to change our process to meet the new 2015 HRM standards in the BH manual?
No. If your behavioral health program wants to continue to use your hospital’s current process for credentialing and privileging, that is acceptable to TJC.


Do the HRM standards apply to volunteers and contractors?
Yes. TJC has clarified that the HRM standards apply to all individuals who provide care, treatment, or services for the organization. This includes contractors and volunteers. Of course, some of the HRM requirements (such as orientation) will need to be tailored to the specific role that the contractor or volunteer fulfills within your organization.