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As reported in our October newsletter, there are revisions to the standards in the Behavioral Health Human Resources chapter (effective January 2015) that will make the process for “credentialing and privileging” of licensed independent practitioners simpler. As our clients have been reviewing these revisions, we’ve received some questions about both old and new requirements in the Human Resources chapter that we thought might be useful to clarify:

How often does primary source verification need to be done?

Primary source verification of licensure, certification, or registration must be done both at time of initial hire and when this credential is renewed. (The problem that we have seen organizations sometime have on survey is a lapse in verifying the renewal of the credential so be sure to have a solid “tickler” system for doing this.)

Can primary source verification of licensure suffice for primary source verification of education/training for licensed independent practitioners?

Yes, primary source verification of licensure can satisfy the requirement for primary source verification of education/training IF you have confirmed with the state licensing board (for that profession) that they verify the individual’s education and training prior to granting the license.

TJC requires that clinical competency be assessed by an individual who has similar training and experience. We have only one dietician in our organization so who can assess her competence?

In situations such as this when there is no other “like practitioner” in the organization, input on competence can be obtained from a like practitioner outside of the organization. For example, this input could be from a dietician at another agency where your dietician works. If this is not possible, a process could be set up whereby you arrange for an outside dietician to conduct peer review on your dietician. Also, keep in mind that the administrative portion of this individual’s performance evaluation does not need to be done by a clinical peer. It is only the clinical competence assessment that requires peer input.

TJC requires an initial assessment of staff competence as part of orientation. What are they looking for?

This requirement (HR.01.06.01 EP 5) is focused on making sure that you not only orient staff to their job responsibilities but also assess their competence (during the orientation period) to carry out those job responsibilities. For most organizations, there are a couple of key components of orientation that they can show to demonstrate that they have done this competence assessment:

  • Tests, quizzes, and/or return demonstrations that staff are required to complete for the different modules of orientation
  • Documentation of mentoring during the orientation period
  • Initial/probationary performance evaluations completed at the end of the orientation period: If your organization conducts some type of initial or probationary performance evaluation (for example at three months after hire,) this is also evidence of an initial assessment of competence during the orientation period. (Note: If it is your policy to conduct this type of probationary performance evaluation and the surveyor finds that this has not been done, you will be out of compliance.)

Do contracted staff need to have the same orientation as employees?

Similar to employees, contracted staff need to have some type of orientation but it does not need to be as extensive as that done for employees. Orientation for contractors can be an abbreviated one that addresses key topics such as client safety, confidentiality, documentation requirements, etc.

Do we now need to review driver’s licenses for all staff to verify their identity?

Effective January 1, 2015, it is required that you view a valid picture ID issued by a state or federal agency (e.g. driver’s license or passport) to verify the identity of the individual. Previously, this was required only for licensed indecent practitioners.

We have a process in place for credentialing and privileging our physicians according to the current HR standards and this is working for us. Do we need to change anything based on the new 2015 standards?

No. If your process is working for you, you can continue using it. The changes to the standards that help simplify this process provide an option for organizations that found the previous process too cumbersome.