CREDENTIALING POLICIES

Purpose: To assure the health care professional providing services are trained, competent and able to respond to the needs of patients in safe and effective manner. Procedures set in place to be in accordance with The Joint Commission’s standards of a complete personnel file.

Table of ContentsJOB APPROPRIATE CREDENTIALS..............................................................................................................................2

Personnel File Element/Required Documentation: Job Appropriate Credentials....................................................2

Definitions................................................................................................................................................................2

EVIDENCE OF CURRENT COMPETENCY.....................................................................................................................3

Personnel File Element/Required Documentation: Evidence of Current Competency............................................3

Definitions................................................................................................................................................................3

HEALTH STATUS........................................................................................................................................................4

Personnel File Element/Required Documentation: Health Status...........................................................................4

Definitions................................................................................................................................................................5

BACKGROUND CHECK...............................................................................................................................................6

Personnel File Element/Required Documentation: Background Check...................................................................6

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JOB APPROPRIATE CREDENTIALS

Personnel File Element/Required Documentation: Job Appropriate Credentials

1. Primary Source of current license for employees licensed / registered by state boards of Professional Regulation and Education, OR

2. Primary Source/verification of certification program completion for employees not licensed by state boards of Professional Regulation and Education (i.e. Clinical Nursing Assistants), AND

3. Current CPR card for those categories of employees required under state law to be certified in basic life support (e.g., RN, LPN / LVN, etc.)

Note: At no time should there be a lapse of a valid Primary Source Verification and Certifications in a care providers profile. Before a license or certification expires the steps of Primary Sourcing their updated license or certification must be followed.

Definitions Primary Source Verification: Primary Source verification applies only to licensure/certification or registration required to practice a profession. Current licensure/certification or registration is verified at the time of hire or renewal via a secure electronic communication. Telephone verification is acceptable, if that verification is documented. Primary Source verification will be obtained from a state licensing board or another agency officially designated to provide such services. Primary Source verification is not required for organizational requirements such as cardiopulmonary resuscitation (CPR), advanced cardiac life support (ACLS), pediatric advanced life support (PALS), or clinical certifications such as peripherally inserted central catheter (PICC) line certification. (1)

Licensure: The granting of a license by a state board or professional regulatory body.

Certifications: Requirements such as cardiopulmonary resuscitation (CPR/BLS), advanced cardiac life support (ACLS), pediatric advanced life support (PALS), or clinical certifications such as peripherally inserted central catheter (PICC) line certification. If the care provider is a CNA their BLS can be obtained from an organization that follows the AHA guidelines, examples are Red Cross, Pro CPR, and National CPR Foundation. If the care provider is an RN or LVN these certifications must be accredited by the American Heart Association (AHA). Example of AHA BLS certification:

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EVIDENCE OF CURRENT COMPETENCY

Personnel File Element/Required Documentation: Evidence of Current Competency

1. A minimum of at least two recent Professional References, references must be someone the care provider reported to (i.e. Charge Nurse, Unit Manager, House Supervisor).

2. Resume3. Clinical Self-Assessment appropriate to the specialty at the time of becoming a FleetNurse

contract staff and annually thereafter, completed via the Relias Prophecy Lite tool.4. Clinical Competency Assessment appropriate to the specialty at the time of becoming a

FleetNurse contract staff and annually thereafter, completed via the Relias Prophecy Lite tool.5. OSHA and HIPPA compliance training at the time of becoming a FleetNurse contract staff then

annually thereafter, completed via the Relias Prophecy Lite tool.

Definitions Skills Assessment: A self-assessment done by the care provider to document their skill level.

Clinical Competency: The assessment of a care providers skills and ability to be competent in their particular assignment. Done through an online test on Relias Prophecy Lite.

OSHA: Occupational Safety and Health Administration. A government agency in the Department of Labor to maintain a safe and healthy work environment.

HIPPA: Health Insurance Portability and Accountability Act, a 1996 Federal law that restricts access to individuals' private medical information.

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HEALTH STATUS

Personnel File Element/Required Documentation: Health Status

1. Hepatitis B, one of the following is required: a. Document from a medical professional showing proof of immunity by way of a surface antibody

titer test, ORb. Document showing dates of the series of 3 immunization injections. This credential will be

satisfied as care taker stays on schedule for all 3 injections. All dates must be clearly documented from a medical professional showing name of vendor, name of medical professional and/or clinic, OR

c. A signed declination.2. MMR, one of the following is required:

a. Proof of immunity for all three diseases (Mumps, Measles [Rubeola], and Rubella) via an antibody titer test, OR

b. Proof of a completed series of 2 immunizations given at least 28 days apart (care providers will be considered compliant with this credential while shot series is in progress). Both dates must be clearly documented from a medical professional showing name of vendor, name of medical professional and/or clinic, OR

c. If the facility allows: A signed electronic declination.3. Seasonal Flu Vaccine, one of the following is required annually:

a. A document from a medical professional or clinic with evidence of the date the care provider received the current season's flu vaccination (shot or mist). Information must be on doctor/clinic letterhead (preferably also indicating address/phone), OR

b. If facility allows, a signed declination. 4. TB Screening, one of the following is required:

a. TB Skin Test. The document must include:i. Read date and results of testing. A negative result is determined by less than 10mm

induration read 48-72 hours after testing.ii. The organization or health center that performed the test. Information must be on

doctor/clinic letterhead and clearly indicate member’s name. Self-attested documentation will not be accepted.

b. A document indicating negative results of Interferon Gamma Release Assay (IGRA-type). QuantiFERON is an example of this.

c. Documentation that employee previously tested positive (e.g., CXR report, physician note or physical exam)

5. Tdap, one of the following is required:a. A document from a medical professional or clinic with evidence of Tdap immunization.

Document must show date of vaccination, your name, name of medical professional and/or clinic and, preferably, address and phone. Document must clearly indicate Tdap vaccination, OR

b. If facility allows, a signed declination. 6. Varicella – Chicken Pox, one of the following is required:

a. Documented proof of immunity via a titer test from a medical professional. Document must show vendor's name, name of medical professional and/or clinic, OR

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b. Proof of a completed series of 2 immunizations given at least 28 days apart (will be considered compliant with this credential while shot series is in progress). Dates must be listed, OR

c. A document clearly indicating documented evidence of Chicken Pox or herpes zoster (shingles) from a medical professional.

7. Drug Screen – 10 Panel Drug Screen completed at time of care provider submitting all credentialing documentation to FleetNurse.

DefinitionsTiter: A blood draw and lab report to show if someone is immune or needs a vaccination or declination form.

Hepatitis B: A severe form of viral hepatitis transmitted in infected blood, causing fever, debility, and jaundice.

MMR: Mumps, Measles [Rubeola], and Rubella virus vaccine live.

Seasonal Flu Vaccine: The influenza vaccination is an annual vaccination using a vaccine specific for a given year to protect against the highly variable influenza virus.

TB Screening: The process of examining and testing a patient that does not have any symptoms of active TB. Screening is undertaken to identify and treat latent TB, so that it can be effectively treated before it becomes active infection

Tdap: A booster immunization given to help develop immunity to three deadly diseases caused by bacteria: diphtheria, tetanus, and whooping cough (pertussis).

Varicella: A herpesvirus that causes chickenpox and shingles.

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BACKGROUND CHECK

Personnel File Element/Required Documentation: Background Check

1. Cleared Background Report - To verify that care provider is not disqualified from patient contact due to criminal conviction or other conduct substantially related to patient care

a. National Criminal Background, verify that none of the following are true. These are potential flags that would disqualify the care provider from patient care:

i. Criminal convictions or other conduct substantially related to patient careii. Health care related civil judgments in federal or state court

iii. Health care related civil judgments in federal or state court iv. Injunctions (a judicial order that restrains a person from beginning or continuing an

action threatening or invading the legal right of another, or that compels a person to carry out a certain act, e.g., to make restitution to an injured party)

v. Actions taken by federal or state licensing and certification agencies, including revocations, reprimands, censures, probations, suspensions, any other loss of license, or the right to apply for or renew a license

vi. Exclusions from participation in federal or state health care programsvii. Registered Sex Offender

b. OIG Sanctions Checksc. National Sex Offender

2. Verification of current employment, in appropriate specialty, at time of becoming a FleetNurse Care Provider. Verified by one of the following:

a. Current paystubb. Employment Verification letter from the employers Human Resources Departmentc. Employment Verification done by FleetNurse staff to verify current employer

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1. (n.d.). Retrieved from https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=807&ProgramId=46

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