NOTE: This resource complements the Site Visit Protocol (SVP), which is the primary tool for assessing compliance with Health Center Program requirements during Operational Site Visits (OSVs). Refer to the
Health Center Program Compliance Manual as the principal resource to assist health centers in understanding and demonstrating compliance with Health Center Program requirements and the SVP for complete guidance on OSVs. This resource applies to the Site Visit Protocol (SVP) Clinical Staffing section and addresses the credentialing and privileging of all current clinical staff. This resource is intended to facilitate site visit review of documentation found in credentialing and privileging files. Health centers may also use this resource to prepare for a site visit and evaluate the completeness of their credentialing and privileging files. This resource provides
common examples of credentialing and privileging documentation that may demonstrate compliance with credentialing and privileging requirements. The examples are NOT exhaustive, and health centers may have other documentation that demonstrates compliance. HRSA encourages health centers and site visit reviewers to use this resource along with the SVP and the Compliance Manual. Note the following when using this resource: Back to top Primary source verification directly from the state licensing agency/body. Primary source verification for LIPs could include direct correspondence and telephone, fax, e-mail, or paper reports received from original sources (for example, telephone confirmation from an educational institution that the individual graduated with the degree[s] listed on his or her application,
confirmation through a state’s database that a provider’s license is current, reports from credentials verification organizations). Primary source verification directly from the state licensing agency/body or certification agency/body, as applicable. Not applicable (N/A) for other clinical staff in states, territories or jurisdictions that do not require licensure or certification for such staff. Primary source verification required. Verification of graduation from medical, dental, or other clinical professional school and, if applicable, residency, including receipt of sealed transcripts. Possible sources of verifying education and residency for physicians: American
Medical Association (AMA) Physician Masterfile, American Osteopathic Association (AOA) Physician Profiles, Educational Commission for Foreign Medical Graduates (ECFMG) for international graduates licensed after 1986. Possible sources of verifying certifications for other LIPs:
American Nurses Credentialing Center (ANCC), American Midwifery Certifying Board (AMCB), National Commission on Certification of Physician Assistants (NCCPA). Note: The health center may rely on the state licensing agency, specialty board or registry to verify
education and training if the health center can document that these entities conduct education and training primary source verification. When using such a source, the health center should verify at least annually the state licensing agency continues to primary source verify. Same as LIPs. Note: The NPDB’s subjects include all health care practitioners, providers, and suppliers in the United States. Health care practitioners include any individual who is licensed or otherwise authorized by a state to provide health care services (or any individual who, without authority, holds himself or herself out to be so licensed or authorized). Therefore, anyone involved in the delivery or provision of health care services may be reported
to the NPDB. For more information, visit National Practitioner Data Bank. Back to top Immunization Status:Copy of immunization records/status in provider’s file or provider attestation, including, if applicable, any declinations. Note:The CDC has published recommendations, and many states have their own recommendations or standards for provider immunization and communicable disease screening. For more
information about CDC recommendations, visit CDC: Recommended Vaccines for Healthcare Workers. Health centers will determine what vaccinations are required for their clinical staff based on state requirements and other resources. Communicable Disease Status:Copy of completed tuberculosis (TB) test or screening (for example, copy of purified protein derivative (PPD) testing or
chest x-ray (CXR)) and any other communicable disease testing or screening as determined by the health center (for example, Hepatitis). Note: The health center determines communicable disease screening protocols for its health care workers as well as what sources will be accepted as verification, and circumstances, if any, when providers can decline to present for testing or screening. For initial privileging: Verification of current clinical competence via training, education, and, as available, reference reviews. For renewal of privileges: Verification of current clinical competence via peer review or other comparable methods (for example, supervisory performance reviews). Back to top 1 Categorization of providers (for example, pharmacists or registered dietitians) as LIPs or OLCPs may vary from state to state based on the
specific licensure and certification requirements and scope of practice prescribed by that state. Date Last Reviewed: May 2022 Which of the following positions is responsible for achieving organizational goals and objectives?Top-Level Managers
These top managers are responsible for setting the overall direction of a company and making sure that major organizational objectives are achieved. Their leadership role can extend over the entire organization or for specific divisions such as finance, marketing, human resources, or operations.
Which of the following is a dimension of the public health system?There are five (5) dimensions of health: physical, mental, emotional, spiritual, and social.
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