As Operational Site Visits (OSVs) resume virtually, it is important for Community Health Centers to maintain continuous compliance. Compliatric is excited to continue their “Compliance Webinar Series” where each month, program requirements are reviewed to assist health centers in understanding various elements. Participants will be able to utilize these webinars to increase their knowledge of the requirements, and also take compliance to the next level. This month’s webinar will focus on the following chapter: Chapter 5: Clinical Staffing Webinar attendee takeaways will include: · Understanding the requirements and why they are important · Methods to maintain continuous compliance (without addressing it last minute or only during an OSV) · How to use the requirement in everyday practice to improve your Community Health Center

1. www.compliantfqhc.com
Continuous Compliance Series- It’s not JUST an OSV Prep
COMPLIATRIC WEBINAR SERIES
Presented by: Michelle Layton BSN, MBA
michellel@infidiumhs.com

2. Chapter 5 – Clinical Staffing

3. ThankYou For Providing Care

4. Disclaimers
 This presentation is not endorsed by Management Strategists
Consulting Group (MSCG)
 This presentation is not endorsed by Health Resources
Services Administration (HRSA) or the Bureau of Primary
Health Care (BPHC).
 Not employed by MSCG or BPHC
 Independent Consultant who is contracted to conduct
Operational Site Visits (OSV), provide Technical Assistance
and assist health centers with preparation for their OSV
 This information should not be considered legal advice
Confidentiality Notice: This document is confidential and contains proprietary information and intellectual property
of Infidium Healthcare Solutions. Neither this document nor any of the information contained herein may be
reproduced or disclosed under any circumstances without the express written permission of the aforementioned
party.

5. Purpose of the Compliatric Series
 Virtual Operational Site Visits (VOSVs) are here to stay
◦ Time frames for notification can be short
 Compliance = HRSA funding
◦ Non-compliance can affect other Federal Programs (i.e.,
FTCA)
 Continuous Compliance = High performing health
center
◦ Eliminates the chaos of having to “prepare”

6. Agenda
 Requirements for Compliance
 Evaluation of Compliance
 Fundamentals of Credentialing and Privileging/Peer Review
 Maintaining Continuous Compliance – Factors to Consider
 Clinical Reviewer Insight
 Question and Answer Session

7. Requirements for Compliance

8. Requirements for Compliance
 Health center must have adequate clinical staffing
to carry out the required and additional services on
Form 5A
◦ Can be provided either directly or through formal written
contracts/referral arrangements
 Health center must have the appropriate number
and mix of staff to ensure reasonable patient
access to health center services
◦ Must be appropriate for the health center’s patient
population
◦ Must consider the size, demographics and health needs

9. Requirements for Compliance
 Health center must have operating procedures for the initial
and recurring review of credentials for all clinical staff
 Health center must have operating procedures for the initial
granting and renewal of privileges for all clinical staff
 This applies to all health center employees, individual
contractors and volunteers:
◦ Licensed Independent Practitioners (LIP)
◦ Other Licensed and Certified Practitioners (OLCPs)
◦ Other Clinical Staff (OCS)

10. Requirements for Compliance
 Health center must maintain secure files for all categories of
clinical staff
 Files must contain up to date documentation of all
credentialing and privileging elements
 Health center must ensure all contracted or referral providers
are appropriately credentialed and privileged
 How is this accomplished??
◦ Language in the formal written contract or referral arrangement
◦ Documentation of the credentialing and privileging procedures
utilized by the organization you are contracting with or referring to

11. Evaluation of Compliance

12. Evaluation of Compliance
 Review of Documentation
◦ Current staffing profile with name, position, hire date, FTE
status, specialty and translation capability (spreadsheet)
◦ Policy/procedures for credentialing and privileging of LIPs,
OLCPs and if applicable, other clinical staff
◦ Sample credentialing and privileging files (SVP, page 17)
◦ Credentials Verification Organization (CVO) contract
◦ Sample of the formal contracts/referral arrangements
reviewed under Required and Additional Health Services

13. Evaluation of Compliance
 Staff Interviews
◦ Verification of process with Clinical Leadership and staff
responsible for credentialing and privileging
 Site Tours
◦ Tour of two sites, one where the majority of services are
provided
◦ If a Column I service can not be observed during a site
tour, documentation of the service in the patient’s medical
record must be provided (Refer to Required and Additional
Health Services)

14. Fundamentals of Credentialing
and Privileging

15. Back to Basics
Credentialing and
privileging…
Oh… I thought they were
the same thing?

16. Definitions
Credentialing
The process of assessing and confirming the
qualifications of a licensed or certified health care
practitioner
Privileging/Competency
The process of authorizing a licensed or certified
health practitioner’s specific scope and content of
patient care services

17. Definitions
Licensed Independent Practitioner (LIP)
Physician, Dentist, Nurse Practitioner and Nurse
Midwife, or “ any other individual permitted by law and
the organization to provide care and services without
supervision, within the scope of the individual’s
license and consistent with individually granted
clinical privileges

18. Definitions
Other Licensed or Certified Health Care
Practitioner (OLCP)
An individual who is licensed, registered or certified but is not
permitted by law to provide patient care services without
direction or supervision. Examples include:
• Laboratory Technicians
• Medical Assistants
• Registered Nurses
• Dental Hygienists

19. Definitions
Other Clinical Staff
A clinical staff member that performs services in a state,
territory or other jurisdiction that does not require licensure or
certification. Examples include:
• Medical Assistants
• Dental Assistants
• Community Health Workers

20. Definitions
Primary Source Verification
Verification by the original source of a specific
credential to determine the accuracy of a qualification
reported by an individual health care practitioner.
Examples include:
• Internet verification (i.e., state database)
• Direct correspondence
• Reports from Credentials Verification Organization

21. Definitions
Primary Source Verification
Possible sources for PSV of education and residency
for physicians include:
• American Medical Association (AMA) Masterfile
• American Board of Medical Specialties
• American Osteopathic Association Physician
Profiles
• Education Commission for Foreign Medical
Graduates (ECFMG) – International graduates
licensed after 1986

22. Definitions
Primary Source Verification
Possible sources for PSV of certifications for other
LIPs (i.e., PA, NP, etc.) include:
• American Nurses Credentialing Center
• American Midwifery Certifying Board
• National Commission on Certification of Physician
Assistants

23. Definitions
Secondary Source Verification
Methods of verifying a credential that are not
considered an acceptable form of primary source
verification. Examples include:
• Notarized copy of the credential
• Copy of the credential that is made from an
original by approved staff

24. Definitions
Reappointment
The process of verifying expired credentials and re-
privileging of a licensed or certified health care
practitioner on a recurring basis

25. Credentialing and Privileging Activities
Credentialing and Recredentialing activities for
LIPs include:
• Verification of identity – Initial only
• Verification of current licensure, registration or
certification – Primary source
• Verification of education and training – Primary source,
initial only
• National Practitioner Data Bank Query
• Verification of DEA Registration
• Verification of basic life support training

26. Credentialing and Privileging Activities
Privileging and Reprivileging activities for LIPs
include:
• Verification of fitness for duty
• Verification of immunization and communicable disease
status
• Verification of current clinical competence
• Initial – Verification via training, education, reference reviews
• Renewal – Verification via peer review, performance improvement
activities

27. Credentialing and Privileging Activities
Credentialing and Recredentialing activities for
OLCPs include:
• Verification of identity – Initial only
• Verification of current licensure, registration or
certification – Primary Source
• Verification of education and training – Primary or
Secondary Source, initial only
• National Practitioner Data Bank Query
• Verification of DEA Registration (if applicable)
• Verification of basic life support training

28. Credentialing and Privileging Activities
Privileging and Reprivileging activities for OLCPs
include:
• Verification of fitness for duty
• Verification of immunization and communicable disease
status
• Verification of current clinical competence
• Based on Supervisory evaluation of clinical
competence per the job description

29. Temporary Privileges
• Privileges SHOULD:
• Be granted in accordance with FTCA Guidelines
• Be approved by the CEO upon the recommendation of
appropriate department head
• Privileges SHOULD NOT:
• Exceed more than 90 days
• Be renewed
• Be granted in lieu of expired credentials

30. Credentialing and Privileging Activities
Initial Privileging and Reappointment
 Privileging is completed after the health center has verified all
necessary credentials for a practitioner
 Re-appointment is completed on a recurring basis (i.e., every
two years), as determined by the health center
 Re-appointment involves the verification of expired
credentials and re-privileging of practitioners
 The health center determines who has approval authority for
credentialing and privileging

31. Credentialing and Privileging Activities
Delineation of Privileges (Clinical Services)
• Subsequent to credentials verification, the practitioner
submits a request for clinical privileges, which includes
completion of a Delineation of Clinical Services Form.
• The Delineation of Clinical Services Form:
• Includes only services and sites listed in the health center’s
approved scope of project
• Is specific to each specialty within the health center (i.e., Dental,
Behavioral Health, Family Practice, Obstetrics)
• Outlines Requested Services, Non-Requested Services,
Approved Services and Non-Approved Services

32. Peer Review

33. Peer Review
Peer Review must be completed:
 On a “routine and regular basis”
◦ Considered a quarterly QI Assessment per the Site Visit Protocol
 Between providers within the same specialty who are similarly
credentialed
 In all clinical areas within the health center’s scope of project (Family
Medicine, Obstetrics, Dental, Behavioral Health)
 Using an industry standard tool that clearly evaluates the quality of
services provided and does not only perform administrative review
 Using a blinded methodology that ensures confidentiality of patient
information

34. Peer Review – Basic Concepts
The results of Peer Review must be part of the
health center’s Quality Improvement Program and
incorporated into the LIP reappointment process,
which is evidenced by documentation in:
• Credentialing and Privileging Policy
• Peer Review Policy
• Quality Improvement Plan
• Credentialing and Privileging Files

35. Maintaining Continuous
Compliance – Factors to
Consider

36. Factors to Consider
 The Credentialing and Privileging Policy does NOT
require board approval – Best Practice? No
 Credentialing and privileging of clinical staff
(including LIPs) does not require board approval –
Best Practice? No
 The health center determines who has approval
authority for credentialing and privileging
 If the health center does not have other clinical
staff, they do not need to be included in the
procedures

37. Factors to Consider
 The Compliance Manual is the minimum standard
for credentialing and privileging of clinical staff
 Federal Tort Claims Act (FTCA) regulations are the
highest standard for credentialing and privileging of
clinical staff
 Follow the guidelines and examples for primary
and secondary source verification outlined in the
HRSA Credentialing and Privileging File Review
Resource

38. Factors to Consider
 An NPDB Query is required for ALL categories of
clinical staff – No longer “as reportable”
 Health Centers must ensure contracted and
referral providers are appropriately credentialed
and privileged
◦ Contracts/referral arrangements must include provisions to
support credentialing and privileging of the
contracted/referral providers; or
◦ Review the contracted organization’s credentialing and
privileging process

39. Resources

40. Additional Resources
Compliatric
https://www.compliatric.com/
HRSA Health Center Compliance Manual
Health Center Program Compliance Manual | Bureau of Primary Health
Care (hrsa.gov)
HRSA SiteVisit Protocol
Health Center Program SiteVisit Protocol | Bureau of Primary Health
Care (hrsa.gov)
HRSA Credentialing and Privileging File Review Resource
Credentialing and Privileging File Review Resource (hrsa.gov)

41. Questions & Answers

42. Michelle Layton BSN, MBA
Infidium Healthcare Solutions, LLC
michellel@infidiumhs.com
Direct: 214-766-0333