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We are in the process of restructuring our credentialing and privileging files. Can you please tell us what is required to demonstrate compliance for verification of education and training of Other Clinical Staff?
As outlined by the Health Resources and Services Administration (HRSA) Health Center Program Compliance Manual, health centers must have operating procedures for the initial and recurring review of credentials and the initial granting and renewal of privileges/verification of competency for all clinical staff members, including Licensed Independent Practitioners (LIPs), Other Licensed and Certified Practitioners (OLCPs) and Other Clinical Staff (OCS). This requirement is applicable to all clinical staff who are health center employees, individual contractors, or volunteers.
OCS is a category of clinical staff members that provide clinical services in a state, territory or other jurisdiction where licensure, certification or registration is not required. Typically, clinical staff members in this category are medical assistants, dental assistants, health educators and community health workers.
Verification of education and training is considered a component of the credentialing process. In accordance with the HRSA Compliance Manual, the health center’s initial credentialing procedures must ensure verification of education and training for all categories of clinical staff. In the case of OCS, verification of education and training can be completed via primary or secondary source and is at the discretion of the health center. Examples of verification of education and training for OCS may include, but are not limited to, the following: GED certificate, high school diploma, college degree or training certificate from a vocational school. Industry standard best practices support verification of the individual’s highest degree. It is important to remember that health centers who do not hire OCS are not required to have credentialing and privileging/verification of competency procedures in place for this category of staff.
Health centers should follow the guidance outlined in Chapter Five of the HRSA Health Center Compliance Manual (Compliance Manual Chapter 5) and the HRSA Credentialing and Privileging File Review Resource (Credentialing and Privileging File Review Resource). Additionally, health centers can conduct a self-evaluation of compliance by answering the questions in the “Clinical Staffing” section of the HRSA Site Visit Protocol (Site Visit Protocol Clinical Staffing), as it pertains to OCS.