Recent federal arrests in a scheme to sell fake nursing diplomas serve as a critical reminder to behavioral health facilities about the importance of verifying credentials for licensed personnel.

Accreditation Commission for Health Care (ACHC) has long considered credential verification essential to confirming quality and safety of service recipient care.

Behavioral Health Standards

For behavioral health providers, ACHC Standards require organizations to verify qualifications of all licensed personnel.

Standard BH4-3B: Licensed/certified personnel credentialing activities are conducted at time of hire and upon renewal to verify qualifications of all licensed/certified personnel.

The standard applies to all healthcare professionals who furnish services directly, under an individual contract, or under arrangement on behalf of your facility and must act only within the scope of their state license, certification, or registration.

Credentialing information includes a review of professional occupational licensure, certification, registration, or other training as required by state boards and/or professional associations for continued credentialing.

Tips for Compliance

• Your facility’s personnel file must contain evidence that primary source credentialing information is obtained and validated from the issuing state authority.
  • This helps your facility confirm that personnel credentials are valid, current, and/or have no restrictions imposed.
• ACHC recommends that your facility develop a tracking system to continuously monitor credential expiration dates and revalidation due dates for each licensed professional who provides direct care.

Here for You

ACHC is your partner in accreditation. For more information, contact your Account Advisor, email [email protected], or call (855) 937-2242, ext. 457.