For acute care hospital providers, ACHC Standards require organizations to verify qualifications of all licensed personnel.

Standard 01.00.04 Licensure of Personnel: The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. §482.11(c)

Standard 04.00.02 Licensure: The hospital must verify that all employees meet licensure and all other applicable standards for employment. This includes certification, minimum qualifications, training and education requirements, and permits (such as food handlers permits). This standard applies to contract or agency staff as well as hospital employees. §482.11(c)

These standards apply to all healthcare professionals defined in the state practice acts or associated standards who require certification, licensure, or registration and who furnish services directly, under an individual contract, or under arrangement on behalf of your facility. These healthcare professionals must act only within the scope of their state license, certification, or registration. Examples of applicable staff include, but are not limited to, nurses, medical doctors (MDs) or doctors of osteopathic medicine (DOs), physician assistants, dietitians, X-ray technologists, dentists, physical therapists, occupational therapists, respiratory therapists, and hospital administrators.

Mechanisms must be established – by mail, electronic communication, or telephone – to verify with the appropriate licensing agency that all initial and renewal licenses and certificates conform to state practice acts. Practice in a facility by an individual without appropriate state license or certification may be grounds for loss of accreditation by the facility.

Tips for Compliance

• The hospital’s policy and procedure must include a process for verifying credentials at hire and at renewal.
• Hospital policy must include guidelines on the hospital process for when licensures are suspended or revoked.
• Each personnel file must contain evidence that primary source credentialing information was 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.