Chapter 5: Clinical Staffing

Authority

Sections 330(a)(1), (b)(1)-(2) of the PHS Act; and 42 CFR 51c.303(a), 42 CFR 51c.303(p), 42 CFR 56.303(a), and 42 CFR 56.303(p)

Requirements

  • The health center must provide the required primary and approved additional health services1 of the center through staff and supporting resources of the center or through contracts or cooperative arrangements.
  • The health center must provide the health services of the center so that such services are available and accessible promptly, as appropriate, and in a manner that will assure continuity of service to the residents of the center’s catchment area.
  • The health center must utilize staff that are qualified by training and experience to carry out the activities of the center.

Demonstrating Compliance

A health center would demonstrate compliance with these requirements by fulfilling all of the following:

  1. The health center ensures that it has clinical staff2 and/or has contracts or formal referral arrangements in place with other providers or provider organizations to carry out all required and additional services included in the HRSA-approved scope of project.3
  2. The health center has considered the size, demographics, and health needs (for example, large number of children served, high prevalence of diabetes) of its patient population in determining the number and mix of clinical staff necessary to ensure reasonable patient access to health center services.
  3. The health center has operating procedures for the initial and recurring review (for example, every two years) of credentials for all clinical staff members (licensed independent practitioners (LIPs), other licensed or certified practitioners (OLCPs), and other clinical staff providing services on behalf of the health center) who are health center employees, individual contractors, or volunteers. These credentialing procedures would ensure verification of the following, as applicable:
    • Current licensure, registration, or certification using a primary source;
    • Education and training for initial credentialing, using:
      • Primary sources for LIPs4
      • Primary or other sources (as determined by the health center) for OLCPs and any other clinical staff;
    • Completion of a query through the National Practitioner Data Bank (NPDB);5
    • Clinical staff member’s identity for initial credentialing using a government-issued picture identification;
    • Drug Enforcement Administration (DEA) registration; and
    • Current documentation of basic life support training.
  4. The health center has operating procedures for the initial granting and renewal (for example, every two years) of privileges for clinical staff members (LIPs, OLCPs, and other clinical staff providing services on behalf of the health center) who are health center employees, individual contractors, or volunteers. These privileging procedures would address the following:
    • Verification of fitness for duty, immunization, and communicable disease status;6
    • 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); and
    • Process for denying, modifying or removing privileges based on assessments of clinical competence and/or fitness for duty.
  5. The health center maintains files or records for its clinical staff (for example, employees, individual contractors, and volunteers) that contain documentation of licensure, credentialing verification, and applicable privileges, consistent with operating procedures.
  6. If the health center has contracts with provider organizations (for example, group practices, locum tenens staffing agencies, training programs) or formal, written referral agreements with other provider organizations that provide services within its scope of project, the health center ensures7 that such providers are:
    • Licensed, certified, or registered as verified through a credentialing process, in accordance with applicable Federal, state, and local laws; and
    • Competent and fit to perform the contracted or referred services, as assessed through a privileging process.

The following points describe areas where health centers have discretion with respect to decision-making or that may be useful for health centers to consider when implementing these requirements:

  • The health center determines its staffing composition (for example, use of nurse practitioners, physician assistants, certified nurse midwives) and its staffing levels (for example, full- and/or part-time staff).
  • The health center determines who has approval authority for credentialing and privileging of its clinical staff.
  • The health center determines how credentialing will be implemented (for example, a health center may contract with a credentials verification organization (CVO) to perform credentialing activities or it may have its own staff conduct credentialing), including whether to have separate credentialing processes for LIPs versus other provider types.
  • The health center determines how it assesses clinical competence and fitness for duty of its staff (for example, regarding clinical competence, a health center may utilize peer review conducted by its own providers or may contract with another organization to conduct peer review).
  • The health center determines (consistent with its established privileging criteria) whether to deny, modify, or remove privileges of its staff; whether to use an appeals process in conjunction with such determinations; and whether to implement corrective action plans in conjunction with the denial, modification, or removal of privileges.
  • The health center determines (consistent with its contracts/cooperative arrangements) whether to disallow individual providers or organizations from providing health services on the health center’s behalf.

Footnotes

  1. These terms are defined in section 330(b) of the Public Health Service (PHS) Act. For more information, see http://bphc.hrsa.gov/programrequirements/scope.html.
  2. Clinical staff includes licensed independent practitioners (for example, Physician, Dentist, Physician Assistant, Nurse Practitioner), other licensed or certified practitioners (for example, Registered Nurse, Licensed Practical Nurse, Registered Dietitian, Certified Medical Assistant), and other clinical staff providing services on behalf of the health center (for example, Medical Assistants or Community Health Workers in states, territories or jurisdictions that do not require licensure or certification).
  3. Health centers seeking coverage for themselves and their providers under the Health Center FTCA Medical Malpractice Program should review the statutory and policy requirements for coverage, as discussed in the FTCA Health Center Policy Manual (PDF - 435 KB).
  4. In states in which the licensing agency, specialty board or registry conducts primary source verification of education and training, the health center would not be required to duplicate primary source verification when completing the credentialing process.
  5. The NPDB is an electronic information repository authorized by Congress. It contains information on medical malpractice payments and certain adverse actions related to health care practitioners, entities, providers, and suppliers. For more information, see https://www.npdb.hrsa.gov/.
  6. 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, see https://www.cdc.gov/vaccines/adults/rec-vac/hcw.html.
  7. This may be done, for example, through provisions in contracts and cooperative arrangements with such organizations or health center review of the organizations’ credentialing and privileging processes.

 

Have a question about the Health Center Program Compliance Manual?

Date Last Reviewed:  September 2018


Health Center Compliance Manual

Download the Health Center Compliance Manual (PDF - 1.8 MB - Last Updated August 2018)