Accreditation, Regulatory, and Statutory Compliance — Credentialing Resource Center Forums

Gap Explanations

angelia.guthrie@arcare.net — Thu, 23 Feb 2017 21:35:03 +0000

I'm searching for any accrediting organization that requires an explanation of all gaps greater than 28 days. Any advise?

Compliance requirement of record archival?

sasikumar.k — Wed, 24 Feb 2021 00:07:30 +0000

Can someone help clarify how credentialing records are archived? Our current process is to archive only the PSV checklist for 7 years, but actual provider data that was credentialed is not archived, it gets lost as it gets updated as part of regular provider data updates. Is there any compliance requirement that states to retain the provider record which went through credentialing process.

Any recommendations from other colleagues would be greatly appreciated. Thank you for your time.

NCQA Appropriate Documentation

daniel.johnson — Thu, 15 Oct 2020 18:34:26 +0000

I am wondering how other facilities address the standard below:

CR 1: NCQA Appropriate Documentation. Policies and procedures must define the process for documenting information in the credentialing files using any of the following methods or a combination.

• Credentialing documents signed/or initialed and dated by the verifier.

• A checklist that includes for each verification:

○ The source used.

○ The date of verification.

○ The signature or initials of the person who verified the information.

○ The report date, if applicable.

• A checklist with a single signature and a date for all verifications with a statement

confirming the signatory verified all the credentials on that date and includes the source

and report date, if applicable.

• A system generated checklist with electronic signature and dates.

Thank you!

Delegated Credentialing Among Hospitals with separate Medical Staffs and Governing Bodies

Melmar — Fri, 09 Nov 2018 12:18:46 +0000

Does anyone know of any regulatory guidance for two separate health systems that allows for delegated credentialing of the members of the Medical Staffs to work between the two facilities (not telemedicine)? The two health systems have combined to form one entity which has a separate Governing Body for the "combination" but, they the two hospitals still each have their own Medical Staffs and Governing Bodies (it is not a merger or buy-out of one facility over the other).l Everything I have researched mentions delegated credentialing with Health Plans or the CMS Telemedicine rule. Any guidance that can be provided is greatly appreciated.

"automatic relinquishment" and Data Bank reports

easesq@snelsonlaw.com — Wed, 15 Mar 2017 16:00:13 +0000

I just saw proposed bylaws addressing the effect of a hospital's decision to discontinue services on privileges to provide those services. Under this proposed language, a discontinuation of the service triggers "automatic relinquishment" of those privileges, which can be restored if the service is later restored. On the surface, this looks tidy. However, under the Data Bank Guidebook, such a relinquishment would have to be reported if the privileges-holder is under investigation (whether or not the investigation is related to the privileges relinquished.) Also, the privileges-holder would have to acknowledge this "relinquishment" in future applications. Consequently, the privileges-holder is being punished in credentialing for the hospital's setting up this automatic relinquishing provision. Are others seeing this? Can it be justified?

Sedation QA Program Requirements

maryod — Tue, 27 Jun 2017 15:06:13 +0000

Hello,

Both JC and CMS require facilities to have a Sedation QA program.

What are you doing for your program? What indicators/triggers are you looking at?

If you use Cerner, do you have a report written that gathers data for you?

Any help or policy and forms examples would be much appreciated.

Thanks,

Mary O'Donnell

Medical Staff Coordinator

Lakeview Medical Center

Rice Lake, Wisconsin

Resuscitative training for Clinical Psychologists

de12 — Thu, 20 Apr 2017 09:38:18 +0000

I would like to know whether Clinical Psychologists are required to be certified in BLS resuscitative training in your organization. we are accredited by the Joint Commission International

Joint Commission SAFER matrix scoring

kathymatzka — Tue, 04 Apr 2017 18:47:45 +0000

For those who have been surveyed by TJC under the SAFER matrix scoring methodology. Can you share where in the matrix they scored any areas in need of improvement?

kathymatzka@kathymatzka.com

Federation of State Medical Boards

daniel.johnson — Thu, 02 Feb 2017 22:50:50 +0000

Hi All:

I am wondering how many people use continuous query for the Federation of State Medical Boards? We have been checking the Federation at initial appointment only and wondering if we should upgrade to continuous monitoring.

Thanks for any guidance,

Penny Watkins

Health Systems with Integrated Medical Staff

pgilcher3404 — Fri, 20 Jan 2017 23:42:55 +0000

I'm hoping to get some guidance regarding a CMS/TJC standard that reads, "For hospitals that use Joint Commission accreditation for deemed status purposes: When a multihospital system has a unified and integrated medical staff, the bylaws describe the process by which medical staff members at each separately accredited hospital (that is, all medical staff members who hold privileges to practice at that specific hospital) are advised of their right to opt out of the unified and integrated medical staff structure after a majority vote by the members to maintain a separate and distinct medical staff for their respective hospital."

We have two hospitals with a single medical staff and board of directors since 2000. There is nothing in our Bylaws that addresses this standard (MS.01.01.01, EP 37). If you have any suggested language that I can use to help me address this in our Bylaws, I would appreciate receiving a copy.

Thanks, as always, and have a wonderful weekend!