By Michael Rosen, Esq.
ProviderTrust Co-Founder
mrosen@providertrust.com
Ever wonder if today is the day the Joint Commission shows up to audit your compliance practices? How will you confidently demonstrate compliance with Joint Commission HR standards?
For most people, this causes waves of panic and uncertainty.
Will they find you compliant with your internal requirement policies, do you have a record of monthly OIG exclusion checks, are you missing any key licenses or certificates…the list goes on. Failure of compliance in any one of these areas can result in a possible exception and/or recertifying under Joint Commission standards.
But no need to panic. Educating your organization on how to implement best practices will result in an “audit-ready” compliance plan. Keep in mind an effective compliance plan incorporates the 7 Fundamental Elements.
Let’s look at Joint Commission Standard HR.01..02.05, Hospital Standards. It addresses an individual’s qualifications must be consistent with their assignments. To meet this standard, the hospital must identify which positions are governed by a law or regulation that requires care providers to be licensed, certified or registered to practice in his/her profession. The hospital must implement and prove adherence to maintaining, verifying and storing Primary Source (meaning from the public record source/Board/Agency) at the time of hire and renewal of those certified licenses.
How to comply:
- Designate a centralized electronic system to capture, store and be the single source repository.
- Designate how such documents (Licenses, Certificates, Immunizations….) are uploaded.
- Designate who is in charge of obtaining and uploading documents
- Ensure monthly review by a designated staff member (best if in HR or Compliance) to determine missing documents, expired documents or restrictions
- Ensure the documents are verified at the Primary Source
As you can see, proper documentation and a centralized repository has many benefits. These include:
- Single source to centralize all records
- Not having to rely upon documentation in the field that may not be updated or easy to locate
- Quick and easy way to demonstrate compliance to Joint Commission auditors
- Ability to scan and store electronic copies, in addition to keeping hard copies in personnel file
- Ability to track, report and notify staff of missing or expired documents
Remember in addition to the Joint Commission standards, an organization should monitor license status, its staff and OIG exclusions on a monthly basis. Do this and you will meet the Joint Commission’s golden standards and demonstrate best practice.
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