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Home My WebLink AboutCredentialingIdaho Department of Correction Standard Operating Procedure Operations Division Operational Services Control Number: 401.06.03.018 Version: 2.2 Page Number: 1 of 5 Adopted: 11-9-1998 Reviewed: 6-11-2012 Title: Credentialing This document was approved by Shane Evans, director of the Education, Treatment, and Reentry Bureau, on 6/11/12 (signature on file). Open to the general public: Yes BOARD OF CORRECTION IDAPA RULE NUMBER 401 Medical Care POLICY CONTROL NUMBER 401 Clinical Services and Treatment DEFINITIONS Standardized Terms and Definitions List Contract Medical Provider: A private company or other entity that is under contract with the Idaho Department of Correction (IDOC) to provide comprehensive medical, dental, and/or mental health services to the IDOC’s incarcerated offender population. Facility Health Authority: The contract medical provider employee who is primarily responsible for overseeing the delivery of medical services in an Idaho Department of Correction (IDOC) facility. Facility Medical Director: The highest ranking physician in an Idaho Department of Correction (IDOC) facility. Health Authority: The Idaho Department of Correction (IDOC) employee who is primarily responsible for overseeing or managing the IDOC’s medical services. (The health authority is commonly referred to as the health services director.) Qualified Health Professional: A physician, physician assistant, nurse practitioner, nurse, dentist, mental health professional, or other health professional who — by virtue of his education, training, credentials, and experience — is permitted by law (within the scope of his professional practice) to educate, train, evaluate, provide services, and care for patients. PURPOSE The purpose of this standard operating procedure (SOP) is to establish procedures for ensuring that all healthcare personnel who provide services to offenders are appropriately credentialed according to the licensure, certification, and registration requirements of the State of Idaho. Control Number: 401.06.03.018 Version: 2.2 Title: Credentialing Page Number: 2 of 5 SCOPE This SOP applies to all Idaho Department of Correction (IDOC) healthcare services staff, offenders, contract medical providers and subcontractors. RESPONSIBILITY Health Authority The health authority is responsible for: • Monitoring and overseeing all aspects of healthcare services; • Reviewing and maintaining copies of qualified health professional’s credentials, as furnished by the facility health authority; and • The implementation and continued practice of the provisions provided in this SOP. When healthcare services are privatized, the health authority will also be responsible for: • Reviewing and approving (prior to implementation) all applicable contract medical provider policy, procedure, and forms; and • Monitoring the contract medical provider’s performance, to include but not limited to reviewing processes, procedures, forms, and protocols employed by the contract medical provider to ensure compliance with all healthcare-related requirements provided in respective contractual agreements, this SOP, and in National Commission on Correctional Health Care (NCCHC) standard P-C-01, Credentialing. (See section 2 of this SOP.) Contract Medical Provider When healthcare services are privatized, the contract medical provider is responsible for: • Implementing and practicing all provisions of this SOP, unless specifically exempted by written contractual agreements; • Ensuring that all aspects of this SOP and NCCHC standard P-C-01 are addressed by applicable contract medical provider policy and procedure; • Ensuring that the credentialing process for qualified health professional new hires contains the elements described in section 1; • Ensuring facility health authorities utilize all applicable contract medical provider policy, procedure, forms, and educational information to fulfill all healthcare- related requirements provided in this SOP, NCCHC standard P-C-01, or as indicated in their respective contractual agreement(s); and • Ensuring all applicable contract medical provider policy, procedure, and forms are submitted to the health authority for review and approval prior to implementation. Note: Nothing in this SOP shall be construed to relieve the contract medical provider(s) of any obligation and/or responsibility stipulated in respective contractual agreements. Control Number: 401.06.03.018 Version: 2.2 Title: Credentialing Page Number: 3 of 5 Facility Medical Director The facility medical director and facility health authority (or designees) will be jointly responsible for: • Establishing and monitoring applicable contract medical provider policy and procedure to ensure that all elements of this SOP and NCCHC standard P-C-01 are accomplished as required; and • Ensuring the presence of an adequate number of appropriately trained staff and materials are available to meet the requirements of this SOP. Facility Health Authority The facility health authority will be responsible for: • Establishing practices and processes to ensure that qualified health professionals do not perform tasks beyond those permitted by their credentials; • Maintaining copies of qualified health professional’s credentials in a readily accessible location in the facility; • Ensuring that authorized prescribers of controlled substances (see SOP 401.06.03.089, Medication Services) have current individual Drug Enforcement Agency (DEA) registration numbers, (also see SOP 401.06.03.090, Pharmaceutical Operations); Note: DEA-controlled substances come under the jurisdiction of the federal Controlled Substance Act (United States Code, Title 21, Chapter 13). • Ensuring that all healthcare personnel who do not require licensure, registration, or certification by the State of Idaho, receive appropriate supervision and documentation by qualified health professionals to ensure all tasks performed are in compliance with all applicable laws, regulations, rules, policies, and procedures; • Ensuring that qualified health professionals who have restricted licenses are not employed to provide any healthcare services to offenders; • Ensuring that students who are receiving training in the facility and supplementing services (a) are supervised by appropriate qualified health professionals, (b) are properly oriented, and (c) do not perform tasks beyond those permitted by their student status; • Establishing and monitoring applicable contract medical provider policy and procedure to ensure that all elements of this SOP and NCCHC standard P-C-01 are accomplished as required; and • Ensuring the presence of an adequate number of appropriately trained staff and materials are available to meet the requirements of this SOP. In addition, the facility health authority and facility medical director (or designees) will be jointly responsible for: • Establishing and monitoring applicable contract medical provider policy and procedure to ensure that all elements of this SOP and NCCHC standard P-C-01 are accomplished as required; and Control Number: 401.06.03.018 Version: 2.2 Title: Credentialing Page Number: 4 of 5 • Ensuring the presence of an adequate number of appropriately trained staff and materials are available to meet the requirements of this SOP. Table of Contents General Requirements ......................................................................................................... 4 1. Guidelines ...................................................................................................................... 4 2. Compliance .................................................................................................................... 4 References ........................................................................................................................... 5 GENERAL REQUIREMENTS 1. Guidelines Qualified health professionals (or designee) shall maintain current licensure and provide their original current license to the facility health authority for verification. The license must not be restricted (i.e., have stipulations attached that must be followed). The facility health authority (or designee) shall maintain copies of qualified health professional’s credentials (i.e., licensure, registration, certification) in a readily accessible location in the facility. The facility health authority (or designee) shall provide copies of qualified health professional’s credentials to the health authority. The facility health authority (or designee) shall verify the licensure, registration, and certification for qualified health professional new hires. The verification process shall include, but not be limited to, the following: • The identification of the person responsible for conducting the verification process; • The actions the person conducting the verification should take in the verification process; • The agencies the person conducting the verification should contact; • Inquiries about sanctions (e.g., disciplinary actions) that state licensing boards, current and previous employers, and the National Practitioner Data Bank (NPDB) have taken; and • The procedures that must be followed for periodic reconfirmation. 2. Compliance Compliance with this SOP and all related IDOC-approved protocols will be monitored by the health authority (or designee) by using various sources to include: this SOP, clinical practice guidelines, routine reports, program reviews, and record reviews. The health authority (or designee) must conduct two (2) audits per year, per facility (or more frequently as desired based on prior audit results). The audits must consist of monitoring applicable contract medical provider, IDOC policy and procedures, applicable NCCHC standards, and the review of a minimum of 15 individual records. Control Number: 401.06.03.018 Version: 2.2 Title: Credentialing Page Number: 5 of 5 REFERENCES National Commission on Correctional Health Care (NCCHC), Standards for Health Services in Prisons, Standard P-C-01, Credentialing Standard Operating Procedure 401.06.03.089, Medication Services Standard Operating Procedure 401.06.03.090, Pharmaceutical Operations United States Code, Title 21, Chapter 13, Parts A thru F, Drug Abuse Prevention and Control United States Department of Health and Human Services (www.hhs.gov) United States Department of Health and Human Services, National Practitioner Data Bank (www.npdb-hipdb.hrsa.gov) – End of Document –