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Employee Licensing and Certification

General Policy Statement

Practicing professionals are regulated by State licensing boards; and must meet [PROVIDER] employment standards as identified in the current job description.  [PROVIDER’S] employees are responsible for maintaining their current licensure and for providing appropriate proof to the [PROVIDER]. Employees who become aware of potential licensing and certification violations must immediately report those violations to their supervisor, Administrator, Compliance Officer or through the [COMPLIANCE HOTLINE, ANONYMOUS DROP BOX, POST OFFICE BOX, ETC.].  In instances where the violation could place any [PROVIDER] resident in substantial jeopardy, the employee must immediately report directly to his/her director supervisor, Administrator or Compliance Officer.

 

Suggested Elements

To ensure that [PROVIDER’S] employees are licensed and certified to properly care for the residents in the facility, providers may wish to include the following elements as part of their corporate compliance policies:

  1. Proof of Licensure/Certification: 
    • The hiring supervisor is responsible to verify that each newly hired employee possesses a valid license in good standing applicable to his or her position;
    • The hiring supervisor is responsible to check with the State Board Licensing database to review the potential employee’s licensing status;
    • The  Human Resource Department is responsible for verifying that each newly hired employee has not been suspended or excluded by any government agency or court from participating in the Medicare, Medicaid or any Federal or State health care program; and
    • The Human Resource Department is responsible for a [PERIODIC, QUARTERLY OR MONTHLY] review of the Office of Inspector General (OIG) Exclusion Database and the Government Services Agency (GSA) databases.
  2. Expired Credentials: 
    • Employees who do not provide proof of renewal by the expiration date of their credentials will be subject to immediate job reclassification, and their pay may be adjusted; and 
    • Employees who fail to provide proof of renewed credentials within 10 days of expiration will be terminated.
  3. Loss of Licensure:
    • Employees must inform their supervisors immediately if they lose their licensure or are placed on probation for any reason; and
    • Employees who lose their license will be subject to immediate job reclassification, with appropriate pay change or termination.
  4. Failed Licensure Exam:
    • Employees must notify their supervisor immediately of licensure test results;
    • Employees who does not pass their licensure exam are subject to immediate job reclassification, with appropriate pay change or termination; and
    • Employees who fail either a National and or State credentialing examination two consecutive times (regardless of whether both failures occur under employ) will be terminated.
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