Chapter 1 – Health Care Governance and Administration

Policy

• The Division of Health Care Services (DHCS) and California Correctional Health Care Services (CCHCS) shall ensure patients receive health care services from properly licensed and/or credentialed health care providers. Health care providers whose positions or job descriptions by law or regulation require current licensure, certification, and credentialing shall be in compliance with all applicable federal and state requirements. DHCS/CCHCS shall verify all required health care provider licenses, certificates, and credentials with the primary source and document this verification upon hire and when credentials are renewed.

Purpose

• To ensure compliance with all federal and state requirements regarding the credentialing of health care providers within DHCS/CCHCS.

Scope

• Credentials for civil service and contract providers shall be approved on a statewide basis. Reappointment shall occur every three years.

Responsibility

• The Deputy Directors of DHCS and Directors of CCHCS are responsible for the statewide planning, implementation, and evaluation of credentialing processes.

Policy

• California Correctional Health Care Services (CCHCS) shall maintain a process to credential and privilege all licensed medical providers who provide patient care services at California Department of Corrections and Rehabilitation (CDCR) institutions to ensure that they meet minimum credentials, privileging, and performance standards. Licensed medical providers shall not perform any job duties prior to having their credentials approved nor provide direct patient care until privileges have been granted. CCHCS considers credentialing and privileging activities to be peer review activities within the meaning of Business and Professions Code, Section 805 and Evidence Code, Section 1157.

Purpose

• To ensure that all licensed medical providers subject to this policy and who provide patient care services at CDCR institutions meet minimum credentials, privileging, and performance standards.

Applicability

• This policy and procedure applies to all licensed medical providers.

Responsibility

• Hiring or Contracting Authority

  • The Hiring or Contracting Authority (HCA) is responsible for ensuring that licensed medical providers are appropriately credentialed and operate within the scope of their clinical privileges. Prior to submitting a request for credentialing and privileging, the HCA shall ensure that all pre-appointment human resources requirements have been met including, but not limited to, completing Live Scan reviews.

• Medical Reviewer

  • The Medical Reviewer (MR) shall review and make a determination regarding all credential and core privileging applications referring to the Medical Peer Review Committee for a recommendation as specified in Referral Criteria (Appendix 4).

• Physician Manager

  • The physician manager is responsible for reviewing requested additional clinical privileges and for making a determination regarding privileging actions and for monitoring and surveillance of the professional competency and clinical performance of those who provide patient care services with delineated clinical privileges.

• Medical Executive

  • The medical executive is responsible for coordinating and facilitating the Performance Evaluation Meeting (PEM) where a recommendation regarding advancing provisional privileges to active privileges for newly hired civil service licensed medical providers, including those who are not subject to a probationary period, is made.

• Local Governing Body

  • The Local Governing Body (LGB) for each institution or facility where direct patient care services are provided within a licensed unit is responsible for reviewing requested clinical privileges and for making a determination regarding privileging actions.

• Credentialing and Privileging Support Unit

  • The Credentialing and Privileging Support Unit (CPSU) shall review and process all applications for credentials and privileges in accordance with this policy and procedure.

• Medical Peer Review Committee

  • The Medical Peer Review Committee (MPRC) shall review and act on credentialing and privileging application referrals received from the MR.  The committee shall monitor credentialing and privileging activities within CCHCS and ensure that program-specific standards for credentials and clinical privileges remain current and up-to-date under applicable legal, accreditation, and community standards.

  • The MPRC shall refer all proposed actions that will impact the privileges of a licensed medical provider to the Health Care Executive Committee (HCEC) for approval and further action. All other actions taken by the MPRC shall be reported to the HCEC on an informational consent item report. This includes placement of credential alerts and credential bars as well as privilege modifications which are not taken for medical disciplinary cause or reason (i.e., lapse or expiration of credentials or privileges or a failure to secure required certifications or licenses).

• Health Care Executive Committee

  • The HCEC shall oversee the MPRC’s credentialing and privileging activities and shall review all privileging actions taken by the MPRC.  The HCEC may act independently as necessary to ensure that patient health care at CCHCS meets the standard of care.

• Licensed Medical Providers

  • Licensed medical providers are responsible for the following items:

    • Providing evidence of licensure, registration, certification and other relevant credentials as set forth in this section for verification prior to appointment and throughout the appointment process as requested.

    • Notifying CCHCS of information or actions that would adversely affect or otherwise limit their privileges at the earliest date after information is received by the licensed medical provider but no later than 15 calendar days. This includes not only final actions but also pending and proposed actions.

    • Maintaining licenses, registrations, and certifications in good standing and informing the HCA of any changes in these statuses, including but not limited to, any pending or proposed actions, at the earliest date after notification is received by the licensed medical provider but no later than 15 calendar days.

    • Obtaining and producing all required information for a proper evaluation of professional competence, character, ethics, and other qualifications. The information shall be complete and verifiable. The licensed medical provider has the responsibility for furnishing information that will help resolve any questions concerning these qualifications.

  • Failure to keep CCHCS fully informed on these matters may result in administrative or disciplinary action.

Procedure Overview

• The credentialing and privileging process includes primary source verifications for credentialing determinations for licensed medical providers.  The minimum qualifications reviewed for all providers shall include, but not be limited to, licensure, certification, education, training and experience, competence, and physical and mental ability to discharge patient care responsibilities appropriately in a correctional setting.  This includes any information which impacts a provider’s:

  • Clinical skills, competency, and judgment necessary to perform the health care services provided to patients.

  • Judgement and ability to perform procedures required of any specialty for which credentials are reviewed.

  • Consistent observance of professional and ethical standards including a history of acting in a professional and collegial manner.

  • Written and verbal communication skills.

• The CPSU shall work collaboratively with appropriate stakeholders in collecting, reviewing, tracking, and evaluating licensures, relevant training, experience, and competencies of each licensed medical provider.

• Credential decisions for licensed medical providers shall be made on a statewide basis. If credentials are approved, core privileges shall be granted on a statewide basis.

• Additional privileges (not included in the core privilege or procedure list) shall be evaluated by the physician manager at the institution where such additional privileges are requested once credentials have been approved and core privileges have been granted.

• Reappointment shall occur every three years.

Procedure

• Initial Appointment

  • During initial appointment credentialing and privileging, the type of privileges that may be granted will depend on employment status.  Initial privileges may be provisional, active or contract, depending upon whether the applicant is required to serve a civil service probationary period or is providing services pursuant to a contract.

  • The applicant shall submit a completed CCHCS credential and privilege application package as outlined in the Licensed Medical Provider Credentialing and Privileging Documentation Requirements (Appendix 1) within 30 calendar days of receipt of the application. In addition, the applicant shall:

    • Attest that all information submitted for the credentialing and privileging process is accurate.

    • Agree to immediately report any change in the status of the information in the application or maintained in the credentials file.

    • Agree to abide by the CDCR Code of Conduct, CDCR Department Operations Manual, Section 33030.3.1, and the Licensed Medical Provider Code of Professional Conduct.

    • Agree to renew credentials and active privileges at least every three years.

  • The CPSU shall review the application and supporting documentation, which shall include the documents listed in the Primary Source Verification Documents (Appendix 2), to determine whether the applicant meets credentialing and privileging standards as listed in the Minimum Professional Requirements for Credentialing and Privileging Approval (Appendix 3).

    • If the application is incomplete, the CPSU shall actively work with the applicant and physician manager or HCA to gather missing information until the necessary information is obtained.

    • If unable to gather information within 30 days of receipt of the credential request, the CPSU shall inform the HCA and the medical executive or physician manager who will make a determination on whether to close the request or continue with the credentialing and privileging process.

  • When the application is determined to be complete, the CPSU shall forward the credentialing and privileging application and supporting documentation to the MR for review and a determination within seven calendar days of the review being assigned.

  • For institutions with a licensed unit, the Chief Medical Executive (CME) shall make a privilege recommendation to the LGB for determination.  The CME shall report the LGB’s privilege determination to the CPSU.

  • Upon receipt of the credentialing and privileging determination, the CPSU shall do the following:

    • Civil service applicants subject to a probation period: If credentials were approved, and provisional privileges granted, the CPSU shall inform the HCA, physician manager, medical executive, and applicant of the determination.  The length of time for provisional privileges shall be equivalent to the probationary period not to exceed 365 calendar days.

    • Civil service applicants not subject to a probationary period: If credentials were approved, and active privileges granted, the CPSU shall inform the HCA, physician manager, medical executive, and applicant of the decision.  The length of time for active privileges shall not exceed three years.

    • Contract Applicants: If credentials are approved and contract privileges granted, the CPSU shall inform the Contracting Authority of the decision.

  • For primary care advanced practice providers (APP), the CPSU shall request that the physician manager or medical executive complete and submit a signed APP Practice Agreement within five calendar days from the applicant’s start date.

  • If credentials are not approved, the CPSU shall notify the HCA, medical executive or DD, Medical Services or designee, and the Contracting Authority (for licensed contract providers) of the decision.

  • Additional Privileges

    • A licensed medical provider may request additional privileges based on their training, experience, and the institution’s needs. The licensed medical provider shall “self-report” competency which means they are attesting that they are proficient in the procedure and have successfully completed at least three cases within the past 24 months without complications.

    • If the licensed medical provider has requested additional privileges, the CPSU shall forward the application for additional privileges and supporting documentation to the physician manager for review and determination. For CMEs who have requested additional privileges, upon credential approval, the CPSU shall forward the privileging application and supporting documentation to the Regional Deputy Medical Executive (RDME) for review and determination.

    • When privileges for additional procedure(s) are requested, the physician manager or peers competent in the requested procedure(s) shall proctor a minimum of three cases. If the licensed medical provider requesting privileges has demonstrated competency in performing the procedure(s), this shall be noted in the privileging record and no further evaluation is needed.

    • If additional oversight is needed in the performance of a procedure, the physician manager shall make the determination regarding how many more cases need to be proctored. If the physician manager or peers at the institution are unable to provide proctoring, the institution may reach out to the RDME for assistance. If proctoring is unavailable, the request for additional privileges shall not be granted.

• Provisional to Active Privileges

  • No less than 60 calendar days prior to expiration of provisional privileges, the CPSU shall:

    • Inform the medical executive that the licensed medical provider’s provisional privileges will be expiring, the date of expiration, and the PEM due date.

    • If applicable, the CPSU shall also identify any referral criteria items which are listed in Referral Criteria (Appendix 4) and:

      • Inform the physician manager of any referral criteria items.

      • Request that the physician manager provide additional information regarding any referral criteria items.

  • Once all necessary materials are gathered and no less than 30 calendar days prior to expiration of provisional privileges, the medical executive shall facilitate a PEM to review the Initial Focused Professional Practice Evaluation (IFPPEs), available peer review documentation, and referral criteria items to make a determination regarding active privileges for the licensed medical provider. The following individuals may participate in the PEM:

    • DD, Medical Services or designee

    • Assistant Deputy Medical Executive (optional)

    • Deputy Medical Executive

    • MR

    • Both the CME and Chief Physician and Surgeon

    • Institution Hiring Authority

    • Health Care Employee Relations Officer (HCERO) (if there are significant concerns regarding the licensed medical provider’s performance which may warrant progressive discipline or rejection during probation)

  • Once the PEM has been completed, the physician manager or medical executive shall inform CPSU of the outcome and provide a signed Attestation of Clinical Competence (ACC).  If the physician manager or medical executive is unable to attest to the medical provider’s clinical competency, an explanation of the reasons they are unable to do so shall be provided to the CPSU.

  • If active privileges are granted, the CPSU shall notify the licensed medical provider.

  • For licensed medical providers subject to a probationary period: If, after the PEM, the determination is that active privileges shall not be granted, the CPSU shall inform the MPRC of their recommendation, and the HCA shall work with the HCERO to prepare a Rejection During Probation (RDP). A copy of the RDP shall be provided to the MPRC.  The MPRC shall determine whether or not the RDP was for medical disciplinary cause or reason and thus needs to be reported to the licensed medical provider’s licensing board or the National Practitioner Data Bank.

• Reappointment

  • No less than 60 calendar days prior to expiration of active credentials or privileges, the CPSU shall:

    • Inform the HCA, physician manager, medical executive, and licensed medical provider of the pending credentials or privileges expiration date.

    • Identify and gather available peer review documentation and professional practice evaluations from the MPRC.

    • Identify any referral criteria items which are listed in the Referral Criteria (Appendix 4).

    • Request that the physician manager or medical executive submit an ACC based on the clinical performance over the preceding three years for licensed medical providers.

    • For primary care APPs, request that the physician manager or medical executive review and submit an APP Practice Agreement.

    • Inform and request from the physician manager any referral criteria items.

  • The licensed medical provider shall submit the reappointment application no less than 30 calendar days prior to expiration of active credentials or privileges.

  • When all required elements of the application have been received, the CPSU shall forward the credentialing and privileging application and supporting documentation to the MR for review and determination within seven calendar days of the review being assigned.

  • Upon approval of credentials and granting of statewide core privileges, the CPSU shall notify the HCA, physician manager, medical executive, and the licensed medical provider of the decision.

  • If the licensed medical provider has requested additional privileges, upon approval of credentials and granting of statewide core privileges, the CPSU shall forward any application for additional privileges and supporting documentation to the physician manager. For CMEs who have requested additional privileges, upon credential approval, the CPSU shall forward the privileging application and supporting documentation to the RDME for review and determination.

  • If a licensed medical provider will be providing patient care services within a licensed unit, the CPSU shall forward the approved credentialing and privileging application and supporting documentation to the HCA and their designee.  Upon completion of the review and determination, the HCA, or designee, shall forward the LGB determination to CPSU.

  • If reappointment is not approved, the CPSU shall notify the HCA of the decision and shall concurrently refer the file to the MPRC to determine whether any reports are required by law to be filed with the licensed medical provider’s licensing board, the National Practitioner Data Bank, or both, and whether a referral to the HCA is necessary for further disciplinary action as a result of privileges not being granted.

• Changes to Privileging Status

  • Privileging status changes may be initiated by the MPRC, HCEC, HCA, physician manager, medical executive, DD, Medical Services or designee, or licensed medical provider. Changes to privileging status include, but are not limited to, expiration, resignation, rejection, denial, termination, revocation, suspension, restriction, withdrawal, or abandonment of a request for credentials or privileges.

  • Expiration of Privileges

    • Licensed medical providers shall not be allowed to continue providing patient care if the licensed medical provider’s privileges expire.

    • If a civil service licensed medical provider’s privileges have expired for any reason (including the licensed medical provider’s failure or refusal to complete the reappointment process), the CPSU shall notify the HCA, physician manager, medical executive, or DD, Medical Services or designee of the expiration of privileges.  The HCA shall ensure that the licensed medical provider is removed from providing patient care and shall initiate any further action which may be warranted, including progressive discipline.  The CPSU shall concurrently refer the file to the MPRC which shall take further action pursuant to Section (d)(7).

    • Contracted licensed medical providers shall be subject to termination of contract services upon the expiration of privileges.

  • Automatic Termination of Privileges

    • Privileges shall automatically be terminated under the following circumstances:

      • Upon permanent separation from civil service employment.

      • Upon the passage of 180 consecutive calendar days without providing contract services as a licensed medical provider, for any reason.

      • Upon termination or expiration of the contract pursuant to which the licensed medical provider is providing services

    • A licensed medical provider whose privileges were automatically terminated shall be required to reapply for credentials and privileges prior to resuming clinical care.

  • Voluntary Termination of Privileges

    • A licensed medical provider who currently possesses any type or set of privileges and no longer wishes to exercise such privileges may voluntarily terminate their privileges by providing written notice to their HCA or physician manager, or medical executive, which shall include the effective date of the termination. The HCA, physician manager, or medical executive shall forward the notice of voluntary termination of privileges to the CPSU within five calendar days of the licensed medical provider’s written notice.

    • Voluntary changes to any privileging status initiated by a licensed medical provider shall not automatically be deemed to be an unfavorable action for medical disciplinary cause or reason, triggering any form of peer review.  However, the MPRC and HCEC retain the discretion to review all voluntary changes to a licensed medical provider’s privileging status and to make an independent determination as to whether the change in privileging status warrants further reporting or action as required by law.

  • Leaves of Absence

    • In the event that a licensed medical provider’s active statewide privileges expire during a leave of absence, temporary privileges may be granted without the need for a new application, not to exceed 60 calendar days from the date the licensed medical provider returns to work.

    • The CPSU shall forward the most recent privileging application and supporting documentation to the MR to determine if temporary privileges should be granted.

    • The licensed medical provider shall submit a current reappointment application within ten calendar days of returning to work.

• Disaster Privileges

  • Disaster privileges may be granted to administer care, treatment, and services to patients when a disaster has been declared by the individual or agency with authority to declare a disaster or state of emergency (such as the Governor). The institution’s local emergency operations plan must be activated to authorize disaster privileges. At a minimum, the process for granting disaster privileges shall include:

  • A completed Disaster Privileging Form.

  • A valid, government-issued photo ID (i.e., driver’s license or passport) and at least one the following:

    • Current picture identification card from a health care organization that clearly identifies professional designation.

    • Current license, certification, or registration to practice.

    • Identification indicating that the practitioner is a member of a Disaster Medical Assistance Team, the Medical Reserve Corps, the Emergency System for Advance Registration of Volunteer Health Professional, or other recognized federal or state response organization or group.

    • Identification indicating that the practitioner has been granted authority by a government entity to provide patient care, treatment, or services in a disaster circumstance.

    • Confirmation by a licensed medical provider currently privileged by the hospital or by a staff member with personal knowledge of the practitioner’s ability to act as a licensed independent practitioner during a disaster.

    • The CPSU shall confirm and verify the information above and Disaster Privileges shall be reviewed and granted by the MR. The physician manager or medical executive shall document their review of the licensed medical provider’s clinical performance within 72 hours of granting disaster privileges to determine whether the privileges shall be continued.

• Emergency Privileges

  • For the purpose of this section, an “emergency” is defined as an unexpected or sudden event that significantly disrupts the ability to provide care or that results in a sudden, significant change or increase in the demand for the services, or a condition in which serious or permanent harm would result to a patient or in which the life of the patient is in immediate danger and any delay in administering treatment would add to that danger.

  • In the case of an emergency, any licensed medical provider, to the degree permitted by their license and regardless of service or staff status or lack of it, shall be permitted and assisted to do everything possible to save the life of a patient, using every facility of the institution necessary, including the calling for any consultation necessary or desirable.

  • When an emergency situation no longer exists, such licensed medical provider shall request the privileges to continue to treat the patient. In the event such privileges are denied, or they do not desire to request privileges, the patient shall be assigned to health care staff as appropriate.

• File Closure

  • The CPSU shall close the credentialing and privileging file when any of the following conditions are met:

  • The licensed medical provider withdraws the credentialing or privileging application.

  • The HCA, physician manager, medical executive, or MR withdraws the credentialing or privileging request.

  • The CPSU is notified of a licensed medical provider’s resignation, retirement, or death.

  • The MR determines that an application will no longer be pursued.

• Privileging Actions

  • One of the following actions may occur upon request for approval of credentials and granting of privileges:

    • Credentials approval: The MR determines the licensed medical provider meets the standards for credentialing and core privileging.

    • Credential alert: If the MPRC determines that certain facts should be considered as part of the current or any subsequent request to approve credentials or grant privileges to the licensed medical provider, then a credential alert shall be placed in the credentials file and the MPRC, HCA, physician manager, medical executive, DD, Medical Services or designee, and MR shall consider the facts before acting on any subsequent application for credentials or privileges.

    • Credential bar: The MPRC shall place a credential bar in the credentials file if the MPRC determines that the licensed medical provider’s unsatisfactory service has resulted in any one or more of the following:

      • Suspension or revocation of the licensed medical provider’s privileges by the HCEC.

      • Separation for cause from civil service employment with the CCHCS.

      • Termination for cause of the licensed medical provider’s services as a contract licensed medical provider with the CCHCS.

      • Any legally enforceable agreement including, but not limited to, a settlement agreement prohibiting the licensed medical provider from practicing as an employee or contract licensed medical provider with the CCHCS.

      • The placement of a credential bar by the MPRC shall be forwarded to the HCEC as a consent calendar item. After placement of a credential bar in the credentials file, any subsequent application for credentials or privileges shall be reviewed by the HCEC.

    • Referral to the MPRC: The MR shall refer the credentials and privilege application to the MPRC for a determination in the event that the MR determines there is a need for further review of the application by the committee due to concerns as outlined in categories I & II of the Referral Criteria (Appendix 4).  The MR is not required to refer the file to the MPRC for matters that occurred more than five years prior to the date of application submission.

  • Denial of Privileges: If the MPRC determines that the privileges of the licensed medical provider shall be denied, the MPRC shall prepare a recommendation and referral to the HCEC.  The MPRC shall also determine whether the denial is for a medical disciplinary cause or reason, and whether the denial shall be reported to the licensed medical provider’s licensing board or the National Practitioner Data Bank, or the HCA for potential disciplinary action.

• Consideration of Requests for Credentials or Privileges

  • Before making a determination on a credential and privilege request, the MR shall:

    • Consider all credentialing and peer review information including credential alerts or bars, in the credentials file.

    • Confirm that the HCA who requested the credentialing is informed of and has considered all facts relevant to the employment or contracting decision including facts that resulted in the placement of a credential alert or bar.

  • If the credentials file contains a credential bar, the MR shall refer the request to the MPRC with a recommendation for approval or disapproval. The MR is not required to refer files containing a credential alert to the MPRC if they have previously reviewed the information on which the alert is based and are satisfied that the information will not negatively reflect on the competence of the licensed medical provider.

  • The MR shall approve credentials and core privileges only if they determine that the licensed medical provider:

    • Meets all credentialing and privileging requirements as delineated in this section.

    • Possesses the current competence and mental and physical ability to adequately discharge patient care responsibilities in a correctional setting.

• Referring Actions for Medical Disciplinary Reasons

  • The MR is not authorized to deny any application for credentials or privileges based on a medical disciplinary cause or reason within the meaning of the California Business and Professions Code, Section 805, et seq.

  • Where the MR recommends denial of the credentials and privilege request based on a medical disciplinary cause or reason, the MR shall refer the case to the MPRC which shall take further action pursuant to Section (d)(6).

• Civil Service Licensed Medical Provider Transfers and Promotions

  • Regardless of whether statewide privileges have expired, upon appointment to a new classification, licensed medical providers shall submit a new credentialing and privileging application pursuant to Section (f)(1) prior to starting the new position.

  • If a licensed medical provider laterally transfers to a different institution or facility and stays in the same job classification, full reappointment is not required prior to the expiration of the licensed medical provider’s current credentials and statewide privileges, but the licensed medical provider may apply for additional privileges at the new facility or institution.

Policy

• California Correctional Health Care Services (CCHCS) shall maintain a process to credential and privilege all behavioral health professionals within Medical Services who are subject to this policy and provide patient care services at California Department of Corrections and Rehabilitation (CDCR) institutions and from the regional and headquarters offices of CCHCS to ensure that they meet minimum credentials, privileging, and performance standards. Behavioral health professionals, to include Clinical Social Workers and psychologists, shall not provide any direct patient care services to CDCR patients prior to having their credentials approved and privileges granted.  This policy only applies to behavioral health classifications such as Chief Psychologists, Senior Psychologist (Specialists), Psychologists, Supervising Psychiatric Social Workers, licensed and unlicensed Clinical Social Workers when employed under Medical Services. CCHCS considers credentialing and privileging activities to be peer review activities within the meaning of California Business and Professions Code, Section 805 and Evidence Code, Section 1157. (NOTE: Unlicensed clinical social workers are not subject to Business and Professions Code, Section 805(c)).

• Credentials Review

  • The credentials reviewed for all providers shall include, but not be limited to, licensure, certification, education, training and experience, current competence, and physical and mental ability to discharge patient care responsibilities appropriately in a correctional setting. This includes any information which impacts a provider’s:

  • Clinical skills and competency necessary to perform the health care services provided to patients.

  • Judgment and ability to perform techniques in any specialty for which credentials are reviewed.

  • Consistent observance of professional and ethical standards including a history of acting in a professional and collegial manner.

  • Written and verbal communication skills.

• Scope

  • Credentials for civil service and contract providers shall be approved on a statewide basis.

  • Privileges shall only be granted for the specific location where a behavioral health professional intends to provide services. If a behavioral health professional intends to provide in-person services at more than one CDCR facility, the behavioral health professional shall apply for privileges specific to each physical location.  Privileges shall only be granted once credentials have been approved.

• Reappointment, Expiration of Privileges, and Termination

  • Reappointment shall occur every three years and at other times during a behavioral health professional’s reappointment cycle as set forth in this section. If a behavioral health professional fails to complete the reappointment process, they shall not continue providing patient care services, and their privileges shall expire, resulting in an automatic revocation of privileges. The failure of any civil service employee to participate in or complete reappointment shall be subject to progressive discipline, up to and including termination. Contract  providers shall be subject to termination of contract services upon the expiration of privileges.

  • Privileges shall automatically be terminated at the time of separation under the following circumstances. The provider’s credentials and privileges shall be renewed and approved prior to the resumption of clinical care.

    • Any permanent separation from civil service employment.

    • Any separation of 180 calendar days or greater from contract employment as a behavioral health professional.

    • Any contract termination or expiration as a contract behavioral health professional.

Purpose

• To ensure that all behavioral health professionals who are subject to this policy and provide patient care services within the CCHCS Medical Services at CDCR institutions meet minimum credentials, privileging, and performance standards.

Applicability

• This policy and procedure applies to civil service and contract behavioral health professionals used by Medical Services as follows (this policy only applies to behavioral health classifications such as Chief Psychologists, Senior Psychologist (Specialists), Psychologists, Supervising Psychiatric Social Workers, licensed and unlicensed Clinical Social Workers when employed under Medical Services):

• Chief Psychologist

• Senior Psychologist, Specialist

• Psychologist

• Supervising Psychiatric Social Worker (SPSW)

• Licensed Clinical Social Worker (LCSW)

• Unlicensed Clinical Social Worker

Responsibility

• Hiring or Contracting Authority

  • The Hiring or Contracting Authority (HCA) for each CDCR institution or facility where providers provide direct patient care services is responsible for ensuring that health care providers are appropriately credentialed and practice within the scope of their clinical privileges. Prior to submitting a request for credentialing and privileging, the HCA shall ensure that all pre-appointment human resources requirements have been met including but not limited to, checking references and completing Live Scan reviews.

• Deputy Medical Executive

  • The Deputy Medical Executive (DME) is responsible for reviewing requested clinical privileges for Chief Psychologists.

• Credentialing Reviewer

  • The Credentialing Reviewer (CR) is responsible for reviewing credentials applications and making a determination as to whether credentials can be approved or whether the application requires additional evaluation.

• Chief Psychologist

  • The Chief Psychologist is responsible for reviewing requested clinical privileges for SPSWs, Psychologists, and Senior Psychologist, Specialists.

• Supervising Psychiatric Social Worker

  • The SPSW is responsible for reviewing requested clinical privileges for Clinical Social Workers.

• Credentialing and Privileging Support Unit

  • The Credentialing and Privileging Support Unit (CPSU) shall review and process all applications for credentials and privileges in accordance with this policy and procedure.

• Behavioral Health Professional Peer Review Committee (BHPPRC)

  • The Behavioral Health Professional Peer Review Committee (BHPPRC) shall review and act on credentialing and privileging applications that are referred to it, monitor credentialing and privileging activities within  CCHCS and CDCR for Clinical Social Workers and psychologists, and ensure that program-specific standards for credentials and clinical privileges remain current and up-to-date under applicate legal, accreditation, and community standards.

  • The BHPPRC shall refer all proposed actions that will impact the privileges of a social worker or psychologist to the Health Care Executive Committee (HCEC) for approval and further action. All other actions taken by the BHPPRC shall be reported to the HCEC on an informational consent item report. This includes placement of credential alerts and credential bars as well as privilege modifications which are not taken for disciplinary cause or reason (i.e., lapse or expiration of credentials or privileges or a failure to secure required certifications or licenses).

• Health Care Executive Committee

  • The HCEC shall ensure that providers who provide services to CCHCS and CDCR patients provide clinical services that consistently meet the standard of care. This includes oversight of the BHPPRC’s credentialing and privileging activities.

  • The HCEC shall review all privileging actions taken by the BHPPRC and may act independently as necessary to ensure that patient health care at CCHCS and CDCR meets the standard of care.

• Applicants and Behavioral Health Professionals

  • Applicants and behavioral health professionals are responsible for the following items:

    • Providing evidence of licensure, registration, certification and other relevant credentials as set forth in this section for verification prior to appointment and throughout the appointment process as requested.

    • Notifying CCHCS and CDCR of information or actions that would adversely affect or otherwise limit their privileges at the earliest date after notification is received by the behavioral health professional but no later than 15 calendar days. This includes not only final actions but also pending and proposed actions.

    • Maintaining licenses, registrations, and certification in good standing and informing the HCA of any changes in the status of these credentials at the earliest date after notification is received by the behavioral health professional but no later than 15 calendar days including, but not limited to, any pending or proposed actions.

    • Obtaining and producing all needed information for a proper evaluation of professional competence, character, ethics, and other qualifications. The information shall be complete and verifiable. The applicant and behavioral health professional has the responsibility for furnishing information that will help resolve any questions concerning these qualifications.

  • Failure to keep CDCR, CCHCS fully informed on these matters may result in administrative or disciplinary action.

Procedure Overview

• The credentialing and privileging process includes primary source verifications and privileging determinations for behavioral health professionals listed in Section (c) who perform services and are requesting privileges related to clinical performance in CCHCS and CDCR.

• The HCA, CPSU, Headquarters and Regional Medical Executives, CR, DME, Chief Psychologist, SPSW, BHPPRC, and HCEC work collaboratively in collecting, reviewing, tracking, and evaluating licensures, relevant training, experience, and current competencies of each behavioral health professional.

Procedure

• Initial Appointment

  • The applicant shall submit a completed CCHCS credential and privilege application package as outlined in the New Behavioral Health Professional Credentialing and Privileging Documentation Requirements (Appendix 1) within 30 calendar days of receipt of the application. In addition, the applicant shall:

    • Attest that all information submitted for the credentialing and privileging process is accurate.

    • Agree to immediately report any change in the status of the information in the application or maintained in the credentials file.

    • Agree to abide by the CDCR Code of Conduct, CDCR Department Operations Manual, Section 33030.3.1, and the Behavioral Health Professional Code of Professional Conduct (Appendix 2).

    • Agree to renew credentials and active privileges at least every three years.

  • The CPSU shall review the application and supporting documentation, which shall include the documents listed in the Mandatory Primary Source Verification Documents (Appendix 3), to determine whether the applicant meets credentialing and privileging standards as listed in the Minimum Professional Requirements for Credentialing and Privileging Approval (Appendix 4).

    • If the application is incomplete, the CPSU shall actively work with the applicant and DME, Chief Psychologist or SPSW or contract vendor to gather missing information until the necessary information is obtained or until the Chief Psychologist or SPSW makes a determination regarding a final disposition for the application.

    • If the CPSU is unable to gather and/or verify all documents in a timely manner due to circumstances beyond either their control, or the behavioral health professional’s control, after the making a good faith and reasonable effort to do so, the CPSU may, in consultation with the Chief Psychologist or SPSW, move the application forward to the next step in the process.

  • When the CPSU determines the application is ready for review, the CPSU shall forward the credentialing application and supporting documentation to the CR for review and determination within seven calendar days.

  • Upon credentials approval, the CPSU shall forward the privileging application and supporting documentation to the DME, Chief Psychologist or SPSW, for review and determination.

    • For institutions with a Correctional Treatment Center (CTC), the SPSW shall make a privilege recommendation to the Local Governing Body (LGB) for determination. The SPSW shall report the LGB’s privilege determination to the CPSU. For institutions without a CTC, the SPSW shall make a privilege determination to the CPSU.

    • If mentoring or proctoring is requested, proctoring shall be done at the institution by behavioral health leadership or other peers who are experienced with performing the procedures. If there are no peers at the institution who can provide the mentoring, the institution may reach out to the Chief Psychologist for assistance.

    • A provider may request any additional procedures based on their expertise and the institution needs. The provider shall “self-report” competency which means they are proficient in the procedure and have successfully completed at least three cases within the past 24 months without complications.

    • When privileges for an additional procedure or procedures are requested, institution leadership or peers competent in the requested procedure(s) shall proctor a minimum of three cases. If the provider requesting privileges has demonstrated competency in performing the procedure(s), this shall be noted in the privileging record and no further evaluation is needed.

    • If additional oversight is needed, the institution leadership shall make the determination regarding how many more cases need to be proctored. If institution leadership or peers cannot provide proctoring for certain procedures, they shall reach out the Chief Psychologist for assistance.

  • Upon receipt of the credentialing and privileging determination, the CPSU shall do the following:

    • Civil Service Full-Time Applicants with six-month probation period: If credentials are approved and provisional privileges granted for up to 180 calendar days (from the behavioral health professional’s date of appointment), the CPSU shall:

      • Inform the HCA, DME, Chief Psychologist or SPSW, and applicant of the decision.

    • Civil Service Full-Time Applicants with one-year probation period: If credentials are approved and provisional privileges are granted for up to 365 calendar days (from the behavioral health professional’s date of appointment) the CPSU shall:

      • Inform the HCA, DME, Chief Psychologist or SPSW, and applicant of the decision.

      • Inform the HCA and designated supervisor of the four-month Initial Focused Professional Practice Evaluations (IFPPE) due date.

    • Civil Service Part-Time Applicants: If credentials are approved and provisional privileges granted for a period proportional to the length of the probation period not to exceed 365 calendar days (from the behavioral health professional’s date of appointment, the CPSU shall:

      • Inform the HCA, DME, Chief Psychologist or SPSW, and applicant of the decision.

    • Contract Applicants: If credentials are approved and active privileges granted, the CPSU shall:

      • Inform the Contracting Authority of the decision.

  • If credentials are not approved, the CPSU shall notify the HCA and Chief Psychologist of the decision.

• Provisional to Active Privileges

  • No less than 60 calendar days prior to expiration of provisional privileges, the CPSU shall:

    • Inform the HCA, DME, Chief Psychologist or SPSW, that the behavioral health professional’s provisional privileges will be expiring and of the date of the expiration.

    • Inform the HCA, DME, Chief Psychologist or SPSW, of the Performance Evaluation Meeting (PEM) due date.

    • Request that the DME, Chief Psychologist or SPSW, submit an Attestation of Clinical Competency.

    • If applicable, the CPSU shall identify any referral criteria items which are listed in Referral Criteria (Appendix 5) and:

      • Inform the DME, Chief Psychologist or SPSW of any referral criteria items.

      • Request the DME, Chief Psychologist or SPSW to provide additional information regarding any referral criteria items.

  • Once all necessary materials are gathered and no less than 30 calendar days prior to expiration of provisional privileges, the DME, Chief Psychologist or SPSW shall facilitate a PEM to review the IFPPEs, results from IIPs, available peer review documentation, and referral criteria items to make a determination regarding active privileges for the behavioral health professional. The PEM shall be facilitated with the following (this policy only applies to behavioral health classifications such as Chief Psychologists, Senior Psychologist (Specialists), Psychologists, Supervising Psychiatric Social Workers, licensed and unlicensed Clinical Social Workers when employed under Medical Services):

    • Headquarters Medical Executive (optional).

    • DME (required).

    • Chief Psychologist (required).

    • CR (optional).

    • SPSW (required).

    • Institution HCA (required).

    • Health Care Employee Relations Officer (HCERO) (if there are significant concerns regarding the behavioral health professional’s performance which may warrant progressive discipline).

  • If active privileges are granted, the CPSU shall notify the behavioral health professional.

  • If after the PEM, the determination is that active privileges shall not be granted, the HCA shall work with the HCERO to prepare a Rejection During Probation (RDP). A copy of the RDP shall be provided to the BHPPRC.  The BHPPRC shall determine whether or not the RDP was for disciplinary cause or reason and thus needs to be reported to the provider’s licensing board, the National Practitioner Data Bank, or both.

• Reappointment

  • No less than 60 calendar days prior to expiration of active credentials or privileges, the CPSU shall:

    • Inform the HCA, as well as the DME, Chief Psychologist or SPSW, and behavioral health professional that the behavioral health professional’s active credentials or privileges will be expiring and the date of the expiration.

    • Identify and gather available Peer Review documentation, including the Ongoing Professional Practice Evaluations (OPPE), any Focused Professional Practice Evaluations (FPPE), and the results from IIPs.

    • Identify any referral criteria items which are listed in the Referral Criteria (Appendix 5).

    • Request that the DME, Chief Psychologist or SPSW submit an Attestation of Clinical Competence based on the performance results obtained from the behavioral health professional’s OPPEs and IIPs completed over the preceding three years.

    • If applicable:

      • Inform the DME, Chief Psychologist or SPSW of any referral criteria items.

      • Request additional information from the DME, Chief Psychologist or SPSW regarding referral criteria items.

  • The behavioral health professional shall submit the reappointment application no less than 30 calendar days prior to expiration of active credentials or privileges.

  • When the CPSU determines the reappointment application is complete, the CPSU shall forward the reappointment application and supporting documentation to the CR for review and credentialing determination.

  • Upon approval of the provider’s reappointment credentials, the CPSU shall forward the reappointment application with requested privileges and supporting documentation to the DME, Chief Psychologist or SPSW for review. The DME, Chief Psychologist or SPSW shall also review the FPPEs, results from IIPs, available Peer Review documentation, and referral criteria items prior to making a determination regarding the reappointment for the behavioral health professional.

  • Behavioral health professionals shall not be allowed to continue providing patient care if the provider’s privileges expire.

  • The CPSU shall refer providers whose privileges have expired to the HCA for further action including, but not limited to, progressive discipline, or an FPPE.

  • If the behavioral health professional fails to complete the reappointment process before their privileges expire, privileges shall not be granted. The CPSU shall notify the HCA, DME, Chief Psychologist or SPSW of the expiration of privileges and shall concurrently refer the file to the BHPPRC which shall take further action in pursuant to Section (d)(7).

  • If reappointment is approved, the CPSU shall notify the HCA, as well as the DME, Chief Psychologist or SPSW, and behavioral health professional of the decision.

  • If reappointment is not approved, privileges shall not be granted. The CPSU shall notify the HCA of the decision and shall concurrently refer the file to the BHPPRC to determine whether any reports are required by law to be filed with the provider’s licensing board, the National Practitioner Data Bank, or both, and whether a referral to the HCA is necessary for further disciplinary action as a result of privileges not being granted.

• Changes to Privileging Status

  • Privileging status changes may be initiated by the BHPPRC, HCEC, HCA, DME, Chief Psychologist, SPSW, or behavioral health professional. Changes to privileging status include, but are not limited to, resignation, rejection, denial, termination, revocation, suspension, restriction, withdrawal, or abandonment of a request for credentials or privileges.

  • A behavioral health professional who currently possesses any type or set of privileges and no longer wishes to exercise such privileges may voluntarily terminate their privileges by providing written notice to their HCA, as well as the DME, Chief Psychologist or SPSW, which shall include the effective date of the termination. The HCA or DME, Chief Psychologist or SPSW shall forward the notice of voluntary termination of privileges to the CPSU within five calendar days of the behavioral health professional’s written notice.

  • Voluntary changes to any privileging status initiated by a behavioral health professional shall not automatically be deemed to be an unfavorable action for disciplinary cause or reason, triggering any form of peer review.  However, the BHPPRC and HCEC retain the discretion to review all voluntary changes to a behavioral health professional’s privileging status and to make an independent determination as to whether the change in privileging status warrants further reporting or action as required by law.

• Temporary Privileges

  • In the event that a provider’s active privileges at the current institution expired during a temporary separation or approved leave of absence, temporary privileges may be granted without the need for a new application, not to exceed 60 calendar days from the date the provider returns to work.

    • The CPSU shall forward the most recent privileging application and supporting documentation to the DME, Chief Psychologist or SPSW to determine if temporary privileges should be granted.

    • The behavioral health provider shall submit a current privileging application within ten calendar days of returning to work.

• Disaster Privileges

  • Disaster privileges may be granted to administer care, treatment, and services to patients when a disaster has been declared by the individual or agency with authority to declare a disaster or state of emergency (such as the Governor). The institution’s local emergency operations plan must be activated in order to authorize disaster privileges. Privileges that are exercised should be equivalent to those exercised at the practitioner’s primary hospital or within the statutory-defined scope of practice for those without primary hospital affiliations. At a minimum, the process for granting disaster privileges shall include:

    • A completed Disaster Privileging Form.

    • A valid, government-issued photo ID (i.e., driver’s license or passport) and at least one the following:

      • Current picture identification card from a health care organization that clearly identifies professional designation.

      • Current license, certification, or registration to practice.

      • Identification indicating that the practitioner is a member of a Disaster Medical Assistance Team, the Medical Reserve Corps, the Emergency System for Advance Registration of Volunteer Health Professional, or other recognized federal or state response organization or group.

      • Identification indicating that the practitioner has been granted authority by a government entity to provide patient care, treatment, or services in a disaster circumstance.

      • Confirmation by a licensed independent practitioner (LIP) currently privileged by the hospital or by a staff member with personal knowledge of the practitioner’s ability to act as an LIP during a disaster.

      • The CPSU shall confirm and verify the information above and Disaster Privileges shall be reviewed and granted by the designee. The designee shall document their review of the practitioner’s performance within 72 hours of granting disaster privileges to determine whether the privileges shall be continued.

• Emergency Privileges

  • For the purpose of this section, an “emergency” is defined as an unexpected or sudden event that significantly disrupts the institution’s ability to provide care, or the environment of care itself, or that results in a sudden, significantly changed or increased demand for the institution’s services, or a condition in which serious or permanent harm would result to a patient or in which the life of the patient is in immediate danger and any delay in administering treatment would add to that danger.

  • In the case of emergency, any practitioner, to the degree permitted by their license and regardless of service or staff status or lack of it, shall be permitted and assisted to do everything possible to save the life of a patient, using every facility of the institution necessary, including the calling for any consultation necessary or desirable.

  • When an emergency situation no longer exists, such practitioner shall request the privileges to continue to treat the patient. In the event such privileges are denied or they do not desire to request privileges, the patient shall be assigned to health care staff as appropriate.

• File Closure

  • The CPSU shall close the credentialing and privileging file if any of the following conditions are met:

    • The behavioral health professional withdraws the credentialing or privileging application.

    • The HCA, DME, Chief Psychologist, SPSW or CR withdraws the credentialing or privileging request.

    • The behavioral health professional fails to submit all required information to constitute a completed application within 30 calendar days of the initial request.

    • The CPSU is notified of a behavioral health professional’s resignation, retirement, or death.

• Credentialing Actions

  • One of the following actions shall occur upon each review of a request for approval of credentials and granting of privileges:

    • Credentials approved: The CR determines that the credentials of the behavioral health professional have been verified to meet the minimum standards for credentialing. The DME, Chief Psychologist, or SPSW shall then proceed with making a privileging determination.

    • Credential file to be closed: The request to credential a behavioral health professional has been withdrawn or the HCA and DME, as well as the Chief Psychologist, SPSW or CR determines that an application shall no longer be pursued.

    • Credential alert: If the BHPPRC determines that certain facts should be considered as part of the current or any subsequent request to approve credentials or grant privileges to the behavioral health professional, then a credential alert shall be placed in the credentials file and the BHPPRC, HCA, DME, Chief Psychologist, SPSW, and CR shall consider the facts before acting on any subsequent application for credentials or privileges.

    • Credential bar: The BHPPRC shall place a credential bar in the credentials file if the BHPPRC determines that the behavioral health professional’s unsatisfactory service has resulted in any one or more of the following:

      • Suspension or revocation of the behavioral health professional’s privileges by the HCEC.

      • Separation for cause from civil service employment with the CCHCS and CDCR.

      • Termination for cause of the behavioral health professional’s services as a contract behavioral health professional with the CCHCS and CDCR.

      • Any legally enforceable agreement including, but not limited to, a settlement agreement prohibiting the behavioral health professional from practicing as an employee or contract behavioral health professional with the CCHCS and CDCR.

      • The placement of a credential bar by the BHPPRC shall be forwarded to the HCEC as a consent calendar item. After placement of a credential bar in the credentials file, any subsequent application for credentials or privileges shall be reviewed by the HCEC.

  • Referral to BHPPRC: The CR shall defer a recommendation on an application for credential approval and refer the case to the BHPPRC in the event that the CR determines there is a need for additional evaluation of a behavioral health professional’s credentials information due to the presence of referral criteria items or issues in the file; refer to the Referral Criteria (Appendix 5).

  • Credential disapproval: If the BHPPRC determines that the credentials of the behavioral health professional shall not be approved, the BHPPRC shall determine whether the disapproval is for a medical disciplinary cause or reason, and whether the disapproval shall be reported to the provider’s licensing board and the National Practitioner Data Bank, or the HCA for potential action. The BHPPRC shall also prepare a recommendation and referral to the HCEC.

• Consideration of Requests for Credentials or Privileges

  • Before taking any action on a request to approve credentials or grant privileges, the DME, Chief Psychologist or SPSW and CR shall:

    • Consider all credentialing and peer review information including credential alerts or bars, in the credentials file.

    • Confirm that the HCA who requested the credentialing is informed of and has considered all facts relevant to the employment or contracting decision including facts that resulted in the placement of a credential alert or bar.

  • If the credential file contains a credential bar, the CR shall refer the request to the BHPPRC with a recommendation for approval or disapproval. The CR is not required to refer files containing a credential alert to BHPPRC if they have previously reviewed the information on which the alert is based, and are satisfied that the information will not negatively reflect on the competence of the provider.

  • The CR shall approve credentials only if they determine that the behavioral health professional:

    • Meets all credentialing requirements as delineated in this section.

    • Possesses the current competence and mental and physical ability to adequately discharge patient care responsibilities in a correctional setting.

  • Where the DME, Chief Psychologist or SPSW and CR lack sufficient information to make a finding regarding current competence and mental and physical ability, the DME, Chief Psychologist or SPSW and CR shall refer the request to the BHPPRC for a determination.

• Referring Actions for Disciplinary Reasons to the BHPPRC

  • The DME, Chief Psychologist or SPSW and CR are not authorized to deny any application for credentials or privileges based on a disciplinary cause or reason within the meaning of the California Business and Professions Code, Section 805, et seq. (NOTE: Unlicensed clinical social workers are not subject to Business and Professions Code, Section 805(c)).

  • Where the DME, Chief Psychologist or SPSW and CR determine that they cannot make a recommendation to approve credentials or grant privileges they shall refer their recommendation to the BHPPRC which shall take further action pursuant to Section (d)(7).

• Civil Service Behavioral Health Professional Transfers and Promotions

  • In addition to reappointment every three years, all civil service behavioral health professionals who are selected for promotional appointments shall be required to undergo initial appointment pursuant to Section (f)(1) prior to beginning job duties for the promotional position. Appointment for a promotion shall be based on available documentation pertaining to the evaluation of the behavioral health professional’s performance.

  • If a behavioral health professional laterally transfers to a different institution or facility and stays in the same job classification, full reappointment is not required prior to the expiration of the behavioral health professional’s current credentialing cycle, but the behavioral health professional shall apply for privileges at the new facility or institution.

  • If a behavioral health professional transfers or promotes while providing services based on provisional privileges, the behavioral health professional shall still be required to complete all aspects of their provisional privileges and probationary period including probationary evaluations, IFPPEs, and IIPs before active privileges may be granted.