{"id":1289,"date":"2023-12-05T16:27:08","date_gmt":"2023-12-06T00:27:08","guid":{"rendered":"https:\/\/www.cdcr.ca.gov\/hcdom\/?post_type=dom&#038;p=1289"},"modified":"2023-12-05T16:27:09","modified_gmt":"2023-12-06T00:27:09","slug":"1-4-1-3-behavioral-health-professional-credentialing-privileging","status":"publish","type":"dom","link":"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-1-health-care-governance-and-administration\/article-4-1-professional-workforce-credentialing-and-privileging\/1-4-1-3-behavioral-health-professional-credentialing-privileging\/","title":{"rendered":"1.4.1.3 Behavioral Health Professional Credentialing Privileging"},"content":{"rendered":"\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Policy<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.\u00a0 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)).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Credentials Review<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>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\u2019s:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Clinical skills and competency necessary to perform the health care services provided to patients.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Judgment and ability to perform techniques in any specialty for which credentials are reviewed.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Consistent observance of professional and ethical standards including a history of acting in a professional and collegial manner.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Written and verbal communication skills.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Scope<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Credentials for civil service and contract providers shall be approved on a statewide basis.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.\u00a0 Privileges shall only be granted once credentials have been approved.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Reappointment, Expiration of Privileges, and Termination<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Reappointment shall occur every three years and at other times during a behavioral health professional\u2019s 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 \u00a0providers shall be subject to termination of contract services upon the expiration of privileges.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Privileges shall automatically be terminated at the time of separation under the following circumstances. The provider\u2019s credentials and privileges shall be renewed and approved prior to the resumption of clinical care.<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Any permanent separation from civil service employment.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Any separation of 180 calendar days or greater from contract employment as a behavioral health professional.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Any contract termination or expiration as a contract behavioral health professional.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Purpose<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Applicability<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>This policy and procedure applies to civil service and contract behavioral health professionals used by Medical Services as follows <em>(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)<\/em>:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Chief Psychologist<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Senior Psychologist, Specialist<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Psychologist<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Supervising Psychiatric Social Worker (SPSW)<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Licensed Clinical Social Worker (LCSW)<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Unlicensed Clinical Social Worker<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Responsibility<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Hiring or Contracting Authority<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Deputy Medical Executive<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>The Deputy Medical Executive (DME) is responsible for reviewing requested clinical privileges for Chief Psychologists.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Credentialing Reviewer<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Chief Psychologist<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>The Chief Psychologist is responsible for reviewing requested clinical privileges for SPSWs, Psychologists, and Senior Psychologist, Specialists.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Supervising Psychiatric Social Worker<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>The SPSW is responsible for reviewing requested clinical privileges for Clinical Social Workers.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Credentialing and Privileging Support Unit<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>The Credentialing and Privileging Support Unit (CPSU) shall review and process all applications for credentials and privileges in accordance with this policy and procedure.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Behavioral Health Professional Peer Review Committee (BHPPRC)<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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 \u00a0CCHCS 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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Health Care Executive Committee<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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\u2019s credentialing and privileging activities.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Applicants and Behavioral Health Professionals<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Applicants and behavioral health professionals are responsible for the following items:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Failure to keep CDCR, CCHCS fully informed on these matters may result in administrative or disciplinary action.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Procedure Overview<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Procedure<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Initial Appointment<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Attest that all information submitted for the credentialing and privileging process is accurate.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Agree to immediately report any change in the status of the information in the application or maintained in the credentials file.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Agree to renew credentials and active privileges at least every three years.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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).<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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\u2019s 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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Upon credentials approval, the CPSU shall forward the privileging application and supporting documentation to the DME, Chief Psychologist or SPSW, for review and determination.<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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\u2019s privilege determination to the CPSU. For institutions without a CTC, the SPSW shall make a privilege determination to the CPSU.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>A provider may request any additional procedures based on their expertise and the institution needs. The provider shall \u201cself-report\u201d competency which means they are proficient in the procedure and have successfully completed at least three cases within the past 24 months without complications.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Upon receipt of the credentialing and privileging determination, the CPSU shall do the following:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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\u2019s date of appointment), the CPSU shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Inform the HCA, DME, Chief Psychologist or SPSW, and applicant of the decision.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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\u2019s date of appointment) the CPSU shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Inform the HCA, DME, Chief Psychologist or SPSW, and applicant of the decision.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Inform the HCA and designated supervisor of the four-month Initial Focused Professional Practice Evaluations (IFPPE) due date.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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\u2019s date of appointment, the CPSU shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Inform the HCA, DME, Chief Psychologist or SPSW, and applicant of the decision.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Contract Applicants: If credentials are approved and active privileges granted, the CPSU shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Inform the Contracting Authority of the decision.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>If credentials are not approved, the CPSU shall notify the HCA and Chief Psychologist of the decision.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Provisional to Active Privileges<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>No less than 60 calendar days prior to expiration of provisional privileges, the CPSU shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Inform the HCA, DME, Chief Psychologist or SPSW, that the behavioral health professional\u2019s provisional privileges will be expiring and of the date of the expiration.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Inform the HCA, DME, Chief Psychologist or SPSW, of the Performance Evaluation Meeting (PEM) due date.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Request that the DME, Chief Psychologist or SPSW, submit an Attestation of Clinical Competency.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>If applicable, the CPSU shall identify any referral criteria items which are listed in Referral Criteria (Appendix 5) and:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Inform the DME, Chief Psychologist or SPSW of any referral criteria items.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Request the DME, Chief Psychologist or SPSW to provide additional information regarding any referral criteria items.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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 <em>(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)<\/em>:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Headquarters Medical Executive (optional).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>DME (required).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Chief Psychologist (required).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>CR (optional).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>SPSW (required).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Institution HCA (required).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Health Care Employee Relations Officer (HCERO) (if there are significant concerns regarding the behavioral health professional\u2019s performance which may warrant progressive discipline).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>If active privileges are granted, the CPSU shall notify the behavioral health professional.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.\u00a0 The BHPPRC shall determine whether or not the RDP was for disciplinary cause or reason and thus needs to be reported to the provider\u2019s licensing board, the National Practitioner Data Bank, or both.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Reappointment<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>No less than 60 calendar days prior to expiration of active credentials or privileges, the CPSU shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Inform the HCA, as well as the DME, Chief Psychologist or SPSW, and behavioral health professional that the behavioral health professional\u2019s active credentials or privileges will be expiring and the date of the expiration.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Identify any referral criteria items which are listed in the Referral Criteria (Appendix 5).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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\u2019s OPPEs and IIPs completed over the preceding three years.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>If applicable:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Inform the DME, Chief Psychologist or SPSW of any referral criteria items.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Request additional information from the DME, Chief Psychologist or SPSW regarding referral criteria items.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The behavioral health professional shall submit the reappointment application no less than 30 calendar days prior to expiration of active credentials or privileges.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Upon approval of the provider\u2019s 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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Behavioral health professionals shall not be allowed to continue providing patient care if the provider\u2019s privileges expire.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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\u2019s 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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Changes to Privileging Status<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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\u2019s written notice.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.\u00a0 However, the BHPPRC and HCEC retain the discretion to review all voluntary changes to a behavioral health professional\u2019s 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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Temporary Privileges<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>In the event that a provider\u2019s 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.<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The behavioral health provider shall submit a current privileging application within ten calendar days of returning to work.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Disaster Privileges<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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\u2019s 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\u2019s 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:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>A completed Disaster Privileging Form.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>A valid, government-issued photo ID (i.e., driver\u2019s license or passport) and at least one the following:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Current picture identification card from a health care organization that clearly identifies professional designation.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Current license, certification, or registration to practice.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Identification indicating that the practitioner has been granted authority by a government entity to provide patient care, treatment, or services in a disaster circumstance.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Confirmation by a licensed independent practitioner (LIP) currently privileged by the hospital or by a staff member with personal knowledge of the practitioner\u2019s ability to act as an LIP during a disaster.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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\u2019s performance within 72 hours of granting disaster privileges to determine whether the privileges shall be continued.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Emergency Privileges<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>For the purpose of this section, an \u201cemergency\u201d is defined as an unexpected or sudden event that significantly disrupts the institution\u2019s ability to provide care, or the environment of care itself, or that results in a sudden, significantly changed or increased demand for the institution\u2019s 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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>File Closure<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The CPSU shall close the credentialing and privileging file if any of the following conditions are met:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The behavioral health professional withdraws the credentialing or privileging application.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The HCA, DME, Chief Psychologist, SPSW or CR withdraws the credentialing or privileging request.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The behavioral health professional fails to submit all required information to constitute a completed application within 30 calendar days of the initial request.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The CPSU is notified of a behavioral health professional\u2019s resignation, retirement, or death.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Credentialing Actions<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>One of the following actions shall occur upon each review of a request for approval of credentials and granting of privileges:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Credential bar: The BHPPRC shall place a credential bar in the credentials file if the BHPPRC determines that the behavioral health professional\u2019s unsatisfactory service has resulted in any one or more of the following:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Suspension or revocation of the behavioral health professional\u2019s privileges by the HCEC.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Separation for cause from civil service employment with the CCHCS and CDCR.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Termination for cause of the behavioral health professional\u2019s services as a contract behavioral health professional with the CCHCS and CDCR.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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\u2019s credentials information due to the presence of referral criteria items or issues in the file; refer to the Referral Criteria (Appendix 5).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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\u2019s 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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Consideration of Requests for Credentials or Privileges<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Before taking any action on a request to approve credentials or grant privileges, the DME, Chief Psychologist or SPSW and CR shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Consider all credentialing and peer review information including credential alerts or bars, in the credentials file.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The CR shall approve credentials only if they determine that the behavioral health professional:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Meets all credentialing requirements as delineated in this section.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Possesses the current competence and mental and physical ability to adequately discharge patient care responsibilities in a correctional setting.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Referring Actions for Disciplinary Reasons to the BHPPRC<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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)).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Civil Service Behavioral Health Professional Transfers and Promotions<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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\u2019s performance.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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\u2019s current credentialing cycle, but the behavioral health professional shall apply for privileges at the new facility or institution.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Appendices<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Appendix 1: New Behavioral Health Professional Credentialing and Privileging Documentation Requirements<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Appendix 2: Behavioral Health Professional Code of Professional Conduct<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Appendix 3: Mandatory Primary Source Verification Documents<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Appendix 4: Minimum Professional Requirements for Credentialing and Privileging Approval<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Appendix 5: Referral Criteria<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>References<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Plata Physician Professional Clinical Practice Review, Hearing and Privileging Procedures, Pursuant to Order Approving, With Modifications, Proposed Policies Regarding Physician Clinical Competency, July 9, 2008; Plata v. Newsom, et al., Federal Court Case No. C01-1351 published September 4, 2008, Court ordered procedures<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Business and Professions Code, Division 2, Chapter 5, Article 12, Sections 2234 and 2261<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Evidence Code, Division 9, Chapter 3, Section 1157<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Penal Code, Part 3, Title 7, Chapter 2, Section 5068.5<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Code of Regulations, Title 22, Division 5, Chapter 12. (22 CCR 79501 et seq.)<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Department of Corrections and Rehabilitation, Department Operations Manual, Chapter 3, Article 22, Section 33030.3.1, Code of Conduct<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Revision History<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Effective: 10\/23\/2023<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Appendix 1:  New Behavioral Health Professional Credentialing and Privileging Documentation Requirements<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Behavioral health professionals shall complete a credentialing and privileging application. Contents of the credentialing and privileging application package shall include, at a minimum:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Licensure information on any active or inactive licenses.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Work History (gaps greater than six months shall be accounted for). <\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Complete contact information for three professional peer references.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Attestation Questionnaire that includes:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Behavioral health professional attesting to reasons for inability to perform the essential functions of the position with or without accommodation.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Lack of present illegal drug use.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>History of loss of license or criminal convictions.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>History of loss or limitation of privileges or disciplinary activity.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Attestation to the correctness and completeness of the credentialing and privileging application.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Authorization to Release Information Form.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Code of Conduct and Professional Behavior Form.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Correctional Health Care Services (CCHCS) Privilege Request Form.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>The CCHCS Human Resources or Contract Branch shall verify that the behavioral health professional requesting approval of credentials and privileges is the same behavioral health professional identified in the credentialing and privileging documents.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Revision History<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Effective: 10\/23\/2023<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Appendix 2:  Behavioral Health Professional Code of Conduct<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>To provide and promote quality health care, emphasizing professionalism, respect and sensitivity, I, _____________________________, will adhere to the following Behavioral Health Professional Code of Professional Conduct in all interactions with patients, colleagues, other health professionals, and the public.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>The Behavioral Health Professional Code of Professional Conduct (Code) is a series of principles and subsidiary rules that govern professional interactions. The Code applies to all behavioral health professionals, as defined in these policies, in the California Department of Corrections and Rehabilitation (CDCR) involved in clinical and administrative activities.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Failure to meet the professional obligations described below represents a violation of the Code. Items marked with an asterisk (*) indicate behaviors that may also violate federal or state laws.<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Respect for Persons<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>The basis of all human interactions at any CDCR facility will be to treat each other with respect and dignity, no matter what station, degree, race, age, sexual orientation, religion, gender, disability or disease. To accomplish this, I resolve to:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Treat patients, colleagues, other health professionals, and the public with the same degree of dignity and respect I would wish them to show me.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Treat patients with kindness and gentleness.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Respect the privacy and modesty of patients.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not use offensive language, verbally or in writing, when referring to patients or their illnesses.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not use offensive language when interacting with any others in the community.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not harass others physically, verbally, psychologically, or sexually.*<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not abuse one\u2019s power or position for sexual or romantic ends.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not discriminate on the basis of sex, gender, religion, race, national origin, ancestry, color, disability, age, genetic information, marital status, medical condition, political affiliation or opinion, veteran status or military service, or sexual orientation.*<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Respect for Patient Confidentiality<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>The confidentiality of patient communication and information is the basis of professional care. To realize its achievement, and consistent with the nature and confines of providing care in a correctional environment, I resolve to:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not share the medical or personal details of a patient with anyone except those health care professionals integral to the wellbeing of the patient or within the context of an educational endeavor.*<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not discuss patients or their illnesses in public places where the conversation may be overheard.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not publicly identify patients, in spoken words or in writing, without patients\u2019 permission.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not invite or permit unauthorized persons into patient care areas, except as necessary in consideration of the correctional setting where care is provided.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not access or attempt to access confidential data on patients unless the information is necessary for the care of that patient.*<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Honesty and Integrity<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Honesty and integrity are the foundations of good physician-patient and professional-professional relationships. To this end, I resolve to:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Be truthful in verbal and in written communications.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Acknowledge an unanticipated outcome to colleagues and patients when the result of a treatment or procedure differs significantly from what was anticipated.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Protect the integrity of clinical decision-making, regardless of financial impact.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not knowingly mislead others.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not otherwise act dishonestly.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Responsibility for Patient Care<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>To maintain my responsibility for patient care, I resolve to:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Obtain the patient\u2019s informed consent for diagnostic tests or therapies.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not abandon a patient. If unable or unwilling to continue care, I have the obligation to assist in making a referral to another competent practitioner willing to care for the patient.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Follow up on ordered laboratory tests and complete patient record documentation conscientiously.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Coordinate with clinical care teams about the timing of information sharing with patients to present a coherent and consistent treatment plan.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not document items in the medical record that were not performed.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not abuse alcohol or drugs.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Awareness of Limitations and Professional Growth<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Lifelong learning is critical to the competent practice of our profession. To achieve this end, I resolve to:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Be aware of my personal limitations and deficiencies in knowledge and abilities and know when and whom to ask for supervision, assistance, or consultation.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Know when and for whom to provide appropriate supervision.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Avoid patient involvement when ill, distraught, or overcome with personal problems.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Behavior as a Professional<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Patients expect appropriate dress and identification. To fulfill this, I resolve to:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Clearly identify myself and my role to patients and staff.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Dress in a neat, clean, professionally appropriate manner.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Maintain professional composure despite fatigue, professional pressures, personal problems, or the challenges of a correctional setting.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not write offensive or judgmental comments in patients\u2019 charts.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Avoid disparaging and critical comments about colleagues and their medical decisions in the presence of patients.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Responsibility for Peer Behavior<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Peer review, reporting and monitoring is part and parcel of my role as a professional who is allowed the privilege of self-regulation. To this end, I resolve to:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Report breaches of the Code to my supervisor, or another individual in my supervisory chain of command if I believe my supervisor has breached this Code.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Respect for Personal Ethics<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Each individual\u2019s beliefs and ethical principles will be respected. To this end, I resolve to:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Inform patients of available treatment options that are consistent with acceptable standards of medical and nursing care.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Respect patient wishes, including advance directives, consistent with acceptable standards of care.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Respect for Property and Laws<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Adherence to the law is integral to professional behavior. To fulfill my commitment, I resolve to:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Adhere to the policies governing CDCR and its institutions.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Adhere to local, state, and federal laws and regulations.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Not misappropriate, destroy, damage, or misuse state property.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Revision History<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Effective: 10\/23\/2023<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Appendix 3:  Mandatory Primary Source Verification Documents<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>The Credentialing and Privileging Support Unit shall verify the following list of documents, as required according to the behavioral health professional\u2019s classification and credential review type:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Health Care License (i.e., Board of Behavioral Sciences or the California Board of Psychology).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>National Practitioner Data Bank report.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Office of Inspector General exclusions.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Curriculum Vitae (Current within 30 calendar days), including:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Education.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Training.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Work History to include clinical duties and responsibilities (last five years).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Explanations to attestation and disclosure questions.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Signature and date on Authorization to Release Information form.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Signature and date on Affirmation of Information form.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Attestation of Clinical Competence.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>The Hiring or Contract Authority\u2019s recommendation (Attestation) for requested privileges.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Current peer review recommendations and decisions.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>References and recommendations from former California Department of Corrections and Rehabilitation institutions where the behavioral health professional has previously provided services.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>For Clinical Social Workers, Board of Behavioral Sciences approved Clinical Supervisor, if the clinical hours toward independent licensure were completed within past 12 months.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>References and recommendations will be requested from any other relevant individuals who may have firsthand knowledge of the applicant\u2019s ability to competently perform the requested privileges.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Revision History<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Effective: 10\/23\/2023<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Appendix 4:  Minimum Professional Requirements for Credentialing and Privileging Approval<\/strong><br>(Requirements listed shall be reviewed annually and updated for each discipline as needed)<br><em>(This policy only applies to behavioral health classifications such as Chief Psychologists, Senior Psychologist (Specialists), <\/em>Psychologists, <em>Supervising Psychiatric Social Workers, licensed and unlicensed Clinical Social Workers, when employed under Medical Services<\/em>)<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Chief Psychologist<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Behavioral health professional shall meet the following requirements:<\/strong><\/p>\n\t\t\t\t\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong>License<\/strong><\/td><td>Current unrestricted license as a Psychologist issued by the Board of Psychology.<\/td><\/tr><tr><td><strong>Education<\/strong><\/td><td>Completion of a doctoral degree program from an accredited school of Psychology (i.e., Psy.D. or PhD).<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Senior Psychologist, Specialist<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Behavioral health professional shall meet the following requirements:<\/strong><\/p>\n\t\t\t\t\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong>License<\/strong><\/td><td>Current unrestricted license as a Psychologist issued by the Board of Psychology.<\/td><\/tr><tr><td><strong>Education<\/strong><\/td><td>Completion of a doctoral degree program from an accredited school of Psychology (i.e., Psy.D. or PhD).<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Psychologist<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Behavioral health professional shall meet the following requirements:<\/strong><\/p>\n\t\t\t\t\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong>License<\/strong><\/td><td>Current unrestricted license as a Psychologist issued by the Board of Psychology.<\/td><\/tr><tr><td><strong>Education<\/strong><\/td><td>Completion of a doctoral degree program from an accredited school of Psychology (i.e., Psy.D. or PhD).<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Supervising Psychiatric Social Worker<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Behavioral health professional shall meet the following requirements:<\/strong><\/p>\n\t\t\t\t\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong>License<\/strong><\/td><td>Current unrestricted license as a Licensed Clinical Social Worker issued by the California Board of Behavioral Sciences.<\/td><\/tr><tr><td><strong>Education<\/strong><\/td><td>Completion of a master&#8217;s degree program from an accredited school of Social Work, approved by the Council on Social Work Education (CSWE).<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Licensed Clinical Social Worker<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Behavioral health professional shall meet the following requirements:<\/strong><\/p>\n\t\t\t\t\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong>License<\/strong><\/td><td>Current unrestricted license as a Licensed Clinical Social Worker issued by the California Board of Behavioral Sciences.<\/td><\/tr><tr><td><strong>Education<\/strong><\/td><td>Completion of a master&#8217;s degree program from an accredited school of Social Work, approved by the Council on Social Work Education (CSWE).<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Unlicensed Clinical Social Worker<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Unlicensed Provider shall meet the following requirements:<\/strong><\/p>\n\t\t\t\t\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong>License<\/strong><\/td><td>Current unrestricted registration as an Associate Clinical Social Worker ASW issued by the California Board of Behavioral Sciences.<\/td><\/tr><tr><td><strong>Education<\/strong><\/td><td>Completion of a master&#8217;s degree program from an accredited school of social work, approved by the Council on Social Work Education (CSWE).<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Revision History<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Effective: 10\/23\/2023<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Appendix 5:  Referral Criteria<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Additional evaluation by the Hiring or Contracting Authority and the Behavioral Health Professional Peer Review Committee (BHPPRC) is required based on the presence of one or more of the issues identified below. However, if any of the following referral criteria items have previously been reviewed and credentials were approved, they do not need to be reviewed as part of any subsequent credentialing or privileging evaluations if it is the exact same referral criteria item.<\/p>\n\t\t\t\t\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong>License Status<\/strong><\/td><\/tr><tr><td>State health care license presents with a Board Accusation.<\/td><\/tr><tr><td>State health care license presents with a Board Action \u2013 Suspension, Probation<\/td><\/tr><tr><td>Business and Professions Code Section 805 report (exclude reports for non-change of address).<\/td><\/tr><tr><td><strong>National Practitioner Data Bank Report<\/strong><\/td><\/tr><tr><td>Any claims history.<\/td><\/tr><tr><td><strong>Performance<\/strong><\/td><\/tr><tr><td>The supervisor does not endorse the applicant for core or requested privileges.<\/td><\/tr><tr><td>Open or pending peer review action which has resulted in summary suspension of privileges pursuant to a Safety Assessment.<\/td><\/tr><tr><td>Prior peer review proceeding which were initiated, but not completed, or action items resulting from the prior peer review finding remain incomplete.<\/td><\/tr><tr><td><strong>Criminal Background<\/strong><\/td><\/tr><tr><td>Practitioner attests to drug use or criminal activity or background check \u2013 misdemeanor or felony.<\/td><\/tr><tr><td><strong>Miscellaneous<\/strong><\/td><\/tr><tr><td>Federal Office of Inspector General exclusions.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Revision History<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Effective: 10\/23\/2023<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t","protected":false},"parent":253,"template":"","class_list":["post-1289","dom","type-dom","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - 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