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Screening Requirements for Volunteer Practitioners who are Not Licensed Independent Practitioners

03/31/2020

Robert Campbell, PharmD, director, clinical standards interpretation for hospital/ambulatory programs 

Editor’s Note: This blog post is part of The Joint Commission’s daily communication on issues relevant to organizations managing the COVID-19 pandemic. The full list of FAQs is available here. All examples are for illustrative purposes only.

The Joint Commission frequently receives questions as far as what’s required from a human resources standpoint for a volunteer who is NOT a licensed independent practitioner (LIP).

A LIP  is an individual permitted by law and by an organization to provide care, treatment and services without direction or supervision. A LIP operates within the scope of his or her license, consistent with individually granted clinical privileges. When standards reference the term LIP, this language is not to be construed to limit the authority of a LIP to delegate tasks to other qualified health care personnel (for example, physician assistants and advanced practice registered nurses) to the extent authorized by state law or a state's regulatory mechanism or federal guidelines and organizational policy.

However, not all volunteers in an emergency situation are LIPs.

One question we hear frequently is: Are organizations required to confirm health screenings, etc., for volunteers who are not LIPs (nurses, therapists, pharmacists, advance practice nurses, etc.) but are required by law and regulation to have a license, certification or registration when volunteering during a disaster?

No. If an organization has activated its emergency operations plan, there is no requirement to confirm health screenings, criminal background checks, etc., for volunteers who are not LIPs(* ) unless required by state law or facility policy. 

The requirements that address volunteer practitioners who are not LIPs, but who are required by law and regulation to have a license, certification or registration are found in the Emergency Management (EM) chapter of the hospital accreditation manual  at standard EM.02.02.15.  

Disaster responsibilities can only be assigned when an organization’s emergency operations plan has been activated. A disaster is an emergency that, due to its complexity, scope or duration, threatens an organization’s capabilities and requires outside assistance to sustain patient care, safety or security functions. Here are the minimum requirements:
 
Before Assigning Emergency Responsibilities:
 
Obtain a valid, government-issued photo ID (e.g. driver’s license, passport) and at least one of the following:

  • A current picture identification card from a health care organization that clearly identifies professional designation.
  • A current license, certification or registration to practice.
  • Primary source verification (PSV) of licensure(*), certification or registration (if required by law/regulation to practice). NOTE: PSV of licensure, certification or registration (if required by law and regulation in order to practice) of volunteer practitioners who are not LIPs occurs as soon as the disaster is under control or within 72 hours from the time the volunteer practitioner presents him- or herself to the hospital, whichever comes first.
  • Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), the Medical Reserve Corps (MRC), the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), or other recognized state or federal response organization or group.
  • Identification indicating that the individual has been granted authority by a government entity to provide patient care, treatment or services in disaster circumstances.
  • Confirmation by hospital staff with personal knowledge of the volunteer practitioner’s ability to act as a qualified practitioner during a disaster.

Deemed Status
Organizations using Joint Commission accreditation for deemed status purposes may use information from another CMS-certified entity’s PSV of licensure as long as the documentation includes evidence that licensure was verified via PSV or via a Credentials Verification Organization (CVO). 

Organizations that do not use Joint Commission accreditation for deemed status purposes (such as the Veteran’s Affairs, Department of Defense, children’s hospitals) may use information from another like entity as long as the documentation includes evidence that licensure was verified via PSV or CVO. 

During a disaster, the hospital must oversee the performance of each volunteer practitioner who is not a LIP. Based on its oversight of each volunteer practitioner, the hospital determines, within 72 hours after the practitioner’s arrival, whether assigned disaster responsibilities should continue.

Robert Campbell, PharmD, is director, Clinical Standards Interpretation Hospital/Ambulatory Programs and director, Medication Management. Prior to these roles, he served as the pharmacist for Clinical Standards Interpretation in the Division of Healthcare Improvement at The Joint Commission. Campbell also surveys as a field representative for The Joint Commission in the Hospital Accreditation and Critical Access Hospital Accreditation Programs and is a reviewer in the Medication Compounding Certification Program. Prior to joining The Joint Commission, Campbell worked in health care organizations and held leadership positions with oversight responsibilities for performance improvement, accreditation readiness, risk management, infection control, medical staff services, as well as inpatient and outpatient pharmacy services.