Licensing and Certification
Introduction
Date
of Last Review 5/6/07
SME: Director of Personnel Systems Management
This topic provides information about licensing and certification.
Importance
A
fully trained and competent staff is essential to quality treatment. Licensing
and certification represent recognized standards of demonstrated competency.
Therefore, verification of required licensing and/or certification, as established
in the university's job descriptions, is imperative.
Manager
Responsibility
Department
managers are responsible for ensuring that proof of licensing and/or certification
is obtained from each new employee upon hire. Departmental managers will take
necessary actions for ensuring employees who do not possess proper registrations/certifications/licensures
are not followed at work at any time.
Employee's Responsibility
Employees whose positions require license,
certifications, or registrations will be responsible for providing documented
proof of licensure, certification or registration renewals prior to actual expiration
of their license, certification or registration which will include proof of the
new expiration date. If the expiration date falls on a weekend or holiday, the
employee is expected to provide such proof at the beginning of the last business
day prior to the expiration date. The documented proof of licensure, certification
or registration must also be verifiable by Personnel Systems Management through
direct contact with the licensing board. Failure to provide such documented proof
of a current licensure, certification, or registration or the inability for Personnel
Systems Management to obtain verification through the licensing board by the expiration
date last verified directly through the board, will automatically result in disciplinary
action up to and including termination for the employee. It is the responsibility
of the employee to ensure they have met all renewal requirements and that documented
proof of renewal including a new expiration date is provided to the hospital.
Staff are expected to anticipate processing periods needed by their licensing
board to produce a hard copy of their renewal and submit renewal requirements
with sufficient time to allow for such processing periods and time to receive
the renewal prior to expiration. Reminders of impending expiration dates by the
departmental manager or Personnel Systems Management to the employee is merely
a courtesy.
Documentation
The
Personnel Systems Management will record the following in the employee's departmental
personnel folder:
 | Initial verification of employee's licensing and/or certification including the state, number, type, and expiration date of the license
|
|
Continued verification upon month of expiration |
|
All verifications will be made directly with the licensing boards and
documented by a member of the Personnel Systems Management and placed in
the employee's personnel file. |
Reference
See the Medical Staff Bylaws for procedures for the verification of physician license.
Related standards
The Joint Commission Human Resources Standards
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