SOP 508.04: Credentialing Verification and Privileging

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Credentialing Verification & Privileging|Policy Name: Credentialing Verification & Privileging|Policy Name: Credentialing Verification & Privileging|
|Policy Number: 508.04|Effective Date:12/14/2020|Page Number: 1 of 4|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

I. Introduction and Summary:

It is the policy of the Georgia Department of Corrections (GDC) to maintain strict
compliance with credentialing requirements for mental health care providers in
accordance with State Law and the State Personnel Department.

II. Authority:

A. O.C.G.A.: 43-10A-11

B. GDC Board Rule: 125-4-4.02;

C. All professional Licensing Boards operating under the Office of the Georgia

Secretary of State;

D. NCCHC Adult Standard: P-18;

E. NCCHC Juvenile Standard: Y-18;

F. GDC SOP: 508.07 Clinical Supervision; and

G. ACA Standard: 5-ACI-6B-03 (ref. 4-4382, Mandatory).

III. Definitions:

A. Credentialing - A review process whereby the qualifications of mental health

primary care professionals (e.g., licensure, certification, training, experience)
required for employment are verified and maintained in a credentialing file.

B. Mental Health Care Provider - Mental health staff member who is granted specific

clinical privileges.

C. Privileging - The process of the clinical director/psychologist authorizing each

mental health counselor or mental health technician's specific scope of mental health
care services based on their credentials.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Credentialing Verification & Privileging|Policy Name: Credentialing Verification & Privileging|Policy Name: Credentialing Verification & Privileging|
|Policy Number: 508.04|Effective Date:00/00/0019|Page Number: 2 of 4|
|Authority:
Commissioner
|Originating Division
Health Services Division
(Mental Health)|
Access Listing:
Level I: All Access|

IV. Statement of Policy and Applicable Procedures:

A. Credentialing:

1. When hiring, the mental health unit manager/designee, the statewide mental

health director/designee along with an appropriate vendor administrative staff,
when applicable, will jointly share the responsibility for verification of
credentials.

2. Verification of current credentials for employees will be maintained by the

facility mental health unit manager.

3. Employees governed by the State of Georgia's Professional Regulatory Boards

will be responsible for keeping credentials current. This includes acquiring any
continuing education credits that may be mandated.

4. A credential review update will be conducted in January of each year and

whenever needed by the mental health unit manager/designee. The mental health
unit manager will maintain the results of the credential review update on file.

5. The mental health unit manager maintains the responsibility for the annual

credential review.

6. The credential review process includes but is not limited to the following areas:

a. Copy of the current professional license(s), when applicable;

b. Verification of malpractice insurance, when applicable;

c. Copy of degree(s);

d. Internship certification, when applicable;

e. Residency certification, when applicable;

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Credentialing Verification & Privileging|Policy Name: Credentialing Verification & Privileging|Policy Name: Credentialing Verification & Privileging|
|Policy Number: 508.04|Effective Date:00/00/0019|Page Number: 3 of 4|
|Authority:
Commissioner
|Originating Division
Health Services Division
(Mental Health)|
Access Listing:
Level I: All Access|

f. Board certification(s), when applicable;

g. Curriculum vitae;

h. Pre-employment references;

i. GDC background check;

j. Supervisor documentation;

k. Continuing education credits, when applicable; and

l. CPR certification, when applicable.

7. All mental health primary care providers remain responsible for notifying the

mental health unit manager and/or the warden/superintendent's office
immediately if their license to practice has been revoked, restricted, or is under
investigation for any reason.

8. The mental health unit manager/designee is responsible for notifying the

warden/superintendent of the change in a mental health primary care provider's
credentials (revocation, suspension, restriction, or investigation).

9. Verification of current credentials and job descriptions are on file in the facility.

B. Privileging:

1. The clinical duties of all mental health staff will be assigned by a clinical

supervisor, using the Request for Clinical Privileges (Attachment 1 - form M1001-01) (upon hire and every January), who in conjunction with the mental health
unit manager and treatment team has the authority to restrict or place conditions
on staff's clinical duties (see SOP 508.15 Mental Health Evaluations).

2. A description of duties considered to be clinical can be found in Description of

Clinical Functions (Attachment 2 - form M10-01-02). Refer to Criteria for

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Credentialing Verification & Privileging|Policy Name: Credentialing Verification & Privileging|Policy Name: Credentialing Verification & Privileging|
|Policy Number: 508.04|Effective Date:00/00/0019|Page Number: 4 of 4|
|Authority:
Commissioner
|Originating Division
Health Services Division
(Mental Health)|
Access Listing:
Level I: All Access|

Clinical Privileges (Attachment 3 - form M10-01-03) for determining the criteria
by number and letter to justify approving/disapproving an applicant's clinical
privilege request.

3. Psychiatrists, licensed psychologists, licensed clinical social workers and

Advance Practice Registered Nurses (APRNs) will be fully privileged upon hire.

4. An active privileging file pertaining to the clinical privileges granted each mental

health provider will be kept by the mental health unit manager.

5. The mental health unit manager and the clinical supervisor will jointly review

privileging files on an annual basis (every January) to ensure compliance.

V. Attachments:

Attachment 1: Request for Clinical Privileges (M10-01-01)
Attachment 2: Description of Clinical Functions (M10-01-02)
Attachment 3: Criteria for Clinical Privileges (M10-01-03)

VI. Record Retention of Forms Relevant to this Policy:

Upon completion, the original of Attachment 1 shall be placed in the applicant’s/staff
member’s credentialing/privileging file and a copy will go to the applicant/staff member.
Attachments 2 and 3 shall be utilized until obsolete or replaced.