Chapter 5: Clinical Staffing – Communicable Disease and Immunization Verification

The Health Center Program HRSA Site Visit Protocol: Credentialing and Privileging File Review Resource states that “The health center determines communicable disease screening protocols for its health care workers as well as what sources will be accepted as verification, and circumstances if any, when providers can decline to present for testing or screening” and that, “Health centers will determine what vaccinations are required for their clinical staff based on state requirements and other resources.”

However, in the same document, it states as an example that, for communicable disease status they should provide a “Copy of completed TB test or screening (e.g., copy of PPD testing or CXR) and any other communicable disease testing or screening as determined by the health center (e.g., Hepatitis).” This seems to imply that a TB test or screening is required, yet the same document states that the health center may determine communicable disease screening. Some reviewers have been reading this document and declare that a TB screening is required. However, this is given as an example of documentation for this area.

HRSA’s FAQ also states that “the Examples of Credentialing and Privileging Documentation resource is intended to complement the Site Visit Protocol by providing common examples of credentialing and privileging documentation methods and sources. This resource helps with the review of a health center's clinical staff file samples. The examples in the Examples of Credentialing and Privileging Documentation resource are not exhaustive. The health center determines the specific documentation it uses to credential and privilege health center providers, as long as there is consistency with the Health Center Program Compliance Manual and the health center's own procedures”.

In short, health centers should:

• Review any local or state requirements for healthcare worker immunizations or communicable disease screenings.

• Review the CDC’s current immunization recommendations for healthcare workers and decide as a team which immunizations your health center wishes to encourage and/or require.

• Clearly define the health center’s credentialing and privileging requirements for communicable disease screening and immunizations in the health center’s Credentialing and Privileging Policy.

• Ensure all credentialing and privileging files contain current copies of documented immunization or communicable disease screenings demonstrating continuous HRSA compliance.

As your health center works toward a state of HRSA continual compliance, leaders should review the current HRSA Compliance Manual and the HRSA Site Visit Protocol as a reference to guide their work. When reviewing your credentialing and privileging systems, review the HRSA Program Requirements and consider having some outside “eyes” on your documentation. This can be done by performing a health center mock site visit or inviting colleagues from other health centers to share best practices with you. As the Health Resources and Services Administration (HRSA) and the Bureau of Primary Health Care (BPHC) continue to work to align their key guidance documents, following our conservative recommendations will help you move toward continuous compliance as an FQHC of excellence.

Updated: October 28, 2024