Chapter 5: Clinical Staffing – Communicable Disease and Immunization Verification

The Health Center Program HRSA Site Visit Protocol: Credentialing and Privileging File Review Resource, Updated August 1, 2019 says 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 be implying that a TB test or screening is required yet in the same document, it 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.

Though further clarification from HRSA may be helpful, our most conservative recommendation is to:

  • Define the health center’s credentialing and privileging requirements for communicable disease screening and immunizations in the health center’s Credentialing and Privileging Policy.
  • Include TB test or screening (e.g., copy of PPD testing or chest x-ray) as a required element of credentialing and privileging.
  • Ensure all credentialing and privileging files contain current copies of documented TB tests or 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.