Credentialing and Privileging: Fitness For Duty Verification

Fitness for duty, according to the Compliance Manual, refers to “the ability to perform the duties of the job in a safe, secure, productive, and effective manner”.

The HRSA Site Visit Protocol asks, “Do the health center’s privileging procedures require verification of the following for all clinical staff (LIPs, OLCPs, and other clinical staff who are health center employees, individual contractors, or volunteers) upon hire and on a recurring basis: Fitness for duty?” (Chapter 5, Element d, Question 7).

The HRSA Site Visit Protocol directs reviewers to, “Interview individual(s) or committee that completes or has approval authority for privileging of clinical staff to determine: How fitness for duty, immunization, and communicable disease status are verified.”

Also, the HRSA Compliance Manual says, “The following points describe areas where health centers have discretion with respect to decision-making or that may be useful for health centers to consider when implementing these requirements:” … “The health center determines how it assesses clinical competence and fitness for duty of its staff” (Chapter 5, Page 30).

Where reviewers commonly get confused is that the HRSA web resource called the “Health Center Program Site Visit Protocol: Examples of Credentialing and Privileging Documentation” gives an example of fitness for duty documentation. The document suggests this example may be a “Completed statement or attestation of fitness for duty from the provider that is confirmed by a licensed provider designated by the health center”. Some reviewers interpret this to be a requirement that the fitness for duty documentation must be a statement confirmed by a licensed physician designated by the health center.

Additionally, HRSA’s Frequently Asked Questions page also echos that this list includes just examples and is not exhaustive. Another question answers the question more explicitly, saying, “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.

It is important to remember that reviewers are directed to use the HRSA Compliance Manual as the source of truth for how health centers are to be evaluated for compliance. This manual is very clear: The health center has the discretion to determine how it assesses fitness for duty of its staff. It is also clear that all credentialed and privileged staff (LIPs, OLCPs, other clinical staff who are employed, volunteers, or individual contractors) must have their fitness for duty verified.

Some health centers require clinical staff to sign an attestation form while others require a licensed physician to perform a physical assessment and evaluate their fitness for duty. There are pros and cons to each of these ideas. But from a HRSA compliance perspective, the health center must simply define the policy and then execute that process for all credentialed and privileged staff.