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Credentialing Frequency Requirement Reminder

Updated: Jul 18, 2023

A Closer Look at Joint Commission Nursing Care Center Standards:

HR.02.01.04 The organization permits licensed independent practitioners to provide care, treatment, and services.

As a reminder, in November 2022, the Joint Commission revised its requirements regarding the timeframe to evaluate a licensed practitioner’s ability to provide care, treatment, and services from two years to three years, unless applicable law and regulation require a shorter period.

This standard requires primary source verification that the licensed practitioner (LP) is licensed to practice as required by state and/or federal law. This standard requires verification through the National Practitioner Data Bank (NPDB) and for the LP to be privileged at a Joint Commission accredited community. If the LP is not currently privileged at a Joint Commission accredited community, the medical director should oversee the monitoring of the practitioner’s performance and review the results of this monitoring. Due to fact that these standards are so frequently cited, it is critical for communities to keep up with the changing requirements and new information specific to the credentialing standards to remain in full compliance.

Reference: The Joint Commission E-dition (

Cheryl Hahn, LNHA is a Senior Consultant at Achieve Accreditation. Achieve Accreditation has helped skilled nursing providers and assisted living organizations to obtain and maintain their Joint Commission Accreditation for 35 years.

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