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Credentialing Standards

Updated: Jun 27, 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.

HR.02.01.05- The organization may permit licensed independent practitioners to provide care, treatment, and services on a temporary basis.

HR.02.01.07- Licensed independent practitioners who provide on-call coverage for attending licensed independent practitioners are competent.

HR.02.02.01- The organization provides orientation to physicians and other licensed practitioners.

Before permitting licensed independent practitioners (LIP’s) to provide care, treatment, and services, a skilled nursing organization must determine whether LIP’s are capable of providing residents with high quality care. This is determined through the credentialing process in which the organization obtains, verifies, and assesses the qualifications of the practitioners. The credentialing process is completed prior to allowing the LIP’s to provide care and at least every two years thereafter.

The steps taken during the credentialing process include verifying through a primary source that the licensed independent practitioner is appropriately licensed to practice as required by state and/or federal law, querying the National Practitioner Data Bank (NPDB), and determining if the LIP is privileged at a Joint Commission-accredited organization. The organization thoroughly documents and reviews their findings to determine if the LIP is competent to provide care, treatment, and services.

Skilled nursing organizations are at risk of receiving Joint Commission survey recommendations when proper protocol is not followed, and proper documentation is not kept up to date for each LIP. For instance, common credentialing recommendations include not running the NPDB query, not verifying the LIP’s license through a primary source, and not completing the credentialing reappointment every two years.

Arely Herrera Franco, MSW, LCSW 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 over 30 years.


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