Attachment 06 - IHSC Credentialing and Privileging Directive.pdf

U.S. IMMIGRATION AND CUSTOMS ENFORCEMENT

ENFORCEMENT AND REMOVAL OPERATIONS

ICE HEALTH SERVICE CORPS

IHSC CREDENTIALING AND PRIVILEDGING DIRECTIVE

IHSC Directive: 01-44 ERO Directive Number: 11770.3

Federal Enterprise Architecture Number: 306-112-002b Effective Date: February 18, 2020

By Order of the Assistant Director Stewart D. Smith, DHSc, FACHE

1. PURPOSE: This directive sets forth policy and procedures for credentialing and granting clinical privileges for health care providers.

2. APPLICABILITY: This directive applies to all U.S. Immigration and Customs Enforcement (ICE) Health Service Corps (IHSC) personnel, including but not limited to U.S. Public Health Service (PHS) officers, civil service employees, and contract personnel. It is applicable to IHSC personnel supporting health care operations in ICE-owned and contracted detention facilities (CDFs), and IHSC Headquarters (HQ).

3. AUTHORITIES AND REFERENCES:

3-1. Detention of Aliens for Physical and Mental Examination, 8 U.S.C. § 1222.

3-2. Medical Care and Treatment of Quarantined and Detained Persons, 42 U.S.C. § 249(a).

3-3. Medical Examination of Aliens, 42 U.S.C. § 252.

3-4. Detention of Aliens for Physical and Mental Examination, 8 C.F.R. § 232 (1996).

3-5. Inadmissible Aliens and Expedited Removal, 8 CFR § 235.3.

4. POLICY: IHSC ensures its licensed independent practitioners (LIPs), licensed supervised practitioners (LSUPs), and licensed dependent providers (LDPs) are professional, qualified to provide quality care to patients, and work within the scope of their credentials.

4-1. IHSC Credentialing and Privileging Office (ICPO) staff assess and confirm the qualifications of every licensed or certified health care practitioner https://www.law.cornell.edu/uscode/text/8/1222 https://www.law.cornell.edu/uscode/text/42/249 https://www.law.cornell.edu/uscode/text/42/249 https://www.law.cornell.edu/uscode/text/42/252 https://www.law.cornell.edu/cfr/text/8/part-232 https://www.law.cornell.edu/cfr/text/8/235.3 through the credentialing process. This includes, but is not limited to, specialist providers who may perform on-site, or telehealth care, based on appropriate license(s) and certification(s) that the facility retain on-site.

4-2. ICPO staff verify the accuracy of qualifications that licensed or certified individual health care practitioners report. IHSC includes this verification in the credentials portfolio for each provider.

4-3. IHSC privileges its licensed or certified health care practitioners, authorizes a specific scope, and delineates the patient care services the practitioner may provide. The IHSC Medical Executive Committee (MEC) recommends privileges for practitioners, after evaluating the individual’s clinical qualifications and/or performance, to the IHSC Executive Governing Board

(EGB).

1. Advanced practice providers (APPs) include nurse practitioners and physician assistants. Within the IHSC health care system, APPs work as LSUPs under the terms of the IHSC Collaborative Practice and Prescriptive Authority Agreement (CP/PAA).

4-3.1a Federally employed APPs should sign a CP/PAA with a federal physician. Contract employed APPs should sign the IHSC CP/PAA with a contract physician.

4-3.1b IHSC may require contract employed APPs to sign a CP/PAA with a federal physician.

4-3.1c The contract vendor must assure that contract employed APPs comply with all IHSC credentialing requirements, to include completion of the IHSC CP/PAA.

4-4. IHSC credentials specialty providers who perform on-site, telehealth care, as well as community providers who provide specialty referral services.

IHSC credentials specialty and community providers who maintain appropriate license(s) and certifications(s) on file at each facility in which the provider practices.

4-5. IHSC appoints individuals to the medical staff without regard to race, religion, color, age, sex, national origin, disability, or sexual orientation.

5. RESPONSIBILITIES:

5-1. The Deputy Assistant Director (DAD) of Administration establishes and maintains a comprehensive credentialing and privileging program directly related to the delivery of quality medical care, professional ability and judgment, and IHSC’s needs.

5-2. The Deputy Assistant Director (DAD) of Clinical Services/Medical Director provides medical oversight, guidance, and instruction to IHSC providers and allied health professionals who deliver medical, mental, and dental health care to individuals in ICE custody. The DAD of Clinical Services/Medical Director reviews MEC recommendations and further presents all initial and reappointment requests to the EGB. Furthermore, the DAD of Clinical Services/Medical Director brings any proposed disciplinary action to the EGB for final review.

5-3. The IHSC Credentialing and Privileging Office (ICPO) administers the appointment, reappointment, and privileging process for all applicants in accordance with the Medical Staff Bylaws, and in compliance with applicable accreditation and regulatory standards.

5-3.1 ICPO establishes the credentials portfolio for all LIPs, LSUPs, and LDPs at IHSC-staffed facilities before the provider commences patient care duties. ICPO also maintains documentation of each provider’s education, training, experience and competency.

5-3.2 ICPO supports the IHSC Deputy Medical Director (DMD) in coordinating and convening the MEC.

5-4. The IHSC Personnel Unit (IPU) identifies PHS and General Schedule (GS) civil service applicants who require credentialing and privileging, prior to the individual providing consultative services or patient care in IHSC-staffed facilities.

5-5. IHSC discipline chiefs administratively manage and oversee clinical privileging and collaborative agreements for their respective professional disciplines. Discipline chiefs include: unit chiefs for the Behavioral Health Unit, Medical Services Unit, Nursing Services Unit (also Chief Nurse), and Psychiatry Services Unit; Chief Dentist; Chief Pharmacist; and Chief APP.

5-5.1 Discipline chiefs review individual provider application packets for their respective disciplines, delineate the scope of clinical privileges for the provider, and communicate recommendations to the MEC. After IHSC privileges the provider, discipline chiefs monitor the provider’s performances through peer review.

5-5.2 Discipline chiefs develop and implement policies, manuals, and procedures that guide and support the provision of care, treatment, and services.

5-6. The contracting officer representative(s) (COR) communicate IHSC credentialing requirements to the vendor.

5-7. The contract vendor is expected to:

1. Ensure that vendor APPs comply with all IHSC credentialing requirements.

2. Notify IHSC when a contract physician and contract APP agree to the

IHSC CP/PAA.

3. Provide IHSC with a signed copy of the IHSC CP/PAA between the contract physician and contract APP.

4. Ensure contract APPs remain in compliance with state licensure requirements. The contract vendor must alert IHSC immediately of any contract APP lapses in state licensing board requirements.

5. Provide adequate personnel to maintain contract physician to contract APP staff ratios, in adherence with state licensing board requirements.

6. Ensure alternate physician coverage is available for contract APPs. At IHSC’s discretion, alternate coverage may include a federal physician.

7. IHSC reserves the right to deny contract physicians from entering a CP/PAA or limit the number of CP/PAAs based on state requirements.

IHSC may require contract APPs to enter a CP/PAA with federal physician(s).

5-8. The Medical Executive Committee (MEC), in accordance with the Medical Staff Bylaws, serves as the executive committee for IHSC’s medical staff.

The MEC reviews credentials and delineates clinical privileges and/or scopes of practice for IHSC medical staff.

5-8.1 The DMD, or designee, chairs the MEC and ensures that new hires undergo a credential verification process that confirms current licensure, certification, and/or registration.

5-8.2 MEC voting members include IHSC discipline chiefs and specialty consultants, as required.

5-8.3 Non-voting members include chiefs for ICPO and the IHSC Personnel Unit.

5-8.4 The MEC meets twice a month to review medical staff credentials portfolios and to approve/disapprove initial and/or reappointments.

Upon approval, the MEC minutes are forwarded to the IHSC EGB for final review.

5-8.5 The MEC reviews initial and reappointment requests (to include peer reviews) and decides whether to recommend the provider for privileges. The MEC presents their recommendations to the DAD of Clinical Services/Medical Director, who further reviews and recommends approval to the EGB. In the event the MEC disapproves a reappointment request for privileges, the DAD of Clinical Services/Medical Director, as outlined in the bylaws, is responsible for notifying the EGB of the MEC’s disapproval.

5-9. The Deputy Medical Director (DMD) leads the IHSC medical staff and is the MEC chairperson. The DMD assists the DAD of Clinical Services/Medical Director in overseeing and efficiently managing the clinical and medical services that IHSC provides to detainees. The DMD is actively involved in medical credentialing and privileging, and in determining the scope of practice for LIPs, LSUPs and LDPs.

5-10. The IHSC Executive Governing Board (EGB) is the final authority and decision-making body in the privileging process. The EGB comprises the Deputy Assistant Director (DAD) of Clinical Services, DAD of Health Systems Support, DAD of Health Care compliance, DAD of Administration, and the IHSC Chief of Staff.

5-11. The EGB reviews the privileging recommendations that the MEC submits.

The EGB may concur, non-concur, or defer and consult with the MEC for additional information.

6. DEFINITIONS: The following definitions apply for purposes of this directive:

6-1. Credentialing – The process of validating a professional’s eligibility for medical staff membership and/or privileges. IHSC credentials medical staff based on academic preparation, licensing, training, certifications, and performance.

6-2. Privileging – The process of authorizing a licensed or certified health care practitioner's specific scope of patient care services. IHSC privileges medical staff in conjunction with an evaluation of the individual’s clinical qualifications and/or performance.

6-3. Licensed independent practitioner – IHSC-privileged providers who are physicians, dentists, psychologists, and licensed clinical social workers.

6-4. Advanced practice provider – IHSC-privileged providers who are nurse practitioners and physician assistants practicing under a collaborative practice agreement.

6-5. Licensed supervised practitioner – Licensed supervised practitioners are practitioners who work under the supervision of a LIP; within IHSC-staffed facilities. LSUPs include nurse practitioners, physician assistants, and clinical pharmacists.

6-6. Licensed dependent provider – Licensed dependent providers are providers who graduate from an approved, accredited program located in the U.S. territories or District of Columbia.

6-7. Primary source verification – The process of verifying a specific credential by speaking with or reviewing original materials published by the organization.

6-8. Secondary source verification - The process may include credential verification from another facility, copies of a credential verification, or confirmation from a source that verified the credential. Secondary sources should only be used if the primary source no longer exists, in accordance with facility policy and accreditation standards. Per accrediting standards and facility regulations, secondary sources are unacceptable for many data elements.

6-9. Medical Executive Committee - The primary governance committee for the IHSC medical staff. The MEC creates the criteria for medical staff appointment and reappointment. The MEC is also responsible for adopting and implementing medical staff policies and procedures.

6-10. IHSC Executive Governing Board -The purpose of the EGB is to advise the Assistant Director on all strategic, administrative, and operational matters relating to IHSC. The EGB comprises the Deputy Assistant Director (DAD) of Clinical Services, DAD of Health Systems Support, DAD of Health Care compliance, DAD of Administration, and the IHSC Chief of Staff.

7. PROCEDURES:

7-1. ICPO notification.

7-1.1 IPU notifies ICPO of any new federal employee provider who requires credentialing, verification, and privileging.

7-1.2 The COR notifies ICPO of a new contract employee who requires credentialing, verification, and privileging.

7-2. ICPO contacts the provider to request documentation.

7-3. All providers must submit required documentation to ICPO.

7-3.1 Federal employee LIPs and LSUPs must submit documentation of the following to ICPO prior to starting patient care duties:

7-3.1.a Education.

7-3.1.b Training and experience.

7-3.1.c References.

7-3.1.d Competency, including unrestricted licensure and certification.

7-3.2 Contract employee LIPs and LSUPs must submit documentation of the following to ICPO prior to starting patient care duties:

7-3.2.a Education, training and experience.

7-3.2.b Professional references.

7-3.2.c Background check.

7-3.2.d Sanctions or disciplinary actions of state boards (where applicable).

7-3.2.e Previous employers.

7-3.2.f National Practitioner Data Bank query.

7-3.2.g Competency, including licensure and malpractice insurance certifications.

7-3.3 ICPO conducts the National Practitioner Data Bank query and reviews sanctions or disciplinary actions of state boards for all LIPs, LSUPs, and LDPs.

7-3.4 ICPO verifies all required credentialing documents through primary sources. This verification is electronic or in writing. ICPO documents verification in the credential’s portfolio for each provider.

7-3.5 Each employee has the right to review or receive a copy of any information in their credentials portfolio, if requested.

7-4. IHSC review of the credentials portfolio.

7-4.1 ICPO completes the credential verification process to confirm unrestricted licensure, certification, and registration, then sends the credentials portfolio to the discipline chiefs for review.

7-4.2 The discipline chiefs review the electronic credentials portfolio and make a recommendation to the MEC for approval or disapproval.

7-4.3 The MEC votes to approve or disapprove the electronic credentials portfolio and makes a recommendation to the EGB through the DAD of Clinical Services/Medical Director. IHSC bases its decision to hire any LIP or LSUP based upon the MEC’s review of a completed, verified credentials portfolio.

7-4.4 The EGB reviews the MEC minutes and concurs or non-concurs with the MEC recommendation. The EGB notifies ICPO of its decision.

7-4.4.a When IHSC does not approve a provider privileges, ICPO generates a letter from the discipline chief to the provider stating the reason for denial.

7-4.4.b When IHSC approves provider privileges, ICPO generates and sends an approval letter to the provider confirming the verification of their credentials and award of IHSC privileges. Qualified LIPs and LSUPs must not perform tasks beyond those permitted by their credentials.

7-4.4.c Upon initial approval, IHSC grants the provider privileges for 12 months.

7-4.4.d Upon requesting reappointment of privileges, the discipline chief conducts a peer review assessing the provider’s performance. The MEC considers peer reviews as part of the reappointment process

7-5. Maintenance of credentials and privileges.

7-5.1 LIPs, LSUPs, and LDPs working in IHSC-staffed facilities, and the respective clinical director and/or health services administrator (HSA) have access to each provider’ credentials portfolio at the local site. However, ICPO retains primary responsibility for all credentialing and privileging documentation.

7-5.2 ICPO completes the initial credentialing process for LIPs, LSUPs, and LDPs assigned to IHSC medical staff. This process is completed only once.

7-5.3 LIPs, LSUPs, and LDPs must submit updated licenses and documentation to ICPO, as well as their HSA and assistant HSA before the items expire.

7-5.4 The initial credentials and privileges for IHSC medical staff are provisionally valid for 12 months. Subsequent reappointments are valid for two years.

7-5.4.a ICPO reviews the annual peer review report for each LIP and LSUP as part of the privilege reappointment process. Providers must have a peer review report on file that is dated within one year of the privilege expiration date.

7-5.4.b IHSC Directive 01-46, Multidisciplinary Peer Review outlines the multidisciplinary peer review process.

7-5.5 ICPO staff members monitor and maintain the credentialing process.

8. HISTORICAL NOTES: This supersedes the previous Operations Memorandum 16-012, Credentials Portfolio Directive and Credentials/Privileging Appendix A regarding the collection and maintenance of providers’ paper files by IHSC field sites. The DMD and discipline chiefs are no longer responsible for solely executing the privileging process.

8-1. Summary of Changes. The DAD of Administration designated ICPO as the primary credentialing and privileging office. ICPO maintains all credentialing and privileging portfolios at IHSC HQ, to include those of LDPs.

8-1.1 The DAD of Administration expanded the privileging process, established the MEC, and included the EGB.

8-1.2 ICPO now stores all credentials portfolios on a secured SharePoint Dashboard for Credentialing/Privileging.

9. APPLICABLE STANDARDS:

9-1. Performance-Based National Detention Standards (PBNDS): Medical Care

9-1.1 Part 4: Care; 4.3 Medical Care; B. Designation of Authority.

9-2. Family Residential Standards (FRS):

9-2.1 Part 4: Care; 4.3 Medical Care; 7. Medical Personnel.

9-3. American Correctional Association (ACA):

9-3.1 Performance-Based Standards for Adult Local Detention Facilities, 4th:

4-ALDF-4D-05, Credentials.

9-4. National Commission on Correctional Health Care (NCCHC), Standards for Health Services in Jails (2018): J-C-01 Credentials.

10. RECORDKEEPING: IHSC creates, receives, stores, retrieves, accesses, retains, and disposes of credential and privilege records in accordance with ICE Records and National Archives and Records Administration approved records retention schedules. Contact the IHSC Records Liaison for further information or guidance.

11. NO PRIVATE RIGHT STATEMENT: This directive is an internal policy statement of IHSC. It is not intended to, and does not create any rights, privileges, or benefits, substantive or procedural, enforceable against the United States; its departments, agencies, or other entities; its officers or employees; or any other person.

12. Point of Contact: Senior Credentialing Specialist, IHSC Credentialing and Privileging Office.