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Hospital Accreditation

Contract Staff Providing Care
Posted by
on 7/5/2022 10:00:00 AM
Here is a scenario that happens all too often. Hospital A is desperate for a night shift nurse. They contact their local staffing agency and Nurse Smith is sent over. Nurse Smith has never been to your facility, so the agency sends over her packet. Included in the packet is her licensing info, health clearances and competencies. The unit is busy, so no one looks at the packet. The charge nurse gives Nurse Smith a quick orientation and off she goes. Unfortunately, her license had expired 2 weeks previously and no one had caught it. So now they have a nurse working with an expired license which can lead to hefty fines, and possible probation. Yes, that nurse holds responsibility for maintaining their license, but the organization holds responsibility in ensuring its staff are compliant with laws as well. CMS regulation §482.23(b)(6) indicates that the hospital and director of nursing are responsible for the clinical activities of all nursing personnel regardless of whether they are hospital employees, contracted staff, or volunteers. This article aims to answer question you may have regarding CMS regulations regarding contract staff and your organization.
Do they need to have a job description on file?
There must be evidence that the staff have been provided with a job description that outlines what the responsibilities of their job is and what duties they will be expected to perform. This may either be from the organization, or the contract service provided it is comparable to the organization’s form.
What about orientation?
The organization is responsible for ensuring all contract staff have been oriented to certain key components prior to or at the beginning of their first shift. These include the hospital and the unit or units they will be working on. The hospital must also be able to demonstrate they have been educated on key safety content in their area prior to providing care. Orientation should include nursing services and procedures, infection control practices such as hand hygiene, isolation signage, universal precautions, and blood-borne pathogens.
Orientation should also include emergency response procedures such as fire and disaster response, key safety policies and procedures and any other information required by state law.
Ok, but what about licensing/certifications/credentials?
When you have contract staff, you must verify their credentials (licensure or certification) just as you would your own staff. This may be in primary source verification or by requiring the contracted organization to furnish this. Either way, it must be a primary source verification. A copy of the license or certificate is not sufficient. Employee health?
An up-to-date file should be maintained that includes all health clearances, immunizations and other standard information that would be kept on your employees. And don’t forget about COVID! I mean, how could you, really? Any individual who provides care, treatment, or other services for the hospital and or its patients, whether under contract or other arrangement must have documented evidence of compliance with the recent vaccine mandate. They are to be included in your organization’s overall compliance percentage. What kind of competencies do they need?
Basically, any competencies you would require of your core staff. Think of things that are not necessarily a part of their core training. These can include bedside glucose monitoring, IV pumps, moderate sedation, any specialized equipment, specialized cleaning techniques, restraints, blood transfusion, etc. Things that carry an inherent high risk of safety to patients. These can also be provided by the contracting agency as a part of their competencies. You also must have evidence they have had an evaluation of their performance.
Now say for instance, a surgeon wants to bring in her personal scrub technician. The hospital must demonstrate that the scrub tech has all competencies and licensure/certification verification prior to assisting the surgeon. The hospital should maintain a file demonstrating the steps have been performed just as they would be for any employee of the hospital. If a Licensed Independent Practitioner brings in a non-employee to provide care and/or treatment to patients, they must have the same qualifications and competencies of employees performing the same or similar services. Most often, organizations provide a packet of information to contract staff. Have the contract employee sign an attestation page indicating they are responsible for the content of the packet and provide an orientation to the care environment. Keep files on your contract employees just as you would your own.
TJC Acute Care Standards, Standard HR.01.01.01 – DEFINING QUALIFICATIONS OF STAFF
CMS Conditions of Participation. Rev 2.20
CIHQ Acute Care Accreditation Standards Rev 2/22
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