LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 613.01 Credentialing / Re-credentialing of LAC DMH Clinician Employees
 
  PROCEDURES
  1. Processing Credentialinq Applications
     
    1. The Department of Mental Health-Human Resources Bureau (DMH-HRB) shall provide the DMH Office of the Medical Director (OMD) with the names of ail prospective employee credentialing applicants.
       
    2. OMD shall notify clinician employees/prospective employees of the credentialing/re-credentialing requirement.
       
    3. The CC shall send a credentialing/re-credentialing application to each credentialing/re-credentialing candidate.
       
      1. Prospective clinician employees shall begin the credentialing process once they are selected from a certification list for possible LAC-DMH employment. This shall occur concurrently with the submission of the personnel action request. The prospective employee must successfully complete the credentialing process before a formal offer of employment can be authorized
         
    4. It is the responsibility of the CC to follow up with each credentialing applicant in order to ensure that the applicant submits a completed application as well as:
       
      1. A current curriculum vitae; and
         
      2. A written explanation of any gaps in employment history greater than six months; and
         
      3. A detailed explanation of any affirmative answer to an attestation question.
         
    5. It is the responsibility of each credentialing applicant to provide a completed credentialing application with any required supporting documentation to the CC within all specified time frames.
       
      1. A prospective clinician employee who does not respond to the CC's request for submission of the credentialing packet within 15 calendar days of the date of the CC's request shall not be considered for employment until his/her packet is complete.
         
      2. A clinician employee who does not respond to the CC's request for submission of the credentialing/re-credentialing packet within 15 calendar days of the date of the CC's request shall receive a reminder e-mail from OMD.OMD will refer all employee credentialing applicants who do not respond to OMD's reminder e-mail by the specified due date to DMH-HRB.
         
  2. Minimum Criteria for Accreditation by LAC-DMH
     
    1. Once a completed credentialing packet is received, the CC shall begin the credentialing process by verifying the following minimum criteria:
       
      1. Discipline specific education and license criteria as outlined below.
         
      2. Absence of current sanctions (i.e., exclusions or suspensions) by federal or State agencies
         
  3. Evaluation of Minimum Criteria for Prospective Clinician Employee
     
    1. The CC shall review the credentialing materials for each prospective clinician employee to determine if minimum criteria are met.
       
    2. The CC shall notify DMH-HRB when a prospective clinician employee's credentialing materials do not meet minimum criteria.
       
      1. The CC shall notify the prospective clinician employee of any criteria that were not met and shall indicate that further consideration of the application will not occur until all minimum criteria have been satisfied.
         
      2. An applicant who is a prospective employee has no right of appeal when the application is denied due to failure to meet minimum credentialing criteria.
         
  4. Evaluation of Minimum Criteria for Clinician Employee
     
    1. The CC shall review the credentialing materials for each clinician employee to determine if minimum criteria are met.
       
      1. The CC shall notify DMH-HRB when a clinician employee's credentialing materials do not meet minimum criteria.
         
      2. The CRC shall conduct a mandatory administrative review when there is an adverse determination for a clinician employee regarding minimum criteria The CC shall notify any clinician employee who does not meet minimum criteria of the criteria that were not met and of his/her right to submit a written response that shall be included in the administrative review by the CRC.
         
  5. Additional Criteria for Accreditation by LAC-DMH
     
    1. To be employed by LAC-DMH, a credentialing applicant must be evaluated with regard to the following additional criteria:
       
      1. There should be no history of involvement in malpractice suits, arbitrations or settlements in the past five years that is not in accordance with the criteria set forth below. Waiver of this requirement can be made only by review of the CRC. Evidence must exist that any such history does not adversely affect the applicant's ability to perform his/her professional duties.No more than three malpractice lawsuits, arbitrations and/or settlements within the last five years that are greater than $100,000 in aggregate.No single judgment, arbitration or settlement within the last five years that is greater than $100,000.No licensing board discipline as a result of a malpractice action within the last five years.
         
      2. There can be no history within the most recent ten years of disciplinary actions affecting the applicant's professional license or other required certification. Waiver of this requirement can be made only by review of the CRC. For a waiver to be considered, there must be evidence that any such history does not adversely affect the applicant's ability to perform his/her professional duties.
         
      3. There should be no history of sanctions by federally-funded health care programs, including Medicare/Medi-Cal and any other public regulatory agency. Waiver of this requirement can be made only by review of the CRC. There must be evidence that the individual is not currently sanctioned and that any such history does not adversely affect the applicant's ability to perform his/her professional duties or the ability of LAC-DMH to bill federally-funded agencies for the employee's services.
         
      4. Any history of alcohol or chemical dependency or of substance abuse must be reported on the questionnaire/attestation portion of the credentialing/re-credentialing application. There must be evidence that any such history does not adversely affect the applicant's current ability to perform his/her professional duties. 
         
      5. There can be no physical or mental condition that would impair the applicant's ability, with reasonable accommodations, to provide professional services within his/her area of practice. without posing a direct threat to the health and safety of others. There must be evidence that any such condition does not adversely affect the applicant's current ability to perform his/her professional duties.
         
      6. Affirmative responses to the attestation questions shall be reviewed by the CRC. Evidence must exist that the issue resulting in such finding does not adversely affect the applicant's ability to perform his/her professional duties.
         
  6. Evaluation of Additional Criteria
     
    1. The CC shall review the credentialing materials for each credentialing applicant to determine if additional criteria are met.
       
    2. Credentialing applications shall be referred to the CRC when:
       
      1. A credentialing applicant fails to meet the criteria set forth in Sections 5.1 and/or 7.1; and/or
         
      2. Any aspect of the application process raises concern regarding practice history or personal/professional characteristics that may influence the quality of care rendered by the applicant; and/or
         
      3. A current clinician employee presents special circumstances, as defined in Section 3.5 of the Credentialing Review Committee Policy 613.02.
         
    3. When there is an adverse finding, the CC shall notify the credentialing applicant of the criteria that were not met and of the applicant's right to submit a written response that shall be considered in the administrative review by the CRC.
       
      1. Referral to the CRC may result in a recommendation to deny credentialing and employment in accordance with Policy No. 613.02.
         
    4. OMD shall notify the credentialing applicant and DMH-HRB if credentialing is denied
       
  7. Approval for Accreditation by LAC-DMH
     
    1. A credentialing applicant is approved for credentialing after the following requirements have been met:
       
      1. Application is completed, accurate, signed and dated; and
         
      2. All required documents are included with the application form and are current; and 
         
      3. All criteria listed are met; and
         
      4. All criteria listed in additional section are met or waived.
         
    2. When both minimum and additional criteria are met, the CC's summary report of the applicant's credentials is brought before the CRC for administrative review. The CRC makes a recommendation to the Medical Director to approve or deny accreditation of the applicant.
       
    3. OMD shall notify the credentialing applicant and DMH-HRB of the effective dateof accreditation.
       
    4. The CC shall make all of the accredited applicant's original credentialing materials available to DMH-HRB