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SANTA BARBARA COUNTY ~ DEPARTMENT OF Behavioral Wellness ~ ~ A System of Care and Recovery Pa g e 1 of 10 Departmental Policy and Procedure Section Sub-section Policy Quality Care Management General Policy# 4.015 Staff Credentialing and Licensing 4~c Director's Approval 1 //~~...,...,..,...-...,,...,...::.,-----'------------- A Ii c e Gleghorn, PhD Chief Quality Care/ Strategy Officer Supersedes: Suzanne Grimmesey, MFT #34 - Staff Credentialing and Licensing 7 Effective: 7/1/2008 Last Revised: 6/13/2018 Date C d:s // r Date (.a..--~ - (3 Audit Date: 6/13/2021 1. PURPOSE/SCOPE 1.1. To establish standards and procedures for staff credentialing and licensing in accordance with state and federal regulatory requirements. 1.2. This policy applies to all of (hereafter "the Department") employees and contracted community-based organizations (CBOs) that provide mental health services and substance use disorder services. 2. DEFINITIONS The following terms are limited to the purposes of this policy: 2.1. Staff - an individual who (a) is employed by or performing services on behalf of the Department or a contracted CBO, or an individual contracted directly with the Department, including locum tenens physicians, and (b) whose duties involve submission of claims, input of information, or access to information through the Department electronic medical records system. 2.2. Credentialing means the process through which QCM: 1. Completes Eligibility Verification; 2. Determines the level of qualification and scope-of-practice category, including professional suffix; 3. Determines appropriate facility-program associations; and 4. Communicates the above information to the Department Management Information Systems (MIS), the immediate supervisor, and Medical Records.

2.3. License Verification - the process through which the Department determines whether or not an individual holds a current, valid, and verifiable professional license, registration, or waiver. 2.4. Licensed staff - individuals who assert that he/she currently holds, and/or whose duties require that he/she hold, a license shall provide a copy to QCM that shows the current expiration date from any of the following California agencies: 1. Medical Board 2. Physician Assistant Board 3. Osteopathic Medical Board 4. Board of Psychology 5. Board of Behavioral Sciences 6. Board of Registered Nursing 7. Board of Vocational Nursing and Psychiatric Technicians 8. Board of Pharmacy 2.5. Certified staff- individuals who assert that he/she currently holds, and/or whose duties require that he/she hold, a certification shall provide a copy to QCM that shows the current expiration date from any of the following California agencies: 1. California Consortium of Addiction Program and Professionals (CCAPP) 2. California Association of DUI Treatment Programs (CADTP) 2.6. Registered staff - individuals who currently hold, and/or whose duties require that he/she hold, an intern registration as an Associate Clinical Social Worker (ASW), a Marriage and Family Therapist Intern (IMF), Professional Clinical Counselor Intern (PCCI) from the Board of Behavioral Sciences or AOD registration from either CCAPP or CADTP shall provide a copy to QCM that shows the current expiration date. 2.7. Waivered staff - individuals who have been verified by QCM to hold a valid waiver from the California Department of Health Care Services (DHCS) which is currently valid for Santa Barbara County. 2.8. Unlicensed staff- all individuals who are not Licensed, Registered or Waivered. 3. POLICY 3.1. The Department of Behavioral Wellness (hereafter "the Department") will ensure that all individuals permitted access to the electronic medical records system (1) are properly credentialed, (2) are verified for eligibility to participate in Medi-Cal, Medicaid, and/or Medicare claiming and related activities and (3) maintain current, valid and verifiable professional status if his/her job classification and/or duties requires a California license, registration, or waiver as indicated by relevant California licensing

agencies, as required by state and federal laws and regulations and/or the policies of this department. 3.2. Verification of eligibility, credentialing, and (when appropriate) verification of license, registration, or waiver must occur prior to employment or finalization of a contract for individuals seeking employment with the Department, and prior to commencement of duties for individuals seeking employment or already employed with a contracted community-based organization (CBO) unless otherwise stated in their contract. 3.3. The verification process will be repeated on a monthly basis to ensure that individuals continue to meet the legal and ethical requirements of his/her employment. 3.4. Each individual whose job classification and/or duties requires a license, registration, or waiver is personally responsible for ensuring that his/her license, registration, or waiver is current, valid and verifiable at all times. The Department recommends that licensed or registered staff submit all requirements to licensing boards at least 8 weeks prior to expiration. Any individual who becomes aware of an action by a licensing board that affects his/her license or registration must notify an immediate supervisor and the Department Quality Care Management (QCM) immediately. 4. ELIGIBILITY VERIFICATION 4.1. If any staff is identified in the databases or lists in section 4.2 below, the Department's Chief of Compliance and QCM manager will be notified immediately. The Chief of Compliance will then: 1. Notify the staff member and the staff member's supervisor of the database screening results and meet with the parties involved to conduct any additional investigations. 2. Immediately suspend the staff member's ability to provide direct services to the Department's beneficiaries while the investigation is being conducted and once the investigation is concluded if the database results are sustained. 3. Ensure that no claims for services provided by the staff member are submitted for payment to Medicare and/or Medi-Cal while the investigation is being conducted and once the investigation is concluded if the database results are sustained. 4. After the investigation is completed, and if the database results are sustained, notify the Department Director and, if appropriate, Human Resources (HR). Determine whether to retain the staff member for a different position.

4.2. The databases/lists and schedule of checks is indicated below: DATABASE/ LIST SAM - System for Award Management (https://www.sam.gov/sam/) Department of Health and Human Services, Office of the Inspector General, Exclusions List (http://oig.hhs.gov/exclusions/exclusions_list.asp) California Department of Consumer Affairs BreEZe Online Services, Licensing and Enforcement System (https://www.breeze.ca.gov/datamart/logincadca.do) CMS National Plan and Provider Enumeration System (NPPES) National Provider Identifier (NPI) (https://nppes.cms.hhs.gov/nppesnvelcome.do) Medi-Cal Suspended and Ineligible List (https://files.medi- National Practitioner and Healthcare Integrity and Protection Databanks (physicians and physician's assistants only) TIMING OF VERIFICATION At or before hire or contract, monthly thereafter. At or before hire or contract, monthly thereafter. At or before hire or contract, prior to expiration and upon renewal thereafter. At or before hire or contract. At or before hire or contract, monthly thereafter. At or before hire or contract, monthly thereafter. 5. POTENTIAL OR NEW COUNTY EMPLOYEES AND CONTRACTOR 5.1. Whenever an individual is considered for employment with the Department, the QCM division completes Eligibility Verification as specified in section 4 above when the application is received, and License Verification when applicable, prior to tendering an offer of employment. For individuals believed to be eligible for waiver, no waiver is valid until written approval of the waiver is received from DHCS. In order for QCM to complete Eligibility Verfication, the following documents must be submitted to QCM: 1. Job application or resume; 2. Job description; 3. Service Provider Identification Request (SPID) form; 4. Code of Conduct - Acknowledgement form (page 31 ); 5. Electronic Signature Agreement form; and 6. Government-issued ID. 5.2. Whenever an individual is considered the most probable candidate for an individual contract with the Department, the Department's Contracts division notifies QCM prior to finalization of a contract, and QCM completes Eligibility Verification as specified above, and License Verification when applicable, prior to finalization of the contract.

For individuals believed to be eligible for a waiver, no waiver is valid until written approval of the waiver is received from DHCS. Notification includes submission of all documents listed in Section 5.1 of this policy. 5.3. The Department will not employ an individual or enter into a contract if the screening shows that the prospective employee or contractor is on an exclusion list. 6. NEW OR POTENTIAL CBO EMPLOYEES 6.1. Before CBO staff may access the Department's medical records or provide services to a beneficiary, the supervisor of the relevant CBO facility/program ensures the completion and submission of all documents listed in section 5.1 of this policy to QCM. 6.2. For staff who do not have a professional license or registration, a current resume or employment application showing education and work history must accompany the documents submitted to QCM. 6.3. On receipt of the required forms and information, QCM completes the Eligibility Verification and Certification processes as specified above, and License Verification when appropriate. 7. CONTINUING STAFF 7.1. Checks of exclusion lists will be conducted on a monthly basis as specified above. If QCM determines that staff continue to be eligible (i.e., staff are not identified on any exclusion list), no further action will be taken. 7.2. If QCM determines that an individual staff is identified on any exclusion list, the Chief of Compliance and QCM manager will be notified immediately. The Chief of Compliance will then conduct an immediate investigation by doing the following: 1. Notify the employee and the employee's supervisor and set up a meeting with all parties involved; 2. Ensure that employee does not provide any direct services to any Department beneficiaries while the investigation is being conducted; 3. Block employee's ability to write notes; 4. Make a decision as to whether to retain the employee. 7.3. Every month, QCM will complete the License Verification process described below for all licensed or registered staff whose license or registration was scheduled to expire at the end of the previous month. 7.4. Within 5 business days of the expiration date for a waiver, QCM will complete the License Verification process to determine whether or not the staff has obtained professional licensure in California.

8. CHANGES IN STAFF FACILITY-PROGRAM 8.1. When an individual staff is transferred or assigned to a different facility and program within Behavioral Wellness, the manager or supervisor of the new facility-program notifies QCM no later than the second business day of the new assignment. Notification must include the name of the new facility-program and the date the staff is to begin providing services there. 8.2. QCM updates the information in the ShareCare records system and notifies MIS of the changes. MIS makes any necessary updates in the Clinician's Gateway system. 8.3. When a legal entity adds a new facility-program, the legal entity may request that some or all of their existing staff be associated with the new program. 8.4. In coordination with the Fac/Prog Credentialing process, QCM may coordinate with MIS to add the new Fac/Prog to the privileges for the identified staff as a batch process rather than dealing with each staff individually. 9. CERTIFICATION PROCESS 9.1. When QCM is notified that an individual has been or may be hired, QCM determines eligibility and: 1. Reviews the information on the Service Provider Identification Request form for completeness. Certification cannot be completed until all required information has been received. 2. Determines whether or not the staff was previously assigned a Service Provider ID. If a Service Provider ID was already assigned, QCM updates the staffs information in ShareCare and notifies MIS. If no Service Provider ID was issued, QCM creates a Service Provider ID and enters the individual's information into ShareCare, including NPI, taxonomy category, facility-program associations, and any license, registration, or waiver. 3. Notifies MIS of the Staff ID, classification and professional suffix, and the facilities and programs with which the staff is associated. MIS then establishes the appropriate permissions and electronic signature in Clinician's Gateway. 10. CREDENTIAL VERIFICATION 10.1. Verification of licenses, certification, and registration is completed using the official online verification system of each California licensing agency or the State Breeze Verification System. Staff must submit a copy of their license, certification, or registration to QCM prior to it expiring. If QCM does not receive a copy of the license or registration prior to it expiring, staff will be blocked from finalizing notes until it is received. 10.2. Upon verification of a "Clear" or "Valid" license or registration, QCM enters the title, number, and expiration of the date into the ShareCare records system.

10.3. Registered staff whose employment, including permission to provide mental health Therapy and Assessment services to the Department consumers, must fully complete licensure within 48 months of their date of hire, or date of initial registration, whichever is later. If a registered staff's license cannot be verified by the end of the 48-month period, the individual will no longer be considered a registered professional and will become a Mental Health Rehabilitation Specialist (MHRS). Such individuals are not permitted to provide, document or claim for Therapy or Assessment services. 10.4. Verification of waivers is completed by obtaining a copy of a current waiver for the Department from the Department of Health Care Services. A waiver is only valid for the department which requested the waiver. 10.5. If QCM finds that a staff member does not have a valid license, certification, registration, or waiver, QCM and MIS will ensure that the staff's authorization to enter information into the Department medical records system is suspended until the license, certification, or registration is verified by QCM. 10.6. If the staff is a Department employee, the staff's Program Manager, Team Supervisor, or other supervisor will prepare a counseling memo for the employee as soon as possible. A copy of the memo will be forwarded to the Department's HR as soon as possible. 10.7. If the staff is providing clinical supervision to any intern, trainee, or other pre-licensed individual, the staff will notify such individuals that their license cannot be verified by the Department and will immediately stop providing such supervision. 10.8. Any pre-licensed individual receiving clinical supervision from such staff must arrange for clinical supervision by another licensed individual until the staff's license has been verified by QCM. 10.9. The staff's manager or supervisor will: 1. Print a copy of each service provided after the expiration date of the license, registration, or waiver, and fax the copies to MIS with a request to block the services from Medi-Cal claiming, or if the services have already been claimed, to initiate the recoupment process. 2. Immediately ensure that the staff stops providing direct services to all the Department consumers, and that services normally provided by that staff are assigned to other staff. 10.10. If the staff is a Network Provider, the provider will stop services to all Department consumers, and will coordinate with QCM to ensure that services are provided by another provider. 10.11. Network providers will not invoice the Department for services provided during any period when their license cannot be verified. Any invoices for such services will be denied.

11. WAIVERED STAFF 11.1. Individuals may qualify for a waiver by meeting either one or both of the following criteria (at least ONE criterion needed to qualify): 1. Have completed a minimum of 48 semester or 72 quarter units of graduate coursework (not including internship, thesis, or dissertation) as part of a doctoral degree program which meets Board of Psychology requirements for licensure in California. 2. In order to become waivered, staff must submit an official transcript from the graduate institution showing units earned or degree granted. Waivers in this category are valid for a total of 5 years and cannot be renewed. 3. Upon receipt of the required documentation, QCM will submit a Waiver Request to the Department of Health Care Services (DHCS). Individuals are not waivered until the Department receives written approval of a Waiver Request from DHCS. 4. Waivers from another county are not valid for the Santa Barbara County Department of Behavioral Wellness. 5. Hold a valid license from another state and a written statement from the California Board of Psychology or Board of Behavioral Sciences verifying that the individual is eligible for admission to the relevant licensing examinations. Waivers in this category are valid for 3 years and cannot be renewed. 12. UNLICENSED STAFF 12.1. Unlicensed staff are classified into the following categories, each of which is associated with a specific professional suffix as part of the individual's electronic signature. 12.2. Mental Health Rehabilitation Specialist (MHRS) meets one of the education and experience requirements below, as specified in 9 CCR 630: 1. B.A. degree and 4 years of experience in a mental health setting as a specialist in the fields of physical restoration, social adjustment, or vocational adjustment. 2. Up to 2 years of graduate professional education may be substituted for the experience requirement on a year-for-year basis 3. Staff may also qualify as MHRS through an A.A. degree and 6 years of clinical experience, including 4 years of experience in a mental health setting as a specialist in the fields of physical restoration, social adjustment, or vocational adjustment.

12.3. Qualified Mental Health Worker (QMHW) holds a college degree or has the equivalent of three (3) years of experience in a field related to mental health, including child development, child psychology, counseling and guidance, counseling psychology, early childhood education, human services, social psychology, social science, social welfare, social work, sociology, or another discipline determined by the Department Director or designee to have mental health application. 1. Staff with an Associate's degree must have the equivalent of two years full-time experience in a mental health setting in the areas of psycho-social functioning, social adjustment, and/or vocational adjustment. 2. Staff with a Bachelor's degree must have the equivalent of one year of such fulltime experience. 3. No experience is required for staff with a Master's or Doctoral degree. 12.4. Mental Health Worker (MHW) holds a high school diploma, GED, or college degree. All progress notes and other documentation in the Clinician's Gateway records system must be approved by a licensed, registered, or waivered mental health professional or MHRS prior to finalization. 1. Staff who were classified as MHW and did not require note review and approval prior to March 31, 2011, will continue to be exempt from this requirement (unless placed on note review by the Compliance Committee or the staff's supervisor) for as long as the staff maintains continuous employment with the same legal entity. 13. REGISTERED OR CERTIFIED AOD COUNSELORS 13.1. Registered or Certified AOD Counselors are classified into the following categories, each of which is associated with a professional suffix as part of the individual's electronic signature. 13.2. Registered AOD Counselor has registered with a certifying organization that is recognized by the Department of Health Care Services in order to obtain certification as an AOD counselor as defined in Section 13005(a)(8) of Title 9, CCR. 13.3. Certified AOD Counselor is certified with a certifying organization as an AOD Counselor that is recognized by the Department of Health Care Services pursuant to Section 13035 of Title 9, CCR. 14. LIMITATIONS 14.1. No changes will be made to the types of services staff may enter and/or bill, nor to the facilities and programs through which staff may enter and/or bill, without authorization byqcm.

ASSISTANCE Tammy Summers, MFT, QCM Coordinator Emily Gularte, QCM Department Business Specialist REFERENCE California Business and Professions Code Division 2 - Healing Arts Code of Federal Regulations - Public Health Title 42, Section 438.214(d) Title 42, Section 438.610 Title 42, Section 455.400-455.470 Department of Health Care Services - Mental Health Plan Letter No. 10-05 Department of Health Care Services - Mental Health Plan Exhibit A, Attachment 1, Program Integrity Requirements REVISION RECORD DATE 6/13/2018 VERSION 1.1 REVISION DESCRIPTION Updated to incorporate information on AOD counselor certification. Culturally and Linguistically Competent Policies The Department of Behavioral We!lness is committed to the tenets of cultural competency and understands that cultura!ly and linguistically appropriate services are respectful of and responsive to the health beliefs, practices and needs of diverse individuals. All policies and procedures are intended to reflect the integration of diversity and cultural literacy throughout the Department. To the tu/lest extent possible, information, services and treatments wi/1 be provided (in verbal and/or written form) in the individual's preferred language or mode of communication (i.e. assistive devices for blind/deaf).