Joint Commission (TJC) 10-Point Credentialing Audit Checklist
Prepare for Joint Commission healthcare staffing surveys with zero citations. Standardized 10-point audit checklist covering primary source licensing, background checks, drug screens, immunizations, and clinical competency assessments.
Nursys electronic primary source verification or state board record confirming active, unencumbered status with zero disciplinary encumbrances.
Government photo identification (Driver's License/Passport) and completed Form I-9 with E-Verify confirmation within 3 business days.
7-year county & national background search plus monthly federal OIG LEIE and SAM.gov exclusion database verification.
Certified negative 10-panel drug screening reviewed by a certified Medical Review Officer (MRO) within 12 months.
Annual Quantiferon-TB Gold blood test or 2-step PPD, MMR/Varicella positive titers, Hepatitis B series/titer, and Tdap within 10 years.
American Heart Association (AHA) hands-on practical certifications appropriate for specialty unit assignments.
Comprehensive specialty-specific clinical self-assessment with score of 80% or greater completed annually.
How to Implement & Enforce This Template
1. Establish a 30-Day Warning Buffer
Configure automated alerts 30, 60, and 90 days before any license, BLS certification, or TB test expires so clinicians have adequate time to recertify.
2. Conduct Monthly OIG Batch Re-Screening
Run monthly automated exclusion checks against the federal LEIE database to catch newly excluded individuals before assigning them to hospital shifts.
3. Standardize Hands-On AHA CPR Checks
Verify that BLS and ACLS wallet cards indicate completion of hands-on mannequin skills evaluations, not 100% online certificates.
4. Export 1-Click Survey Packets
Keep digital folders standardized so that when an auditor requests 10 random clinician files, they can be produced within 15 minutes.
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