1. LICENSE VERIFICATION COMPLIANCE UIC Human Resources 1

2. Training Objectives To understand the importance of Primary Source Verification of licensure and compliance with State Statutes for Professional Practice and Regulation. To identify job titles and duties that require licensure under Illinois law. To understand the process for uploading appropriate documentation of Primary Source Verification through the Front End in BANNER at time of hire. To know the process to properly record license information in BANNER. 2

3. Active Licensure is Required for Individuals Using Titles or Practicing in Regulated Professions in Illinois Anyone who practices or holds oneself out as a professional in a title regulated by the state, must comply with Illinois Statute 225 ILCS. Students, and holders of licenses issued by other states are limited and subject to strict oversight in practice until such time as they receive licensure through Illinois. Due to instances of falsification of paper licenses, proper verification must be done through the original primary source granting licensure. 3

4. New Campus Policy HR 325 Requires Primary Source Verification of Licensure at Time of Hire for All Professionals Regulated by the State Health Science Colleges and other clinical practices such as Social Work and Psychology maintain titles and carry out duties in professions regulated by the State. Campus policy has been created to establish consistent guidelines in the practice of license verification and documentation at time of hire. UIC Human Resources will use the information obtained from BANNER at time of license expiration to verify & document license renewals. 4

5. Why Documentation and Recording of Primary Source Verification of Licensure is Critically Important in Regulated Clinical Professions Formal & informal use of college employees to provide patient care occurs in the University environment. Reimbursement for patient care from Medicare and Medicaid is conditioned on accreditation by The Joint Commission (TJC). TJC conducts unannounced site visits to hospitals and other patient care facilities to award accreditation status based on compliance with its’ standards and Centers for Medicare & Medicaid Services(CMS) regulations. 5

6. What TJC Surveyors are Looking for and Consequence of Non-compliance For license verification, TJC surveyors will only accept documented primary source verification (PSV). A copy of the license is insufficient. Compliance must be 100%! A single employee found working without a license, or whose license has lapsed, can result in loss of accreditation, loss of reimbursement, and shutdown of University of Illinois Hospital & Health Sciences System. Primary Source Verification must be documented with date & time stamp prior to start of job duties. 6

7. TJC Standard is 100% Primary Source Verification of Professional License Prior to Start and at Renewal Documented Primary Source Verification (PSV) MUST OCCUR PRIOR to hire date or start date of change in job duties. Documentation of verification with the issuing agency, generally via website is REQUIRED. TJC surveyors will check to see if the print out date from the website is prior to hire, appointment, or assumption of duties, and at renewal, prior to expiration. Missing documentation, or a screen print with a date after rather than before start or renewal, is a deficiency, and threatens accreditation. 7

8. Where to Find Primary Source Verification of Licensure Most IL licenses are verifiable through the Illinois Department of Financial and Professional Regulation. https://www.idfpr.com/LicenseLookUp/LicenseLookup.asp https://www.idfpr.com/LicenseLookUp/LicenseLookup.asp Exceptions are –EMT (By Phone 217-785-2080 or email) amanda.d.arnold@illinois.gov amanda.d.arnold@illinois.gov –Radiologists, Radiology Technicians, Radiation Therapists. http://www.iema.illinois.gov/iema/radiation/radtech/radtechsea rch.asp http://www.iema.illinois.gov/iema/radiation/radtech/radtechsea rch.asp Next is an example from IDFPR website going through the HR website at http://www.uic.edu/depts/hr/quicklinks/Compliance.shtml. http://www.uic.edu/depts/hr/quicklinks/Compliance.shtml 8

9. Illinois Department of Financial and Professional Regulation website https://www.idfpr.com/LicenseLookUp/LicenseLookup.asp 9

10. Primary Source Verification (click Printer Friendly View) 10

11. Screenshot attached to HR Front End transaction 11

12. TJC Requirements Apply to Everyone in Patient Care Non-employees, such as volunteers, vendors, and those employed by any of the Health Science Colleges, must have the same qualifications, competencies, verifications and checks as employed individuals performing the same or similar services at the hospital. A new hire checklist was created for Health Science College HR employees who process employees working in or on the Medical Center premises, provide direct patient contact, or have access to patient information. 12

13. New Hire Checklist Form You can find this form on the HR website http://www.uic.edu/depts/hr/quicklin ks/hrforms/index.shtml/ 13

14. Other Documentation Required Prior to Assumption of Duties or Hire Date In addition to PSV, other documents required by TJC: –job description that identifies qualifications –verification of previous education and experience –criminal background (CBC) and sanction check –health screen through University Health Services. Certifications, registrations, education and experience done at hire must be documented and kept in the hiring department’s HR file. PSV documents are uploaded into BANNER as an attachment to the transaction before routing in Front End or via HRFE administrative transaction into BDMS. 14

15. Uploading Documentation of PSV and Other Required New Hire and Job Start Images Employment Documents that are submitted through HR Front End at time of hire or job start should include PSV of licensure, not a copy of the license, attached as a screen shot. Document MUST be titled “Professional License.” PSV of required Certifications and Registrations other than licensure should be titled “Certifications.” Internal transfers or promotions from unlicensed to licensed must submit the PSV document via HRFE administrative transaction into BDMS 15

16. Identifying Appropriate Titles and Pclasses for Employees Whose Duties Require License to Practice Renewal of licensure must be documented by a primary source verification prior to its’ expiration, with appropriate date and time stamp, or will be scored as a deficiency by TJC. Standard is 100% compliance! To identify jobs requiring licensure, job titles and pclass must be chosen that accurately reflect licensed occupational duties. A job aid with Job Titles and Pclass information is listed on the HR website under the Compliance section. http://www.uic.edu/depts/hr/quicklinks/LicensePCLASS.pdf http://www.uic.edu/depts/hr/quicklinks/LicensePCLASS.pdf 16

17. 17 Pclasses and job titles requiring PSV

18. Proper Recording of License Information in BANNER is Needed to Track License Renewal Titles and pclasses will be used by UIC Human Resources to generate license renewal reports, track compliance, document PSV, and report non-compliance to the department. A single employee working with a lapsed license found by TJC surveyors can result in LOSS OF ACCREDITATION and immediate SHUTDOWN OF THE UIHHSS. In order to identify renewal and dates of expiration, license information must be entered into the PPACERT screen at time of job start or hire. 18

19. How To Record License Information in BANNER Go to the PPACERT screen, enter UIN number and click on “next block.” Use the pull down menu to enter license certification code. Enter the license number and certification date (original issue date). Enter the next certification/expiration date occurring in the future. Enter status (active). Press F10 to save. Click on “next block” and enter endorsement date, when PSV was printed/documented. Press F10 to save. 19

20. PPACERT Instructions 20

21. License Pending New Hires Illinois Statute allows exceptions for clinical practitioners in some occupations to work in a very limited capacity, with strict oversight, prior to the issuance of a license, in a license pending status. Illinois State Statutes: http://www.ilga.gov/legislation/ilcs/ilcs2.asp?ChapterID=24 http://www.ilga.gov/legislation/ilcs/ilcs2.asp?ChapterID=24 An offer letter with a conditional time limit & identification of person responsible for supervision or Evidence of license application and/or license test results should be submitted as part of the HR transaction. It is the department’s responsibility to obtain the PSV when issued, upload through an HR Front End administrative transaction, & complete the PPACERT screen in Banner. 21

22. Common Examples of Supervision Needed for License Pending 22

23. QUESTIONS? Contact: Marilyn Lablaiks Assistant Director Labor Relations and Compliance 312-996-1232 lablaiks@uic.edu 23