Primary Source Verification presentation

UIC Human Resources
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.
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.
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.
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.
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.
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
• 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.
Where to Find Primary Source Verification
of Licensure
• Most IL licenses are verifiable through the Illinois Department of
Financial and Professional Regulation.
• Exceptions are
– EMT (By Phone 217-785-2080 or email)
[email protected]
– Radiologists, Radiology Technicians, Radiation Therapists.
• Next is an example from IDFPR website going through the HR
website at
Illinois Department of Financial and
Professional Regulation website
Primary Source Verification
(click Printer Friendly View)
Screenshot attached to HR Front End
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.
New Hire
Checklist Form
You can find this form on
the HR website
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.
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
Identifying Appropriate Titles and Pclasses for
Employees Whose Duties Require License to
• 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.
Pclasses and job titles requiring PSV
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
• 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.
How To Record License Information in
• 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
• 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.
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
• Illinois State Statutes:
• 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.
Common Examples of Supervision Needed for
License Pending
Marilyn Lablaiks
Assistant Director Labor Relations and Compliance
[email protected]

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