Piedmont Access to Health Services, Inc s1

PIEDMONT ACCESS TO HEALTH SERVICES, INC.

Policy Number: 02-02-016 SUBJECT: Appointment, Credentialing and Privileging of Licensed Health Care Providers

EFFECTIVE DATE: 04/01/2004 REVIEWED/REVISED: 06/29/2006, 03/03/2009, 03/30/2010, 02/07/2011, 09/17/2012, 05/1/2013 08/27/2013, 11/24/2014 ______

I. GENERAL

A. POLICY: All PATHS practitioners (as defined below) that provide patient care services are required to successfully complete the appointment process, which includes the application, credentialing and clinical privileging process as described in this policy.

B. RESPONSIBILITY: It is the responsibility of the Board of Directors to approve PATHS appointment policy, appoint and reappoint appropriately licensed and qualified individuals to provide patient care, and to grant specific clinical privileges.

1. Such appointments and reappointments will be made upon the recommendation of the Chief Executive Officer, with support of the Chief Medical Officer, Pharmacy Director, Dental Director, or Behavioral Health Director, as appropriate.

2. The Board of Directors will review all applications for appointment or reappointment and privileging.

3. Individual Program Directors will ensure that all program-related contracted services meet the requirements of this policy prior to the commencement of services.

4. The Director of Human Resources will administer, gather and assess the necessary documentation and maintain and secure appropriate files containing all relevant information related to the appointment process for each practitioner.

5. Individual practitioners and subcontractors are responsible for timely submission of applications (and associated documentation) required for appointment/reappointment and for obtaining and maintaining current licensure and certification, including the professional education credits required to maintain licensure.

C. DEFINITIONS:

1. Appointment: The initial process by which PATHS or its subcontractors review the credentials and qualifications of licensed healthcare providers and authorize them to have specific privileges to be involved in any aspect of patient care.

02-02-016 Privileging Providers Page 1 of 36 2. Competency: An individual’s scope and level of performance of professional and/or clinical responsibilities as verified in writing by someone personally acquainted (e.g., supervisors, clinical instructors, etc.,) with the individual’s performance. Written opinions about an individual’s actual performance, including technical skills, clinical judgment, patient record keeping, compliance with clinical protocols, and substantiated patient complaints will be used to determine the current competence for each appointment and reappointment.

3. Credentialing: The process of obtaining, verifying, and assessing the qualifications and competency of clinicians. This is a critical component of the appointment and reappointment processes. PATHS uses a third party service through the Community Care Network of Virginia to facilitate all credentialing activities.

4. Credentials: Documented evidence of licensure, education, training, experience, malpractice coverage and other qualifications of clinicians.

5. Primary Source Verification: Verifying the accuracy of a qualification reported by a clinician through contact with the source from which the qualification originates (e.g., obtaining confirmation from a college that conferred a degree rather than just accepting a copy of the diploma).

6. Delineation of Privileges: The process of authorizing a clinician to be involved in or provide specific patient care services within defined limits based on the clinician’s licensure, education, training, experience, competence, ability to perform tasks assigned, and judgment.

7. Reappointment: The bi-annual process by which PATHS, or its subcontractors are required to review the credentials and qualifications of clinicians and re- authorize them to have specific privileges to be involved in any aspect of patient care.

8. Subcontractor: An agency or individual that has entered into a written agreement with PATHS regarding the provision of health care services. Within the context of this policy, the term “subcontractor” includes participants with PATHS in a Memorandum of Agreement.

D. Specific Procedures: PATHS and its subcontractors shall follow the standards and procedures described below. Appendix A provides a flow chart of required activities from the interview stage through the final appointment and reappointment stages.

II. Appointment and Reappointment

A. Clinicians Required to Complete the Appointment/Reappointment Process. The following clinicians must complete the required Appointment and Reappointment process described herein. The Human Resources department shall provide each applicant for appointment a copy of this policy.

02-02-016 Privileging Providers Page 2 of 36 1. Employed physicians, dentists, pharmacists, nurse practitioners, physician assistants, dental hygienists, and licensed clinical social workers.

2. Contracted (i.e., locum tenem) physicians, dentists, pharmacists, nurse practitioners, physician assistants, dental hygienists and licensed clinical social workers.

B. Clinicians Not Required to Complete the Appointment/Reappointment Process. Students that are providing patient services as part of a training program under the supervision of an appointed PATHS clinician are not required to complete the appointment process.

C. Licensed Support Staff Appointment/Reappointment Process. Licensed support staff are not required to complete a Credentials and Privileging Application (Appendix D), but do have to complete a competency screening process during the first 90-days of employment, and then annually thereafter. This process is described further in PATHS Policy number 01-08-002.

D. Subcontractors. Subcontractors must agree to follow an appointment process that includes an appropriate application and follows the criteria outlined in this policy. Such process shall include, at a minimum, the original source verification, and documentation (further described herein). The appointment process must be completed prior to the execution of patient care covered by the agreement between PATHS and the subcontractor. Subcontractors must also agree to the following:

1. Provide PATHS a list of the practitioners to perform patient care prior to commencement of the agreement.

2. Provide PATHS upon execution of signature to the agreement a copy of the appointment/credentialing policy used by the subcontractor.

3. Allow PATHS, upon request, access to credentialing files to audit for compliance.

4. Ensure current licensure of all other clinical staff that do not require appointment and that the subcontractor will employ in the execution of patient services covered by the agreement and provide PATHS access to audit files as requested.

E. Frequency and Duration of Appointment/Reappointment.

1. Employees: Once approved, the duration of any employee appointments to the medical practice, pharmacy, or dental staff will not exceed two calendar years, at which time a reappointment process must be completed. When temporary appointments and privileges are conferred, while awaiting receipt of verification of appropriate documentation, the duration of such appointments shall not exceed 90-days. Termination of employment shall automatically terminate appointment and associated privileges without further action required by PATHS or its Board of Directors.

02-02-016 Privileging Providers Page 3 of 36 2. Locum Tenens: Locum tenens may be granted temporary privileges only (see section II.F.3 below). Appointment associated clinical privileges shall automatically expire upon cancellation of their contractual obligations without further action from PATHS or its Board of Directors. Locum tenens shall not be entitled to the appeal procedural rights afforded by section III.

F. Appointment/Reappointment Applications.

1. Initial Appointment:

a. PATHS clinicians must complete appointment application forms provided by the Human Resources Department.

b. Appointment must be approved no later than 120 days after the date of application. Assuming appointment approval upon the date of hire, the application must be completed no earlier than 120 days and no later than 60 days prior to the date of hire to ensure ample time for the credentialing and appointment process to be completed.

c. The employment agreement must include a statement of agreement that initial and continual employment with PATHS is contingent upon the applicant’s successful completion of the appointment and reappointment process.

d. The subcontractor’s appointment process must include an application procedure. The subcontractor may use application forms provided by PATHS.

2. Reappointment: The reappointment process must be completed within two years following either the date of the initial appointment or the last reappointment. Applications for reappointment must be completed as required by the clinician no earlier than 120-days, and no later than 45-days, before expiration of the current appointment to ensure ample processing time.

3. Emergency Temporary Appointment:

a. Emergency temporary appointments to the medical practice, pharmacy, or dental staff may be necessary to maintain coverage. Examples of such situations might include when the sudden or unexpected departure of regular clinical staff threatens PATHS’ ability to fulfill important patient care needs, when there is a delay of responses from Medicare or Medicaid regarding a practitioners acceptance, when a completed (but clean) application is merely awaiting review by a committee or governing body, or when other possible staffing situations threaten to interrupt the continuity of patient care.

b. The Chief Executive Officer may make emergency temporary appointments after confirmation is acquired from either the Board Chair, Vice-Chair, Secretary or Treasurer of the Board of Directors. Such

02-02-016 Privileging Providers Page 4 of 36 temporary appointments shall require the recommendation of the Chief Medical Officer, Dental Director, Pharmacy Director, or Behavioral Health Director as appropriate.

c. The term of temporary appointments shall not exceed the agreed-upon term of the emergency coverage, and in no instance exceed 90-days or the time frame for completion of all verification of credentials, whichever comes first.

d. Temporary clinical privileges may be granted to Locum Tenens for an initial period of no more than 30-days. The Board of Directors upon request of the Chief Executive Officer may renew privileges for locum tenens for additional periods of 30-days. However, the temporary appointment may not exceed the period of service covered by the terms of the contract with PATHS.

e. Emergency temporary appointments shall be made only upon completion of minimum requirements for original source verification described in section II.H.3.c. (“Verification Requirements for Temporary Appointments”). A minimum of one reference is required to verify current competency.

f. Clinical privileges for physicians shall be limited to those granted by graduates of a medical school that have completed a 3-year residency program and are board eligible or board certified.

g. The granting of Emergency Temporary Appointments shall be reported to the next regular meeting of the Board of Directors for formal concurrence.

G. Privileging. The appointment/reappointment process includes the request and subsequent approval or disapproval of clinical privileges. The Delineation of Privileges (Appendix B) provide the means through which privileges are requested and approved.

1. The clinical privileges granted to members of the staff will be specific to the individual and to the site(s) where patient care is to be rendered. Privileges will be based not only on the applicant’s qualifications, but also on a consideration of the procedures and types of care that can be performed within a specific clinical setting. In addition, state laws and regulations are adhered to when granting clinical privileges to clinicians other than physicians (for example, physician assistants, or nurse practitioners). If an applicant’s training and experience is in a specific area, corresponding privileges can be granted only if the clinical site has adequate facilities, equipment, number and types of qualified support personnel, and other required support services.

2. The Board of Directors will receive each specific providers CV along with the Chief Medical Officers letter of recommendation for privileging that provider. This letter of recommendation must include the following: the providers printed name and signature, their classification, job duties, and which site they

02-02-016 Privileging Providers Page 5 of 36 will be working. The Board of Directors will have the option to review the full credentialing file by scheduling an appointment with the HR Director.

3. The initial granting, renewal or revision of clinical privileges will be based on the individual’s demonstrated current competence. Current competence is determined, in part, by a review of relevant results of performance improvement activities. Specific instances of treatment outcomes and the results of other improvement activities may also be included. An evaluation of the applicant’s clinical judgment, technical skill in performing procedures, and in patient treatment and management are included in evaluations of current competence.

4. Clinical privileges granted to clinicians include only those activities that are performed at the PATHS site at which the clinician works and are relevant to the mission of PATHS.

5. A clinician can request, and the Board of Directors can add, new privileges at any time as long as (1) there is evidence of sufficient training and competency and (2) the Chief Medical Officer, Dental Director, Pharmacy Director or Behavioral Health Director (as appropriate) evaluates and recommends approval. A request for modification of clinical privileges must be supported by documentation of training and/or experience that is supportive of the request.

H. Credentialing (Verification of Qualifications). PATHS shall, in partnership with the Community Care Network of Virginia, verify through primary sources, and assess the qualifications of each clinician that provides patient care services at PATHS and is listed in Section II.A above.

1. Clinicians Requiring Hospital Privileges: Clinicians that require hospital privileges (i.e., OB/GYN physicians) must successfully complete the hospital’s appointment process. PATHS’ Board of Directors has approved the use of the hospital’s credentialing documentation as the basis for appointment at PATHS. However, PATHS must separately verify outpatient competency and appointment and privilege the clinician for patient care. The use of the hospital’s credentialing documentation is contingent upon the hospital’s retention of JCAHO accreditation.

2. Clinicians Not Requiring Hospital Privileges: Depending upon circumstances, PATHS itself may complete original source verification of all elements (see section II.H.3. below) or submit the completed application and documentation provided by the clinician to the Community Care Network of Virginia for original source verification of credentials. All information provided by the appropriate primary source within 45 days following the date the completed application and required documentation is received from the clinician.

3. Verification Requirements.

a. Verification Requirements for Initial Appointment:

02-02-016 Privileging Providers Page 6 of 36 i. Licensure disciplinary actions as indicated from a check of the National Practitioners Data Bank (NPDB), Licensing Board, or Office of the Inspector General (OIG) Sanctions List. ii. Board (negative report indicates no adverse actions). (NPDB, OIG, or Licensing Board). iii. Current Virginia Licensure Status (Licensing Board). iv. Current DEA certification (DEA record of certification through National Technical Information Services (NTIS) database). v. Board certification or eligibility. (Appropriate specialty board or the American Board of Medical Specialties Compendium (ABMS); Required only for physicians.) vi. Malpractice Insurance. (PATHS clinicians are covered by FTCA; Application statements from practitioner and follow-up with insurance carrier, if appropriate). vii. Relevant education (medical or dental school, internship, residency, or other; Source is the educational institution). viii. Relevant employment history for the prior five years. ix. Three references (individuals qualified to comment on clinical competencies, i.e., professional references that have first-hand knowledge of the individual’s performance as it relates to quality of care, clinical records, and office procedures). x. Medicare and Medicaid participation status. All practitioners must meet one of the two following requirements:

(a) For practitioners hired before January 1, 2002, the practitioner must have received:

(1) A favorable background check from the National Practitioner Database, the OIG Exclusion List, and the Virginia State Licensing Board, or have achieved successful enrollment for participation as required by Medicare or Medicaid, or

(2) Regardless of hire date, the practitioner must have successfully completed enrollment and be accepted for participation as required by Medicare or Medicaid. Source is the federal Department of Health and Human Services. Medicare and Medicaid acceptance is required

02-02-016 Privileging Providers Page 7 of 36 for all physicians; only Medicaid is required for dentists. No requirement exists for pharmacists or dental hygienists.

(b) Signed declarations and statements by the clinician giving permission to verify the information, attesting to the truth of the information and indicating agreement to follow PATHS policies. b. Verification Requirements for Reappointment. The processes listed below must be completed and verified prior to reappointment.

i. National Practitioner Data Bank, OIG Sanctions List, or other disciplinary activity update since prior appointment or reappointment. (NPDB, OIG or Licensing Board).

ii. Current VA licensure status (Licensing Board).

iii. Current DEA certification (DEA record of certification through National Technical Information Service (NTIS) database).

iv. Board certification or eligibility, as applicable. (Appropriate specialty board, or the American Board of Medical Specialties Compendium (ABMS). (Required for physicians only).

v. Malpractice Insurance. (PATHS clinicians covered by FTCA; Application statements from practitioner regarding any judgments or settlements since last appointment, plus follow- up as necessary).

vi. Medicare and Medicaid provider status. The practitioner must have successfully completed enrollment and be accepted for participation as required by Medicare or Medicaid. (Source is the US Department of Health and Human Services; Medicare and Medicaid acceptance is required for all physicians; only Medicare is required for mid-level practitioners; only Medicaid is required for dentists; No requirement exists for dental hygienists or pharmacists).

vii. Licensure disciplinary actions, e.g., sanctions, restrictions, and/or limitations on scope of practice since prior appointment or reappointment. (NPDB, OIG or Licensing Board).

viii. Relevant education and/or training since previous appointment or reappointment. (Original documentation, the appropriate certification Board and/or educational institution).

ix. Relevant experience and competency since last appointment or reappointment. (Supervisor or peers).

02-02-016 Privileging Providers Page 8 of 36 x. Satisfactory performance appraisal. (PATHS Human Resources personnel file).

xi. Current competence at the time of reappointment is determined by factors such as the results of performance improvement activities, performance appraisals, retrospective chart reviews, peer recommendations, and the individual’s professional performance, clinical judgment, and technical skills. Additional criteria for reappointment shall be evaluated in the context of the impact on patient care and shall include the following:

(a) Attendance at meetings;

(b) Patient complaints;

(c) Timely completion of medical records/charts;

(d) Adherence to PATHS policies and procedures;

(e) Collegiality with other practitioners.

c. Verification Requirements for Emergency/Temporary Appointment. Temporary appointment may be approved provided that verification of the following minimum credentials has been obtained from primary sources.

i. Completion and receipt of favorable check from the National Practitioners Data Bank and Office of the Inspector General (OIG).

ii. Current VA License.

iii. Relevant education (medical, dental or pharmacy school, internships, residency, etc.)

iv. Relevant training and previous work experience (school department chairs, etc.)

v. Current competency (minimum of one professional reference who has first-hand knowledge of the individual’s performance as it relates to the quality of care, clinical records and office practices).

I. Application Review, Approval, or Dismissal.

1. Within 5 days after completion of all verifications and with the recommendation of the program director, the Human Resources Department shall complete a

02-02-016 Privileging Providers Page 9 of 36 final review and submit an appointment packet for review to the Chief Executive Officer. Within 5 days after receipt of the packet, the Chief Executive Officer shall review the packet and render a decision as to whether the clinician meets the minimum criteria for appointment as set forth in Section II. The Chief Executive Officer shall present the appointment packet with recommendation to Board of Directors for review and final decision at the next scheduled meeting of the Board.

2. The decision to recommend approval or disapproval of appointment reappointment must involve review by a clinician who has a scope of practice that is equal to, or greater, than that of the applicant (e.g., physician for physician, physician for nurse practitioner, etc.)

3. The final decisions of the Chief Executive Officer and the Board of Directors shall be documented in the clinician’s file. Within 10 days following the date of decision by the Board of Directors, the Chief Executive Officer shall notify the applicant in writing of the decision regarding his or her appointment.

a. The notice must specify the name of the individual, the period covered by the approval, and the scope of practice covered by the approval.

b. A notice of disapproval, or approval with limited clinical privileges must specify the individual, the reason for the disapproval or limitation, the right to appeal the decision and instructions for filing an appeal.

I. Reports. Subcontractors must provide PATHS a list of all clinicians that will provide patient care services. This report is due annually prior to commencement of the contracted services.

J. Monitoring Appointment and Reappointment Requirements. The Human Resources Department shall monitor appointments and reappointment processes to ensure that events within control are started and completed in a timely manner.

K. Termination or Limitation of Privileges or Appointment Status. When privileges or appointments are either terminated or limited, individuals must be notified of the reason for the termination/limitation of their appointment. A decision to terminate or limit an appointment will involve consultation with the program director, or other clinician with a scope of practice that is equal to or greater than that of the clinician under evaluation. Termination of appointment must take effect immediately upon discovery of evidence of any of the following:

1. Suspension or revocation of professional license in Virginia;

2. Suspension or termination as provider from the Medicare or Medicaid Programs;

3. Providing false information or documentation pertaining to employment, appointment, or reappointment applications;

02-02-016 Privileging Providers Page 10 of 36 4. Inappropriate or illegal disclosure of confidential patient information;

5. Falsification of medical or other records;

6. Suspension or revocation of DEA license; 7. Being in possession of, consuming or under the influence of alcohol or illegal drugs or substances while on the job or at the employment site, including the parking area;

8. Acts of violence, abuse, or neglect toward patients;

9. Failure to meet any of the minimum criteria or standards for appointment and reappointment.

10. Failure to satisfy any of the conditions detailed in the Employment Agreement for initial and continued employment by PATHS.

III. CONFIDENTIALITY

A. Individual Responsibilities. Information obtained throughout the appointment and reappointment processes is considered confidential. Only those directly involved in the appointment reappointment processes and with a need to know the information to fulfill their responsibilities shall have access to this information. Individuals who are involved in the processes must have signed PATHS Confidentiality Policy that attests to their agreement and acknowledgement of PATHS’ policies to maintain the confidentiality of information.

B. Administrative Procedures. The following procedures are required to ensure the confidentiality of information obtained through the appointment or reappointment processes.

1. The appointment or reappointment application forms and related documentation shall be maintained in a separate central file from the personnel file in the Human Resources Department. The file shall be marked “confidential.”

2. All appointment and reappointment files must be kept in locked file cabinets when not in use. Precautions shall be taken to prevent accidental disclosure while they are in use.

3. Only persons directly involved in the appointment and reappointment processes and approved auditors may have access to the appointment or reappointment files unless the clinician gives specific written permission for its release to another party. PATHS staff authorized access include the following:

a. PATHS Chief Executive Officer;

b. PATHS Director of Human Resources;

02-02-016 Privileging Providers Page 11 of 36 c. Appropriate Program Director; and

d. Subordinate staff appointed by program director to process related appointment or reappointment matters within their department. 4. Under no circumstances should the information be transported from one site to another, mailed, or sent through any other delivery service.

IV. Record Retention. All documentation regarding appointment and reappointment processes must be retained in a separate file for each clinician while the clinician is employed or actively associated as a contractor with PATHS. Appointment and reappointment documentation must be retained for a minimum of 4 years following the date a clinician’s employment or relationship with PATHS was terminated. If there is a dispute or appeal pending upon termination of a clinician’s relationship with PATHS, documentation in the file must be retained for a minimum of 4 years following the resolution of the dispute or appeal.

SIGNATURES:

______/ ___ /______Chief Executive Officer Date

______/ ___ /______Chief Medical Officer Date

______/ ___ /______Human Resources Director Date

______/ ___ / ______Dental Director Date

______/ ___ / ______Pharmacy Director Date

______/ ___ / ______Behavioral Health Director Date

______/ ___ /______Board Chair Date

02-02-016 Privileging Providers Page 12 of 36 Appendix A

PATHS Credentialing Flow Chart

Applicant CV/Resume Received; Approval to Fill Program Director Position Identified; HR Interview; Forms Conducts Initial Screen given to complete.

Face-to-Face Interview Yes. Interested? Yes. Interested?

Is the candidate a No. No. Is thegood candidate fit? a good fit?

HR Sends “Thank you Yes. Yes. for interest” letter.

Offer made contingent on successful completion of Delineation of Privileges, the Chief Medical Officers Recommendation, along with Credentialing Packet, and approval by PATHS Board of Directors

Copy of Packet forwarded to PATHS’ Board of Directors; Original forwarded to CCNV.

Board of Directors vote and Provider Approved! Board of Directors vote and Provider Approved!

02-02-016 Privileging Providers Page 13 of 36 Appendix B

Piedmont Access To Health Services, Inc. DELINEATION OF PRIVILEGES for MEDICAL PROVIDERS

Applicant Name (Printed): ______Date: ___ / ___ / _____

By proceeding, the applicant identified above certifies that the following criterion has been met:  Must be Board Certified/Eligible (if appropriate);  Has provided documentation of training; and  Has current BLS certification (attach a copy of this certificate).

PATHS Clinical Privilege Checklist

Place check Description of Service/Procedure Approved by (Program mark here to Director Initials) request consideration for Privileges Family Medicine Elicit and record complete health database. Perform and document history, physicals, and exams. Order medical imaging and laboratory tests as indicated by the patient’s diagnosis. Prescribe and/or administer prescription drugs in conformance and in accordance with prescriptive authority. Perform venipuncture as dictated by laboratory studies. Perform/remove clips, sutures, dressing changes, splints, casts, etc. as directed. Counsel patients on the use of medications, expected effects of treatment, diet and other health maintenance matters. Administer lifesaving procedures in emergency situations Basic Emergency Care Basic Life Support and CPR Basic Diagnosis and Management Referral of Diagnostic Problems Independent Care of General Medical Problems Arthrocentesis and joint injection Burns, superficial and partial thickness I & D Abscess Local anesthetic techniques Manage uncomplicated minor closed fractures and uncomplicated dislocations Removal of non-penetrating foreign body from the eye, nose, or ear

02-02-016 Privileging Providers Page 14 of 36 Suture uncomplicated lacerations Point of care testing: Blood Glucose Point of care testing: Hemoglobin A1C Point of care testing: Influenza Point of care testing: Mononucleosis Point of care testing: Pregnancy Point of care testing: RSV Point of care testing: Strep A Point of care testing: Urinalysis Point of care testing: Pertussis Apply the general principles of geriatric rehabilitation, including those applicable to patients with orthopedic, rheumatologic, cardiac and neurologic impairments Assess patient to include medical, affective, cognitive, functional status, social support, economic and environmental aspects related to health Manage areas of special concern to geriatric patients such as falls and incontinence Manage aspects of preventive medicine, including nutrition, oral health, exercise, screening, immunization and chemoprophylaxis against disease Manage the appropriate interdisciplinary coordination of the actions of multiple health professionals, including physicians, nurses, social workers, dieticians and rehabilitation experts, in the assessment and implementation of treatment Recognize and evaluate cognitive impairment Treat and prevent iatrogenic disorders Other: Other: Other: Obstetrical/Gynecological Medicine General Prenatal Care of Uncomplicated Low-Risk OB Patients Evaluation and Treatment of Gynecologic Patients Prenatal Care of High Risk Patients Perform Loop Electrosurgical Excision Procedure (LEEP) Perform Colposcopy IUD Insertion and Removal Implanon Insertion and Removal EMB Vulva Bx Polyp Removal ECC Biopsy of cervix, endometrium Cryosurgery/cautery for benign disease Diagnostic cervical dilation and uterine curettage Excision/biopsy of vulvar lesions 02-02-016 Privileging Providers Page 15 of 36 Incision and drainage of Bartholin duct cyst or marsupialization Elicit and record complete health database. Perform and document history, physicals, and exams. Order medical imaging and laboratory tests as indicated by the patient’s diagnosis. Prescribe and/or administer prescription drugs in conformance and in accordance with prescriptive authority. Perform venipuncture as dictated by laboratory studies. Perform/remove clips, sutures, dressing changes, splints, casts, etc. as directed. Counsel patients on the use of medications, expected effects of treatment, diet and other health maintenance matters. Administer lifesaving procedures in emergency situations Basic Emergency Care Basic Life Support and CPR Basic Diagnosis and Management Referral of Diagnostic Problems Independent Care of General Medical Problems Removal of foreign body from vagina Suturing of uncomplicated lacerations Uterine curettage following incomplete abortion Point of care testing: Blood Glucose Point of care testing: Hemoglobin A1C Point of care testing: Influenza Point of care testing: Mononucleosis Point of care testing: Pregnancy Point of care testing: RSV Point of care testing: Strep A Point of care testing: Urinalysis Point of care testing: Pertussis Other: Other: Pediatric Medicine Care of the General Pediatric Patient Care of the Normal Newborn Infant Physiologic Jaundice of the Newborn Elicit and record complete health database. Perform and document history, physicals, and exams. Order medical imaging and laboratory tests as indicated by the patient’s diagnosis. Prescribe and/or administer prescription drugs in conformance and in accordance with prescriptive authority. Perform venipuncture as dictated by laboratory studies. Perform/remove clips, sutures, dressing changes, splints, 02-02-016 Privileging Providers Page 16 of 36 casts, etc. as directed. Counsel patients on the use of medications, expected effects of treatment, diet and other health maintenance matters. Administer lifesaving procedures in emergency situations Basic Emergency Care Basic Life Support and CPR Basic Diagnosis and Management Referral of Diagnostic Problems Independent Care of General Medical Problems Arthrocentesis and joint injection Burns, superficial and partial thickness I & D Abscess Local anesthetic techniques Manage uncomplicated minor closed fractures and uncomplicated dislocations Removal of non-penetrating foreign body from the eye, nose, or ear Suture uncomplicated lacerations Point of care testing: Blood Glucose Point of care testing: Hemoglobin A1C Point of care testing: Influenza Point of care testing: Mononucleosis Point of care testing: Pregnancy Point of care testing: RSV Point of care testing: Strep A Point of care testing: Urinalysis Point of care testing: Pertussis Other: Other: Other: Surgical Medicine Simple Skin Biopsy or Excision Uncomplicated Removal of Foreign Objects from Body Orifices Care of Uncomplicated Burns Repair of Uncomplicated Lacerations Incision and Drainage of Abscesses (Superficial) Minor Musculoskeletal Trauma Skin Tag Removal Other: Other: Other:

(Signature lines on next page)

02-02-016 Privileging Providers Page 17 of 36 ______/ ___ / _____ Applicant Signature Date

______/ ___ / _____ Program Director Signature Date

______/ ___ / _____ Chief Executive Officer Date

______/ ___ / _____ Board Chair Date

02-02-016 Privileging Providers Page 18 of 36 Appendix C

Piedmont Access To Health Services, Inc. DELINEATION OF PRIVILEGES for DENTAL PROVIDERS

By proceeding, the applicant identified above certifies that the following criterion has been met:  Has provided documentation of training; and  Has current BLS certification (attach a copy of this certificate).

Place check Description of Service/Procedure Approved by (Program mark here to Director Initials) request consideration for Privileges Dental Hygiene Obtain Medical History Examination of Teeth and Oral Structures Dental Prophylaxis and Polishing of Clinical Crowns of Teeth Scaling and Root Planning Application of Sealants to Teeth Topical Fluoride Application to Teeth Polishing of Dental Restorations Diet Counseling Exposure to Dental Radiographs Basic Emergency Care Basic Life Support and CPR Obtain Alginate Impressions Placement of Temporary Dental Restorations Other: Other: General Dentistry Clinical Oral Examination Intraoral Radiograph Interpretation Panoramic Radiograph Interpretation Dental Prophylaxis Topical Fluoride Application Application of Sealants to Teeth Oral Hygiene Instruction Conventional Restorative Dentistry Procedures Indirect Pulp Capping Direct Pulp Capping Pulpotomy Pulp Extirpation

02-02-016 Privileging Providers Page 19 of 36 Conventional Root Canal Therapy Scaling and Root Planning Crown Lengthening Local Anesthesia Diagnostic Blocks with Local Anesthesia Nitrous Oxide/Oxygen Inhalation Conscious Sedation (Pediatric) Dental Prophylaxis (Pediatric) Topical Fluoride Application (Pediatric) Removal of Dental Caries (Pediatric) Conventional Restorative Dentistry Procedures (Pediatric) Pulpotomy (Pediatric) Routine Dental Extraction (Pediatric) Administration of Local Anesthesia Treatment of Geriatric Patients Treatment of Medically Compromised Patients Occlusal Adjustment Desensitization Procedures Occlusal Guard Fabrication Basic Emergency Care Basic Life Support and CPR Other: Other:

______/ ___ / _____ Applicant Signature Date

______/ ___ / _____ Board Chair Date

02-02-016 Privileging Providers Page 20 of 36 Appendix D

Piedmont Access To Health Services, Inc. DELINEATION OF PRIVILEGES for PHARMACISTS

Place check Description of Service/Procedure Approved by (Program mark here to Director Initials) request consideration for Privileges Pharmacist Clinical Therapeutics Compounding Consulting Formulary Management Mail Order Patient Education Adverse Medication Interactions Dosage Calculations Drug-Drug Interactions Drug-Food Interactions Inventory and Stocking Medication Allergies Medication Recall Pharmaceutical Equivalence Appropriate Labeling Drug Utilization Review Basic Emergency Care Basic Life Support and CPR

______/ ___ / _____ Applicant Signature Date

______/ ___ / _____ Board Chair Date

02-02-016 Privileging Providers Page 21 of 36 Appendix E

Piedmont Access To Health Services, Inc. DELINEATION OF PRIVILEGES for BEHAVIORAL HEALTH PROVIDERS

Place check Description of Service/Procedure Approved by (Program mark here to Director Initials) request consideration for Privileges Behavioral Health Clinicians Screening/Evaluation/Intake Case Consultation Consultation/Education Outpatient Treatment – Individual Outpatient Treatment – Group Case Management Case Support Crisis/Emergency Intervention Day Treatment Partial Hospitalization Psychosocial Rehabilitation Psychological Testing – Specify Type(s): ______Forensic Services Involuntary Commitments Psychiatric/Medication Evaluations Psychological Diagnostic Assessments Developmental Day Early Childhood Intervention Respite Driving While Impaired Assessment Client Behavior Intervention High Risk Intervention - Periodic Basic Emergency Care Basic Life Support and CPR

(Signatures on Next Page)

02-02-016 Privileging Providers Page 22 of 36 ______/ ___ / _____ Applicant Signature Date

______/ ___ / _____ Board Chair Date

02-02-016 Privileging Providers Page 23 of 36 Appendix F

Date: ______

As a Program Director of PATHS, I, ______, recommend privileging (Program Director Name/Title)

______as a provider for PATHS. (Provider Name/Title)

This provider’s classification is: Physician (MD/DO) Nurse Practitioner (FNP, PNP) Physician’s Assistant (PA) Dentist (DDS) Pharmacist (RPH) Licensed Clinical Social Worker (LCSW)

This provider will primarily work from: Danville Martinsville Chatham Boydton

02-02-016 Privileging Providers Page 24 of 36 Appendix G

Health Care Provider Credentials & Privileging Application

Completed applications and required documents should be directed to:

PATHS, Attn: HR 705 Main Street Danville, Virginia 24541

Please attached Passport Photo Here

Name: ______

Date: ___ / ___ / ______

02-02-016 Privileging Providers Page 25 of 36 Section 1: Personal Information

Practitioner Name: ______Last First Middle

Prior names, including maiden and previous married: ______

Home Address: ______Street City ST Zip

Phone Number: (_____) _____ - ______Social Security Number: _____ - ____ - ______

E-mail address (required): ______

Date of Birth: ___ / ___ / _____ Place of Birth: ______

Gender:  Male  Female Citizenship: ______

Do you speak and write English fluently?  Yes  No

Do you use sign language?  Yes  No

List languages other than English in which you are fluent: ______

Are you eligible to work in the United States?  Yes  No

Professional Degree:  MD  DO  DDS  NP  PA  RPH  Other: ______

PCP or Specialist?  PCP  Specialist If “Specialist,” indicate: ______

Section 2: Practice Information

Corporate Name (As it appears on W9): Piedmont Access To Health Services, Inc.

Address: 705 Main Street, Danville, Virginia 24541 Phone: 434-791-3630 ext. 1013

Office Contact: Joanie Littleton, HR Director E-mail address: [email protected]

What is your expected start date? ___ / ___ / _____ Date of Hire: ___ / ___ / _____

Do you have any practice limitations?  Yes  No If yes, indicate: ______

02-02-016 Privileging Providers Page 26 of 36 If you are a mid-level provider, please indicate your supervision physician and their specialty: ______

Please indicate your office hours in the chart below: Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Employment Status:  Full-time  Part-time

Additional Offices you may be providing services within:  PATHS Community Medical Center, 380 Washington Street, Boydton, VA 23917 Phone: 434-738-6420 Fax: 434-738-6054  PATHS Community Medical Center, 4 South Main Street, Chatham, VA 24531 Phone: 434-432-4443 Fax: 434-432-3555  PATHS Community Medical Center, 287 Commonwealth Blvd., Martinsville VA 24112 Phone: 276-632-2966 Fax: 276-632-0841  Other: ______Phone: ___ - ___ - _____ Fax: ___ - ___ - _____

List providers who provide coverage after hours or in your absence: Full Name Specialty

Do you have workman’s compensation experience?  Yes  No If “yes,” number of years: ______% of Practice: ______

Section 3: License, Registration, and Numerical Information (Attach current certificates for all active licenses)

License #: ______State of Registration: _____ Type of License: ______Date Issued: ___ / ___ / _____ Expiration Date: ___ / ___ / _____

DEA Registration #: ______Date Issued: ___ / ___ / ____ Expiration: ___ / ___ / ____

CDS Registration #: ______Date Issued: ___ / ___ / ____ Expiration: ___ / ___ / ____

ECFMG #: ______(Copy of Certificate)

02-02-016 Privileging Providers Page 27 of 36 Medicare #: ______NPI #: ______

If PATHS will be maintaining your NPI and/or CAQH, the information below is required:

NPI User Name: ______Password: ______

CAQH User Name: ______Password: ______

Section 4: Hospital Affiliations List all hospitals where you had or currently have privileges and indicate status.

Do you currently admit and care for patients on your own service?  Yes  No

If hospital privileges are pending, or you do not have hospital privileges, please include documentation of arrangements made to provide care to your patients when hospitalized.

% Institution Name/Address Total Privilege Status (Indicate Primary Admitting with an “*”) annual admits Active Courtesy Provisional Allied Other

Section 5: Education and Training Attach copies of diplomas and training certificates.

Please provide appropriate information to enable us to contact the institutions listed, including correct campus name and complete mailing address.

Medical/Professional School Name: ______

Address: ______Street City ST Zip

Degree Obtained: ______

Start Date: ___ / ___ / ______End Date: ___ / ___ / ______

Internship Specialty: ______

Institution Name: ______02-02-016 Privileging Providers Page 28 of 36 Affiliated University: ______

Start Date: ___ / ___ / ______End Date: ___ / ___ / ______Fax #: ___ - ___ - ______

Fellowship Specialty: ______

Institution Name: ______

Affiliated University: ______

Start Date: ___ / ___ / ______End Date: ___ / ___ / ______Fax #: ___ - ___ - ______

Section 6: Board or Professional Certification Submit a copy of any certificates

Primary Practice Specialty: ______

Board Certification?  Yes  No Date of Certification: ___ / ___ / ______

Name of Certifying Board: ______

Sub Specialty: ______

Board Certification?  Yes  No Date of Certification: ___ / ___ / ______

Name of Certifying Board: ______

If you are not Board Certified, indicate any of the following that apply:  I have taken the Board exam for ______(board), results pending.  I intend to sit for the Board exam for ______(board), on ___ / ___ / ______(date).  I am not planning to take the Boards. Number of years’ experience: ______

Section 7: CEU Credits If you are not Board Certified, please provide a list of CEU’s taken in the last two years. Note: CEU credits must be in the specialty in which you will be practicing at PATHS.

 List & Certificates Attached  N/A Recently finished training 02-02-016 Privileging Providers Page 29 of 36 Section 8: Work History Include all positions held since completion of your professional degree. Please provide an explanation of any gaps greater than six months in your work history. A copy of your curriculum Vitae beginning with current employer is acceptable. Start and end dates must be in mm/yyyy format.

Organization Name Address Position Held Start/End Dates Reason for Leaving

Section 9: Academic Appointment

Institution Name: ______Department: ______

Type of Appointment: ______

Start Date: ___ / ___ / _____ End Date: ___ / ___ / _____

Section 10: Liability Insurance Information

Name of current carrier: ______

Address: ______

Agent Name: ______Phone: ____- ____ - ______

Policy #: ______Amount of coverage per occurrence ($): ______

Aggregate: ______Effective Date: ___ / ___ / _____ Expiration Date: ___ / ___ / _____ 02-02-016 Privileging Providers Page 30 of 36 Section 11: Personal References Please list three references willing to provide written comments, upon request, regarding your professional competence, ethics, character, health status, and ability to work cooperatively with others. Professional references must be currently licensed, and able to adequately assess your ability to practice at your current level. If you are just completing training, please use your Residency/Fellowship Program Director and/or the Chairperson of the Department (Please limit to one office associate. At least one reference should be a provider in your specialty, if possible. We encourage the use of email addresses for quicker processing.

Name: ______

Address: ______

Phone: ___ - ___ - _____ Fax: ___ - ___ - _____ Email: ______

In what capacity did this individual observe your performance? ______

Name: ______

Address: ______

Phone: ___ - ___ - _____ Fax: ___ - ___ - _____ Email: ______

Name: ______

Address: ______

Phone: ___ - ___ - _____ Fax: ___ - ___ - _____ Email: ______

02-02-016 Privileging Providers Page 31 of 36 Section 12: Check list Please answer the following questions. For any questions that receive a “yes” answer (excluding #12), please provide a complete explanation. A copy of the “Malpractice Claims Information Form” has been provided for your convenience.

Yes No N/A 1. Do you presently have, or have you ever had, any condition, mental, physical, emotional (including alcohol abuse), which would limit or has in the past limited your ability to provide safe, effective care to your patients, with or without accommodation? 2. Are you now, or have you ever been, an active or habitual user of any illegal or controlled substances? 3. Are you now receiving, or have you ever received, treatment for any chemical dependency or substance abuse including alcohol? 4. Have any of the following ever been, or are in the process of being, voluntarily, or involuntarily, withdrawn, relinquished, not renewed, reduced, limited, placed on probation, denied, revoked, suspended, or investigated? A) State License B) DEA, CDS Registration or other controlled substance authorization C) Hospital or other health care facility staff membership or privileges, including specific clinical privileges? D) Professional organization membership? E) Medicare, Medicaid, or other government health plan participation? F) HMO, PPO, PHO, IPA, or any other health plan participation? G) Educational or training institution or program? H) Academic appointment? I) Medical or professional society or association, or professional board certification? 5. Have you ever voluntarily, or involuntarily, relinquished or withdrawn your application for staff membership or clinical privileges at any hospital or other healthcare facility? 6. Are any actions currently pending against you by any federal or state regulatory authority, or by any hospital or provider? 7. Have you ever resigned in order to avoid revocation, suspension, or reduction of privileges at any facility or institution? 8. Have you been convicted or indicted of a crime, or are you under indictment for an alleged crime, including any narcotics offense, fraud or felony offense? 9. Are you now, or have you ever been involved in any malpractice action(s), including litigation, arbitration, or mediation, regardless of the outcome that resulted? 10. Has a payment to resolve or avoid any allegation(s) concerning your competence, conduct, or quality of care (not including litigation, arbitration or mediation) ever been paid by you or on your behalf? 11. Has your professional liability insurance ever been limited, denied, suspended, canceled, lapsed, not renewed, special rated or experienced gaps? 12. Do you currently have malpractice coverage? 02-02-016 Privileging Providers Page 32 of 36 Do you have the following: Basic Life Support  Yes  No Date of Certification: ___ / ___ / ______Advanced Cardiac Life Support  Yes  No Date of Certification: ___ / ___ / ______Advanced Life Support in OB  Yes  No Date of Certification: ___ / ___ / ______Pediatric Advanced Life Support  Yes  No Date of Certification: ___ / ___ / ______Advanced Trauma Life Support  Yes  No Date of Certification: ___ / ___ / ______Neonatal Advanced Life Support Yes  No Date of Certification: ___ / ___ / ______Cardio-pulmonary Resuscitation Yes  No Date of Certification: ___ / ___ / ______

Section 13: Basic Authorization and Release

The information provided in this application includes specific details regarding my background, character, and competence. I understand that this information will be reviewed. By signing below, I:

1. Certify that all information provided by me in this application is true to the best of my knowledge and belief, and free of omissions;

2. Agree to notify PATHS of any changes to the information provided within 30-days of any such change; and

3. Release PATHS from any liability for inaccurate information provided.

Printed Name: ______

Signature: ______Date: ___ / ___ / _____

02-02-016 Privileging Providers Page 33 of 36 Authorization and Release

I understand and acknowledge that, as an applicant with Piedmont Access To Health Services, Inc. (PATHS), it is my responsibility to provide sufficient information upon which a proper evaluation can be undertaken of my current licensure, relevant training, and/or experience, professional competence, character, ethical qualifications and any other criteria adopted for participation, and for resolving any questions about such information.

I further understand acknowledge that PATHS will investigate the information provided in this application. By submitting this application, I agree to such investigation and to the reporting and information exchange activities of PATHS, as follows:

I hereby authorize all individuals, institutions, and entities who have knowledge concerning information requested in this application to consult with, and release relevant information to PATHS.

I understand and agree that the authorizations and releases given by me herein shall be irrevocable so long as I am an applicant for, or have staff privileges at PATHS.

I understand and acknowledge that PATHS is involved in querying the National Practitioner Data Bank, American Medical Association, Board of Medicine, and other entities as recommended by the National Committee for Quality Assurance.

I acknowledge that the investigation of information in this application and the release of information by PATHS is done to improve the quality of patient care.

All information provided by me in this application is true to the best of my knowledge and belief, and free of omissions. I understand and agree that any material misstatement in or omission from this application may constitute grounds for denial of privileges by PATHS , and that PATHS is responsible for all decisions concerning medical staff membership, and that third party payers shall be solely responsible for all decisions concerning participation with such third party payers.

I understand and agree that I have the right to review information submitted in support of my application and to correct erroneous information provided by either myself or an outside organization.

I further acknowledge that I have read and understand the foregoing authorization and release.

A photocopy of this Authorization and Release shall be as effective as the original.

Signature: ______Date: ___ / ___ / _____

02-02-016 Privileging Providers Page 34 of 36 PATHS Malpractice Claims Investigation Form

C O N F I D E N T I A L

Please complete this form if you answered “yes” to the question concerning malpractice actions on your Credentials or Reappointment Application. All questions must be answered completely. If additional space is needed, please attach additional pages. A separate form must be completed for each malpractice claim, so please photocopy this page prior to completing if you will be describing more than one.

Date of Occurrence: ___ / ___ / _____ Date Claim was Filed: ___ / ___ / _____

Professional Liability Carrier Involved: ______

Patient Name: ______

Name of Plaintiff, if other than patient: ______

Location of Incident: ______

You were (check one):  Primary Defendant  Co-Defendant

Other defendants (if any): ______

Describe the allegation(s) against you in detail: ______

Describe the alleged injury to the patient in detail: ______

Was suit filed in court?  Yes  No

State Court Case Number: ______State: ___ County/Parrish: ______

Federal Court (US District Court) Case Number: ______District: ______

Present status of claim/case:  Pending  Arbitrated  Settled  Dismissed Mediated  Adjudicated  On Appeal

Amount Sued for: $______Amount of Settlement: $______

02-02-016 Privileging Providers Page 35 of 36 Provide any additional information you would like PATHS to consider: ______

I certify that the information provided in this document is complete and accurate. I understand that any misrepresentation may result in my non-selection, or if discovered after selection, in my termination as a provider. I agree to notify PATHS in a timely manner of any change to the information requested in this application.

Signature: ______Date: ___ / ___ / _____

02-02-016 Privileging Providers Page 36 of 36