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Release Notes:
Data Element
Version 2010A1

Data Element Name: Background Check
Collected For: HCSS-3,
Definition:Documentation in personnel file to verify that employee is not disqualified from patient contact due to criminal conviction or other conduct substantially related to patient care.
Suggested Data Collection Question:Is there documentation in the personnel file that a background check has been done and does this documentation verify that the employee is not disqualified from patient contact due to criminal conviction or other conduct substantially related to patient care?
Format:
Length:
Type:Alphanumeric
Occurs:
Allowable Values:

Yes      There is documentation in the personnel file demonstrating that the requirements of the minimum data set for this element have been met.

No      Documentation in the personnel file of the minimum data set requirements for this element is missing, incomplete, or expired.

Notes for Abstraction:None
Suggested Data Sources:

  • OIG on-line check, Sanctions search, License Look-Up, and other computer searches
  • Departments of professional registration and regulation
  • State licensing boards
  • State disciplinary boards
  • State/national background studies
  • State/national data bases
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
For purposes of data collection for this measure, personnel file documents must meet requirements as specified by the minimum data set for background check. Proof of background check includes the following components:
  • Verification of previous employers for new hires
  • Reference checks for new hires
  • Background check, including criminal records search, at the time of hire and rehire

Disqualifications from patient care may include:

  • Health care related civil judgments in federal or state court
  • Health care related criminal convictions in federal or state court
  • Injunctions
  • Actions taken by federal or state licensing and certification agencies, including revocations, reprimands, censures, probations, suspensions, any other loss of license, or the right to apply for or renew a license
  • Exclusions from participation in federal or state health care programs

Background Check
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)