In the healthcare industry, verifying the qualifications and professional credentials of employees is essential—not just for operational excellence, but to meet regulatory and accreditation standards. One of the most important processes in this space is Primary Source Verification.
Primary Sourcing refers to the process of validating an individual’s credentials—such as licenses, certifications, and education—directly with the issuing organization. This might include contacting state licensing boards, certification agencies, or academic institutions to confirm the legitimacy, status, and applicability of a credential. It’s a cornerstone practice to ensure that every staff member is both qualified and properly credentialed for their role.
According to The Joint Commission, which sets accreditation standards for healthcare organizations, primary source verification is required for all licensed independent practitioners and other credentialed staff whose roles impact patient care. Specifically, The Joint Commission mandates that:
Primary source verification must be completed before the individual begins providing care, treatment, or services.
This applies to both new hires and current employees assuming new roles that require verification.
Verification must be conducted by the organization, not the individual practitioner. Accepting a copy of a credential from the practitioner does not meet the intent of the requirement.
Verification must include specific details, such as the date the verification was conducted, the person who conducted it, what was verified, and the results of the verification.
If a credential expires (e.g., a license or certification), it must be re-verified through the primary source prior to its expiration or before the staff member continues in a role that requires it.
Failing to meet these timing requirements can result in accreditation findings or jeopardize patient safety.
Before beginning the primary source verification process, determine which credentials are required for the employee’s position. Typically, this will be outlined in the job description. Ensure that the credential(s) you’re verifying are specifically necessary for the role. Employees are encouraged to obtain additional credentials or certifications that may enhance their qualifications (e.g., advanced certifications, additional licenses), but these do not need to be primary-sourced.
Each licensing or certifying body has its own process for verifying credentials. Here’s how to approach it:
Locate the credentialing body’s official website (e.g., Alabama Board of Nursing, American Nurses Credentialing Center, etc.)
Find the credential verification tool on their site. Most credentialing organizations have an online portal or database where you can verify credentials.
Search by Name or License Number: Most sites will allow you to search using the individual’s full name or license number.
Other Requirements: Some organizations may ask for additional information such as the Social Security Number (SSN) or Date of Birth to verify credentials. When possible, it is better to search on more details than just name as many credential holders have the same name.
Follow the organization’s specific instructions to ensure the process is completed correctly.
Once you’ve completed the search, the credentialing body will typically display a verification result, which might be available as a printable certificate or a screen display.
Ensure the document includes all required details, such as:
The individual’s name
Credential type (e.g., license, certification)
Credential number (if applicable)
Verification date (critical for compliance)
Status of the credential (active, expired, suspended, etc.)
Save the verification document as a PDF. Ensure the document is legible and that all relevant details are clearly visible.
Once the credential verification document is obtained, enter the credential information into Infor. Head to the Employee's Profile -> Talent Profile -> Credentials. If this is a new credential, use the Create button to add a new record. If the credential is being renewed, open the existing record to perform the necessary updates. Ensure the following details are recorded accurately:
| Field | Action: Create New Credential | Action: Renew Existing Credential |
|---|---|---|
| Credential | Select the appropriate credential code. Confirm correct code is selected by matching the Credential Description and Source. All credentials required per Job Description should be entered using a code. The 'Other' field is only for non-required credentials that don't have built codes. If you can't find the proper code, contact HRIS. |
|
| Credential Number | If applicable, input the credential number. | |
| Original Credential Date | Enter the original issue date of the credential. | |
| Most Recent Renewal Date | Enter the most recent renewal date. If none stated, use the same date as the Original Credential Date |
Update with the most recent renewal date. This should be the date the current record expires + 1 day, unless otherwise specified on the verification document. |
| Expiration Date | Enter the credential’s expiration date. | Update with the new expiration date. |
| Primary Source Date | Enter the date the document was pulled from the issuing body. | Update with the date the credential was re-pulled from the issuing body. |
| Validated/Validation Date | Mark Credential as validated & populate the Validation Date with today's date. | Update validation date with today's date. |
Once the credential has been verified and the details have been entered into Infor, store the verification document in OnBase to ensure the document is securely stored, easily retrievable for audits or future verification. When importing the document, be sure to place it into the appropriate Employee's folder with the Document Type of "HR - Credential"
A grace period is a defined window of time during which an employee may perform the duties of a position without yet possessing a required credential, provided they are actively working toward obtaining it. Grace periods are intended to support operational flexibility while maintaining compliance with credentialing standards. However, for a grace period to be applicable, it must be explicitly defined in the employee’s Position Description. If the Position Description does not specify a grace period, one must not be granted or assumed.
When a grace period is applicable, it must be entered into Infor to ensure proper tracking and compliance. Entering the grace period also allows for automated reminders to be sent to employees and managers as the deadline approaches, helping ensure credentials are obtained within the allowed timeframe.
Before entering a grace period, confirm that the employee’s Position Description explicitly allows for one. Look for phrasing such as “Credential X required within [timeframe] of hire.” If no grace period is specified, do not proceed with entering one. Credentials must be obtained prior to hire if a grace period is not documented.
Tip: If you’re unsure whether the Position Description includes a grace period or think one is missing, consult with the HR Director. We cannot simply add one due to the request of a Manager or Recruiter. The request must be evaluated against legal, regulatory, and risk considerations.
Head to the Employee's Profile -> Talent Profile -> Grace Period. Use the Create button to add a new record.
| Field | Action: Create Grace Period |
|---|---|
| Effective Date | Use today's date |
| Grace Period | Select the Grace Period timeframe defined in Position Description If you can't find the proper code, contact HRIS. |
| Grace Period End Date | The system will auto-calculate the end date based on the Grace Period timeframe chosen If you want to set a specific date, you can enter that to use instead |
| Credential | Select the Credential Must match the credential defined in Infor on the Position & must be defined as eligible for a grace period |
| Completed | Leave unchecked |
| Comments | Enter any comments that may be helpful |
Automated Email Notifications will be sent to Employee's with Grace Periods 30 days prior to the expiration
Once an Employee obtains the Credential (or an equivalent) for which the Grace Period was defined, the Grace Period needs to be marked a completed. Else the system will keep notifying the employee they are out of compliance.
This report identifies credentials that are essential to an employee's role and are approaching expiration within 60 days. It is designed to keep you ahead of upcoming renewals and to ensure ongoing compliance.
Report Non-Compliant Credentials HR
This report highlights essential credentials required for an employee’s role that are missing from their profile. It is primarily intended to support the management of Prehire records, helping to identify which credentials are necessary to primary for employees starting in the future. If a missing credential is flagged for an employee, it indicates a compliance issue that must be addressed immediately.
Report Credentials Needing Validation
Employees who are working on advancing their careers, such as those seeking promotions or transitioning into new roles within the organization, may update their profiles with newly obtained credentials. At the time they obtain these credentials, they may not be immediately required for their current role. However, as they transition into new positions or roles that require these credentials, we must ensure compliance with Joint Commission standards by completing Primary Source Verification. This audit report will show these required credentials that have been entered into Infor but not marked Primary Sourced and/or Validated.
The "Completed" status indicates that a credential is no longer required for the employee’s current role and prevents the Employee from getting notified by the system to renew the no longer needed credential. There are several situations in which a credential can be marked as completed:
Switching License Types: If an employee changes their license type but the old and new credentials are essentially equivalent (e.g., RN SSL to RN MSL), the previous credential should be marked as completed.
Changing Job Roles: When an employee moves to a position that no longer requires a particular credential, such as a Medical Laboratory Technician (MLT) transitioning to a Medical Laboratory Scientist (MLS), the former credential should be marked completed.
If a credential has been marked as "Completed", but the employee later returns to a role that requires it, the status should be unmarked so it appears in the reports as a required credential going forward.
No. Never delete a credential from the system. Deleting credentials can cause inconsistencies in record-keeping and reporting, making it difficult to maintain a clear audit trail. If a credential is no longer relevant or required, it should be marked as "Completed" instead of deleted.
No, unless correcting an error. The credential type should never be changed unless there is a mistake that needs to be corrected. For example, if a credential was entered incorrectly (e.g., a typing error), you can make a correction. However, if an employee changes or updates their credential (e.g., from an RN with one certification to an RN with a different certification), create a new record for the new credential type rather than altering the existing one.