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Joint Commission and Criminal Background Checks

Question: Does Joint Commission require criminal background checks?

Response & Analysis:

While Joint Commission itself does not require criminal background checks, in Issue 45 of its “Sentinel Event Alert,” it does generally recommend criminal background checks as a means of preventing violence in the healthcare setting. In its “suggested actions,” Joint Commission recommends that a healthcare organization work with its HR department to ensure that it thoroughly prescreens job applicants and establishes and follows procedures for conducting background checks of prospective employees and staff.

In addition, Joint Commission expects criminal background checks to be conducted on staff, students and volunteers where required by state law and/or organization policies. According to “The Joint Commission Standards FAQ Details” (the “Standards”), staff, students and volunteers who work in the same capacity as staff who provide care, treatment and services are expected to have criminal background checks verified when required by law, regulation and/or organization policy. If criminal background checks, therefore, are required by state law, regulation or organization policy on all employees, volunteers and students, Joint Commission expects them to be done on all three categories. If, however, state law requires background checks on only specified types of healthcare providers, or if the state clearly does not consider volunteers or students to be employees, then Joint Commission would require background checks on only those specified in state law (unless organization policy goes beyond state law).

If state law requires background checks on all “employees,” Joint Commission advises the organization to seek an opinion from the state on what categories of healthcare workers are considered employees. And, if state law is ambiguous as to the definition of employee, Joint Commission permits the organization to define the scope of background checks to fit its own definition.

In the absence of a state law on criminal background checks, Joint Commission provides that each organization can develop its own expectations, only evaluating compliance with the organization’s internal policy. Joint Commission further notes in the Standards that all criminal background checks must be documented by the organization.

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This document and/or presentation is provided as a service to our customers. Its contents are designed solely for informational purposes, and should not be inferred or understood as legal advice or binding case law, nor shared with any third parties. Persons in need of legal assistance should seek the advice of competent legal counsel. Although care has been taken in preparation of these materials, we cannot guarantee the accuracy, currency or completeness of the information contained within it. Anyone using this information does so at his or her own risk.

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