Primary Source Verification Pitfalls and Successes

Many organizations continue to struggle with the primary source verification requirements.  Primary Source Verification(PSV) is required for any license, certification, or registration that is legally required to practice or perform a certain function.  While most organizations have a solid process for the initial primary source verification process at the time of hire, many organizations still struggle with the primary source verification process at the time of expiration.  In an attempt to better manage the process, some organizations have decentralized this verification step by assigning the completion of the verification to Department/Unit leaders or volunteer staff.

Recently during a mock survey, the organization identified that primary source verification at expiration was assigned to each affected Ancillary Department Leader and to a small team of volunteers for the Nursing Units.  As we explored the process implemented, several gaps in the process became apparent:

  • Performance of the PSV was not included in the job descriptions of those assigned to perform, nor was it included in the Job Specific Orientation.  Hence, when the Department Leadership changed, the performance of this duty went incomplete, leaving the organization with a huge vulnerability. 
  • Performance of the PSV was assigned to volunteers to complete, but direction was not provided to those volunteers related to what to look for.  Was the license, registration, or certification not renewed prior to the expiration?  Was the status of the license changed, perhaps from Active to Inactive or Provisional? Exploring this area identified that there were no written instructions or guidance given to the persons performing the duty to immediately notify a member of the Organization’s Leadership of the finding.
  • While the organization decentralized the performance process, no instruction was provided as to what evidence would be required to substantiate that the license, registration, or certification had been primary sourced after renewal and prior to expiration.

Hardwiring the Primary Source Verification process into your organization’s operating procedures is essential. Inclusion in job descriptions builds a pathway to accountability; inclusion in orientation materials sets the person with responsibility for performing up for success. 

Lastly, providing written guidance to those assigned the responsibility is essential, as not every verification site document includes the date and time that primary source verification was completed on. Ensuring that those assigned to perform primary source verification understand that they can print the primary source document and note on the document that primary sourcing was completed on this date at this time and signing that document is an acceptable practice. 

Please contact us for questions or more information at  704-573-4535 or

Courtemanche & Associates specializes in Healthcare Accreditation and Regulatory Compliance Consulting Services. With over 29 years of being in business and 100+ years of healthcare experience amongst our consulting team, we are ready to assist with your accreditation and regulatory compliance needs.

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