Healthcare staffing credentialing checklist (US)

What a complete credential file contains

Joint Commission’s Health Care Staffing Services (HCSS) certification gives the clearest public definition. A complete personnel file has three parts, and a file that is missing, expired or unclear on any of them fails:

Job-appropriate credentials: current license, certification or registration as federal and state rules require, plus proof of education or training, matching the position description.
Evidence of current competency: assessed at hire or rehire and every year after.
A background check at the time of hire or rehire.

Most hospital clients add their own requirements on top, such as immunizations, TB screening and drug testing, so the checklist below combines the federal sources with what facilities commonly ask for.

Licenses and primary source verification

Verify every license with the primary source. Joint Commission accepts verification through a secure electronic communication or by phone if it is documented.
For nurses, Nursys is a primary source equivalent: the data comes directly from the boards of nursing. QuickConfirm gives free license and discipline lookups, and e-Notify sends updates when an enrolled nurse’s license changes.
Some boards do not supply APRN data to Nursys, including California, New York and Illinois. Verify those APRN licenses directly with the board.

The Nurse Licensure Compact

A nurse whose primary state of residence is a compact state can hold one multistate license and practice in the other compact states. 43 jurisdictions have enacted the Nurse Licensure Compact and 40 have implemented it. A nurse who moves to another compact state must apply for a license there within 60 days. Check the current NLC map before relying on a state’s status: implementation dates keep moving.

Life support certifications

BLS, ACLS and PALS cards are issued by the American Heart Association and the American Red Cross. AHA course completion eCards are valid for two years, with renewal recommended by the end of the month two years after completion. Red Cross BLS for Healthcare Providers certificates are also valid for two years. Track expiry dates: an expired card is an incomplete file.

TB screening

Under CDC guidance, baseline screening before placement has four parts:

An individual TB risk assessment
A symptom evaluation
A TB test: a blood test (IGRA) or a skin test (TST). A skin test for baseline must be two-step, repeated 1 to 3 weeks later if the first is negative. A blood test needs no second step.
Further evaluation for TB disease where needed

Since 2019, CDC does not recommend annual TB testing of health care personnel unless there is a known exposure or ongoing transmission at the facility. All health care personnel should get TB education every year. Some facilities still require annual testing for their own staff and clinicians, so check each client’s policy.

Immunizations

The core federal source is the ACIP report on immunization of health care personnel. Facilities commonly require:

Hepatitis B for anyone exposed to blood, body fluids or sharps
MMR and varicella: vaccination or evidence of immunity
Tdap: one dose if not received before
Influenza: every year

CMS withdrew its federal COVID-19 vaccination requirement for health care staff in 2023, and federal vaccine recommendations have been contested in court during 2026. Treat COVID-19 and any other additional vaccines as set by the client facility’s policy and state law.

Exclusion screening

Check the HHS OIG List of Excluded Individuals and Entities (LEIE). Excluded people cannot be paid by federal health care programs for any items or services they furnish, and anyone who hires them may face civil monetary penalties.
OIG says that if a hospital takes an excluded nurse from a staffing agency, the hospital faces overpayment liability and may face penalties, and it recommends providers screen agency nurses. The LEIE is updated monthly, and OIG advises routine screening of new hires and current staff.
Also check SAM.gov exclusions, which lists parties debarred from federal contracts and assistance. SAM does not replace the LEIE.

Background checks and drug screening

When you use a background check company, the Fair Credit Reporting Act applies. Before ordering the report you need a stand-alone written disclosure and the candidate’s written authorization. Before taking adverse action you must send a pre-adverse action notice with a copy of the report and a summary of their rights, then an adverse action notice afterwards.

Joint Commission’s measure requires the check at hire and again at rehire. Findings that may disqualify include health care related criminal convictions, licensing board actions and exclusions from federal or state health care programs.

There is no general federal requirement for private staffing firms to drug test. Requirements come from client contracts and state law, and some states restrict testing: California, for example, bars discrimination based on off-duty cannabis use.

Competency and Joint Commission certification

Competency must be documented at hire or rehire and every year after. Evidence Joint Commission accepts includes discipline-specific skills checklists, competency assessments, continuing education certificates, HIPAA and OSHA training, current CPR, references and verified work history.

HCSS certification runs on a two-year cycle. Certified firms report standardized measures, including completeness of personnel files and do-not-return rates for per diem and travel staff, and reviewers examine at least 20 clinical staff files at each review.

Frequently asked questions

Do travel nurses need an annual TB test?

CDC has not recommended annual TB testing for health care personnel since 2019, unless there is a known exposure or ongoing transmission. Baseline screening before placement is still recommended, and some facilities require annual testing under their own policy.

How long are BLS and ACLS certifications valid?

American Heart Association BLS, ACLS and PALS course completion eCards are valid for two years. Red Cross BLS for Healthcare Providers certificates are also valid for two years.

Do staffing agencies need to check the OIG exclusion list?

Checking the LEIE is not required by statute, but hiring an excluded person exposes the agency and its hospital clients to overpayment liability and penalties. OIG recommends routine screening, and the list is updated monthly.

What is a complete personnel file for Joint Commission?

Under the HCSS measures, a complete file has job-appropriate credentials, evidence of current competency and a background check. A file that is missing, expired or unclear on any of the three fails.

Collecting these documents without the chasing

Getting Docs asks each candidate for exactly the documents they still owe, over WhatsApp or email, checks that what comes back is the right document and can be read, and files it onto the candidate’s record in your ATS. It does not carry out the checks in this guide for you: the verification and the decision stay with your compliance team. It makes sure the documents are in front of them.

See how it works for healthcare staffing and home care staffing, or book a short call.

Related guides

Form I-9 for staffing agencies: acceptable documents, deadlines and remote verification: Form I-9 for staffing agencies: List A, B and C documents, the Section 1 and Section 2 deadlines, receipts, remote examination, reverification, retention and penalties.

Official sources

This guide was checked against these sources on October 2, 2026:

This guide is general information, not legal advice. Rules, fees and document lists change: check the official sources above before you rely on any detail, and take advice for your own situation.