Free printable checklist · Cima Consulting
Staff credential file checklist for behavioral health programs
Every staff member and contractor in a treatment program needs a credential file that shows, with dated proof, that they were qualified and cleared before they worked with clients: a license verified at the board's website, a criminal background check, clear federal and state exclusion checks, references, a signed job description and confidentiality agreement, TB screening and CPR where required, orientation and yearly training, and supervision records for associates and interns. Exclusion checks repeat monthly; licenses at renewal; training yearly. Surveyors from the state and from Joint Commission or CARF pull these files.
Updated October 24, 2026. From the credential file and orientation checklists we write for programs and keep for our own licensed Texas program. Not legal advice.
Three rules for every file
- Primary source, dated. Verify each credential with the board, school or agency that issued it, then print or save the result with the date and initial it. A copy of a license card the employee hands you isn't verification.
- Before client contact. Background, license and exclusion checks clear before the start date; TB screening before client contact. A file completed after the fact shows a gap a surveyor will write up.
- Keep medical and I-9 records apart. The Form I-9 and any medical information, including TB results, go in separate confidential files, not the credential file a surveyor reads.
This list is about your own staff files. The documents insurance plans want for network applications are a different list: the credentialing documents checklist.
Cima Consulting · consulting.cimaehr.com/checklists/staff-credential-file-checklist
Staff credential file checklist
Staff member and position: ________________________Start date: ____________Verified by: ______________
Verify before the start date 14 items
Who needs it, and how it's verified. Date and initial each result.
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Signed and dated, attesting the information is true.
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Reviewed by the hiring manager.
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The board website's printout, dated. In Texas: LPC, LMFT, social work and psychology licenses on the BHEC lookup; LCDCs and counselor interns on the HHSC license lookup; nurses on the Board of Nursing site.
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Counseling is provided by or under qualified credentialed counselors, such as LCDCs and certain other licensed professionals; counselor interns need QCC supervision. Check each person against 26 TAC 564's current definitions.
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The certifying body's lookup.
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From the registrar or a verification service, unless the license check already covers it.
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Who you spoke with, when, and what they said about the role.
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As state law and your policy require, with fingerprints where required.
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The search printout from HHS-OIG. Nobody excluded can work on services billed to federal health programs.
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The search printout from SAM.gov.
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In Texas, the Texas HHS Office of Inspector General's exclusion list.
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An NPPES lookup showing the right name and taxonomy.
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The DEA registration lookup for prescribers, and the certificate of insurance for each licensed clinician the program's policy doesn't cover.
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The result goes in the separate medical file; the credential file notes the date. TB screening rules vary by state and accreditor.
Signed on day 1 4 items
Signed and dated by the employee, filed the same day.
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Listing the license or credential the role requires. Signed again when the job changes.
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Substance use records have the added federal protection of 42 CFR Part 2.
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Hours, pay, leave, conduct, confidentiality, social media, a drug-free workplace and complaints; reviewed by your attorney before staff sign.
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Copies and a motor vehicle record, checked again every year.
Orientation and training 6 items
Sign-in sheets, quizzes or certificates go in the file. The trainer and employee initial each item.
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Tour of exits, meeting point, shelter room, extinguishers, AED and naloxone; emergency procedures and the call tree; the crisis and suicide protocol (who to call, never leaving an at-risk client alone); overdose response and naloxone use.
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HIPAA privacy and security basics and Part 2 for SUD programs; mandated reporting of abuse, neglect and exploitation; EHR account with multi-factor sign-in.
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Documentation deadlines, late entries and never backdating; client rights and the grievance process; infection control and bloodborne pathogens; de-escalation; the schedule, curriculum and group note standard; shadowing groups and sessions.
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Collection, chain of custody and waived testing under the program's CLIA certificate of waiver.
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For staff with client contact; the expiration date goes on the re-check calendar.
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Trauma-informed care and cultural responsiveness; environment of care, ligature risk and safety rounds; the medication policy (staff who handle medications); medical necessity, utilization review and the treatment plan link; fraud, waste and abuse and the anti-kickback rules; a 30-day check-in with the supervisor.
Checked again on a schedule 6 items
The part that slips after opening. Each check is dated and initialed.
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For every staff member and contractor, with the results kept.
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Who supervises whom, how often and how it's documented. Boards, plans and surveyors read the logs.
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A new dated board printout each time; DEA renews every 3 years.
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HIPAA, Part 2, emergency procedures, abuse reporting, naloxone and CPR renewals on schedule, with sign-in sheets.
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By the employee and supervisor.
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On the schedule in your infection control plan, and yearly for drivers.
As of October 24, 2026. Your state rules and accreditor may require more; where a rule is named, check the current version. Cima Consulting isn't a law firm.
The re-check calendar
| How often | What | Who |
|---|---|---|
| Monthly | OIG LEIE, SAM.gov and Texas HHS-OIG exclusion searches; supervision logs | Everyone, including contractors; associates and interns |
| At each renewal | License or certification, board certification, DEA, malpractice, CPR card | Whoever holds it |
| Yearly | Required training, naloxone training, performance review, driving record | Everyone; drivers |
| Per your policy | TB re-screening, background re-checks | Staff with client contact |
| When the job changes | A newly signed job description | The employee |
These sit beside the program's other recurring work (drills, safety rounds, chart reviews). Comply's behavioral health compliance calendar lists the rest by week, month, quarter and year.
Texas specifics
- Who verifies where: the Behavioral Health Executive Council for LPCs, LMFTs, social workers and psychologists; HHSC for LCDCs and counselor interns; the Texas Board of Nursing; the Texas Medical Board for physicians.
- QCCs: in a licensed Texas chemical dependency treatment facility, counseling is provided by or under qualified credentialed counselors, and interns need QCC supervision. The state's survey reads staff files against 26 TAC chapter 564 (HHSC).
- The Texas Medicaid exclusion list is kept by the Texas HHS Office of Inspector General; check it monthly along with the federal lists.
- Hiring paperwork outside the credential file: the I-9, payroll forms and, once you have W-2 employees, a Texas unemployment tax account with the Texas Workforce Commission.
Staffing the program in the first place (directors, the medical director, QCCs, the hiring order) is part of the IOP opening checklist's Hiring and HR phase and the IOP guide's staffing section.
If someone is on an exclusion list
Remove them from work on any service a federal or state health program pays for, and tell the compliance lead and your attorney the same day. Don't bill for anything they did while excluded until your attorney says how to handle it. The monthly checks exist so you find out in weeks, not at an audit.
Help with files and surveys
We set up credential files, job descriptions, the handbook outline and the orientation checklist as part of every IOP / PHP Program Launch. For an open program, a mock survey pulls a sample of personnel files the way a state or accreditation surveyor does, and staff training sessions come with sign-in sheets for the file:
| Service | Price |
|---|---|
| Mock survey A one-day survey the way an accreditor or state surveyor would do it, with a written report and fix list. Includes: Leadership, environment and record tracers; Chart audit sample; Written findings and corrective-action plan. | $3,500 |
| Staff training session A live 60–90 minute training for your team, with sign-in sheet and materials. Includes: HIPAA and 42 CFR Part 2, documentation that holds up, or your topic; Slides and handout; Attendance record for your training files. | $500 per session |
| Program compliance partner Monthly compliance for an open program: chart audits, policy updates, survey readiness. Includes: 10 charts audited every month; Policy updates when the rules change; Quarterly mock tracer; Credentialing upkeep for up to 8 clinicians; Survey and inspection support. | $3,500 per month |
Questions
What goes in an employee file at a treatment center?
The signed application, resume, primary-source license verification, references, background check, exclusion checks, signed job description and confidentiality agreement, orientation and training records, CPR, and supervision records for associates and interns. Medical information (TB results) and the I-9 are kept in separate files.
How often should we run exclusion checks?
Monthly is the common practice, for every staff member and contractor, against the OIG LEIE, SAM.gov and your state's Medicaid exclusion list, keeping each result.
Do contractors need a credential file?
Yes for anyone who provides or bills services or works with clients: license verification, exclusion checks and their agreement at minimum. The monthly exclusion checks include contractors.
Can we keep credential files electronically?
Yes, as long as each item is dated, verifiable and quick to produce for a surveyor, and medical information stays separate with restricted access.
Want a surveyor's read of your files first?
A one-day mock survey, personnel files included, with a written fix list: $3,500.
Or book a free 30-minute call. Words you met here are in the glossary; the client side is the intake packet checklist. All our free checklists.
Sources
- Cima Consulting's credential file and staff orientation checklists, as of October 24, 2026.
- HHS-OIG, List of Excluded Individuals/Entities; SAM.gov; USCIS, Form I-9
- Texas Behavioral Health Executive Council; Texas Board of Nursing; Texas HHSC, hhs.texas.gov (26 TAC ch. 564); Texas Workforce Commission
- eCFR, 42 CFR Part 2; CMS, CLIA; CMS, NPPES