Qualification conundrum

Qualification conundrum

Qualification conundrum

Navigating California’s licensure and certification landscape

(From Summer 2022 Convey magazine)

By Jill Scofield

When it comes to practicing in California as an SLP or audiologist, what’s required? License? Certification? Credential?

According to Paul Sanchez, executive officer of the Speech-Language Pathology & Audiology & Hearing Aid Dispensers Board (SLPAHADB), as far as the State of California is concerned, the difference between licensure and certification comes down to what’s required to practice in the state. And in most instances, that’s a license.

“Every licensee needs to understand the importance of having their license, which is required to go to work every day,” he says. “Maintaining the license is so important because your livelihood depends on it. I realize there are very similar requirements in being licensed and certified, but that’s the difference – the license is required to do your job.”

And while national certification is often preferred or required by specific employers in California, particularly in the medical arena, it is not a requirement of the state.

In California, state laws and regulations across a broad swath of professions and industries tend to be more arduous than in other states in the interest of consumer protection. The California SLPAHADB, like other state licensing entities, operates under the California Department of Consumer Affairs, which, in turn, reports to the governor. With regard to the state licensure requirements for speech-language pathologists (SLPs) and audiologists, they’re more time intensive in terms of the required number of supervision hours, while American Speech-Language-Hearing Association (ASHA) certification documentation and rating requirements are more elaborate.

Clarity fades

As with anything in life, though, clarity fades when getting into the weeds. It turns out there are some exceptions where a state license isn’t currently required. And there are cases where national certification is believed to be required, but isn’t.

Having one’s “Cs” refers to the Certificate of Clinical Competence (CCC) for both Audiology (CCC-A) and Speech-Language Pathology (CCC-SLP). These professional certifications by ASHA are intended, according to ASHA, to demonstrate one has “voluntarily met rigorous academic and professional standards, typically going beyond the minimum requirements for state licensure.”

So, for California SLPs and audiologists, is it necessary to have both your license and certification to practice, or is it more nuanced than that?

The answers are frequently opaque, and confusion about what’s actually required leaves many seeking clarity.

What’s required in California

Those who are both licensed in the state of California and ASHA certified know the requirements run parallel in many regards. Both require a master’s degree or equivalent from an accredited university for an SLP, or a doctoral degree for audiology, and a minimum score of 162 on a Praxis exam.

For licensure in California, SLPs must also complete 300 hours of supervised clinical practicum in three different clinical settings, and 36 weeks of full-time or 72 weeks of part-time supervised Required Professional Experience (RPE), while holding an RPE temporary license. There is also a clinical practicum requirement for ASHA certification: 400 hours of supervised clinical experience.

Licensure requirements for audiologists include the same level of clinical practicum as SLPs. But in 2008, the education requirement changed from having a master’s degree as a minimum to having a doctoral degree. For audiology licensees, the final year of their education must be an externship under the direction of the doctoral program, essentially meeting the RPE requirement of SLP licenses.

In terms of ASHA certification, CCC-SLP candidates are required to complete a Speech-Language Pathology Clinical Fellowship (SLPCF), similar in nature to the RPE required for California licensure. The SLPCF specifically calls for a minimum of 36 weeks and no less than 1,260 hours, and also requires the candidate to have a mentor who holds their CCC-SLP and will commit to 18 hours of direct and 18 hours of indirect observation.

The costs for licensure and certification can be a factor, especially for those just entering the profession. An RPE temporary license, needed to meet the RPE licensure requirement, costs from $234 to $254 in fees, on top of the license fee of $150. Costs for the CCC-A and CCC-SLP remain consistent at $455 without an ASHA membership, and $511 with membership included.

Therefore, if certification is not a requirement of an employer on top of the California-required licensure, the cost alone may be a barrier.

Practicing in California schools

Much of the confusion about what’s required seems to lie in the public K-12 school setting, where over half of California SLPs practice.

According to Kristen Nahrstedt, ClinScD, CCC-SLP, the current chair of the CSHA Professional Practices Advisory Committee and former member of the CSHA Board of Directors, there can be a lot of uncertainty for SLPs entering a public school setting. Nahrstedt also serves as the director of simulation, clinical supervisor and lecturer at California State University, San Marcos, working closely with students as they navigate the path to applying for jobs once they graduate.

“It’s confusing for school SLPs because you’ve got three different agencies issuing three different documents for practicing – the credential from the CTC (Commission on Teacher Credentialing), the certification through ASHA and the state SLP license,” said Nahrstedt. “And every system is different.”

According to Nahrstedt, the minimum requirement for SLPs practicing in the public school system is a credential issued by the CTC. Qualification for a credential is based on verification of Praxis scores, and a 36-week, full-time mentored clinical experience supervised practicum (known as the clinical fellowship), verification of a California SLP license, or verification of ASHA certification.

Any of these will do, Nahrstedt says, so an SLP license is not necessarily required, especially if the therapist is not practicing outside of the school setting. “Many of us disagree with that, because in all other settings, you have to have your license.”

Sanchez of the SLPAHADB agrees that better clarity about the licensing requirement is needed within the school settings, especially for SLP Assistants (SLPAs). “Many of our licensees work in school settings. In order to work in a school setting, SLPs need either a credential or a license. SLPAs are required to hold a valid license to work in any setting, and I think that’s part of the confusion. School districts also need to look to the state licensing board and know what the requirements are and understand the differences [between licensure and certification].”

Lauren Young, MS, CCC-SLP, is a California school speech pathologist who began her career in the New York public school system. When she moved west in 2010, she worked in private practice for several years before deciding to return to the school system. Once she did so, she got her Speech-Language Pathology Services Credential through the CTC and ended up working for a district requiring both a credential and an SLP license.

“At the district I ended up with in California, I needed to have both my credential and my state license,” she says, adding that she assumed the ASHA certification would be needed as well. But in looking at the job requirements more closely, she says the certification was not. “I guess it was just preferred to have your Cs and not actually required.”

The area of frustration for Young as she transferred to California from another state was the change in consistency between licensure and certification. In New York, the maintenance of her state license was more on par with the timing of re-certification through ASHA.

“New York was more consistent with ASHA in terms of continuing education (CE) requirements, as it was every three years. In California, it’s 24 units every two years,” she notes. “If I’m already getting 24 CE units for my state license every two years, why not get the additional six units for the ASHA certification? I try to aim for 12 CE units a year, so I know I’m covered, but it’s a lot more complicated than it was in New York.”

Medical settings

The health care system is one area that does tend to lend clarity to the requirements for therapists, according to Amanda Fazakerly, MS, CCC-SLP, CSHA secretary/treasurer who works for the UC Davis Health Department of Physical Medicine and Rehabilitation.

“In the hospital setting, nearly half of our patients are covered by Medicare, which requires both licensure and certification, so that’s really the limiting factor,” she says. “Students in the classroom and in the clinic know it’s an assumed right of passage that both [licensure and certification] will be required for most in-patient settings and even some outpatient settings.”

Despite that requirement in most settings, some clinics and hospitals are starting to soften their stance on the certification requirement because they know it’s a barrier to hiring qualified people. In those cases, California licensed, but noncertified SLPs do not work with Medicare patients.

For those in hospital or medical settings who do have both licensure and certification as a requirement of their job, the frustration seems to lie in the redundancies that exist between the two.

“Requirements for both licensure and ASHA overlap, and they’re actually quite broad. So, any frustration that exists may be in paying double for essentially the same requirements. You’re essentially paying two different governing bodies,” says Fazakerly, adding that ASHA’s selling point for certification is that the requirements extend beyond what’s required for licensure in most states outside of California.

The audiology perspective

When Tara Roberts began her journey as a California audiologist in the late ’90s, her philosophy was one of over-preparedness. She graduated with a master’s degree from an accredited California university, went on to complete her nine months of clinical training, and ended up earning both her CCC-A and her license to practice in California.

But the world of audiology has evolved since then. In 2008, when the minimum degree required to be both certified and licensed in audiology changed from a master’s to a doctorate, Roberts considered her options. Technically, because she earned her master’s in audiology from an accredited university before the change took place, her licensure and certification were still valid. But she wanted to remain competitive.

“My approach to all of this was to have as much as I could to fall back on. Why not get as much education, and all the licenses and certifications? It just opens up the opportunities available to you,” she reflects. So, she went on to earn her doctorate in audiology as well.

An audiologist for a major health care provider for the past two decades, Roberts has maintained that perspective, continuing to renew both her license and her certification over the years.

But she’s noticed more and more new practitioners who don’t necessarily agree. “When I started my career, having your ASHA certifications was sort of the gold standard. It was a no-brainer. But more and more, I hear younger practitioners questioning the necessity of it a little more.”

Peter Ivory, Ph.D., CCC-A, professor and program director at California State University, Los Angeles, has seen the unfolding of changes in audiology requirements firsthand. He was among a group of professors who saw their university’s audiology accreditation stripped overnight when the doctoral requirement went into effect. For him, the issue of accreditation is on par in terms of importance with licensure and certification for audiologists.

“The bottom line is that there is a linkage between licensure and accreditation. You have to be licensed to work in California. But the eligibility of licensure requires an academic degree from an accredited program that is recognized by an appropriate accrediting organization.”

Herein lies another facet of ASHA’s role. ASHA’s partner organization, the Council on Academic Accreditation (CAA), is the body that accredits SLP programs at universities. And in order to have an accredited program, every faculty member at each accredited university must have their Cs. More information on university accreditation can be found at caa.asha.org.

Accrediting organizations, which are semiautonomous parts of professional organizations such as ASHA, are themselves accredited by an overarching organization – in this case, the Council for Higher Education Accreditation (CHEA).

But for audiology programs like Ivory’s, an alternative path to accreditation is through the American Academy of Audiology (AAA) and its Accreditation Commission for Audiology Education, which also has the CHEA stamp of approval.

Ivory’s university finds itself in the home stretch of regaining its accreditation through AAA after a years-long process, and he is eager to see his first cohort of doctoral students enter the field with the appropriate requirements for licensure under their belts.

Audiologists also have an alternative certification option that is not available to SLPs – American Board of Audiology (ABA) certification. From Ivory’s perspective, both are equal, but employers are less informed of the ABA certification and that it represents the same quality measures as a CCC-A.

“I advise students that you have to get licensed to work in California, end of story,” he says, adding that he does encourage them to seek ABA certification.

When it comes to ASHA certification, his experience of late mirrors what Roberts notes about a perceived decrease in audiologists with their Cs.

“I’m not sure how much traction the CCC-A carries any more. Being prepared for all possibilities would be one benefit. But for new entries into the field, additional certification may be too expensive,” he says, adding “they may have no perceived value in it if it’s not required.”

Improvements needed

CSHA member Anna Krajcin, MS, CCC-SLP, is owner of Communication Across Barriers speech clinics and serves as a clinical supervisor at California State University East Bay (CSUEB). As someone who has the unique perspective of being in private practice and providing real-world guidance and insight to her students at CSUEB, she sees their frustrations as they enter the field.

“Graduation is a time when confetti should be falling from the heavens, and it’s just not for these students,” she says, citing confusion that exists for new SLP practitioners once they enter the field, and the amount of time it takes them to get properly licensed to conduct business after they graduate. “The amount of detail and specificity that’s necessary for these students without any real guidance is really a horrible situation for them.”

She says students tend to hear more about ASHA certification and its importance during their education, then finally learn about licensure and RPEs as they get closer to graduating. “They don’t understand there are two bodies, two sets of fees, plus any additional requirements from the employer. No one creates a checklist for the students, and that’s really what they need.”

The wait time for licensure is another frustration that has been longer for new applicants since the pandemic began and can be further delayed by any small error on paperwork. “These students are essentially in limbo until they get that license. Even if they do everything right, there’s so much that is required, and if there’s one small error, it needs to be corrected and you start the whole process over again” says Krajcin. The licensing delays can keep new clinicians from earning their first paychecks and clients from receiving the services they need.

Paul Sanchez doesn’t disagree that the process can take time, but says improvements are being made. Since he joined the SLPAHADB nearly eight years ago, the number of SLP licenses has grown from about 11,000 to over 25,000, with an additional 6,000 SLP assistant licensees and 1,500 temporary RPE licenses.

“The increase in licenses requires resources. It’s case work – you have to make sure everyone met the requirements, look at transcripts and documentation, et cetera. We have not been able to keep up with the growth for a variety of reasons, but we’ve worked to make sure the board is adequately funded, structured for growth, and has adequate facilities to accommodate that growth,” Sanchez says.

CSHA has actively advocated for the licensing board to receive the necessary state funding to achieve the goals Sanchez has for continuing to decrease the timelines for licensure processing.

With the licensing board recently moving into a less-confined location, Sanchez is hopeful that additional staff can be added to help address the growing workload “These things take a long time, like anything else in government. We had already grown by 30%, but if the licensing population has grown by 70%, then we still need to work toward growth.”

Feasible solutions

With requirements largely driven at the employer level, by funding source, or based on the type of setting, it seems consistency may be difficult to achieve in the short term. But some argue that near-term solutions can help new and veteran practitioners alike better navigate the process and understand what’s actually required to do business in California.

For Anna Krajcin, having additional clarity and documentation specifically for students entering the SLP field would be ideal. “I’d like to see some sort of checklist or documentation, or central clearinghouse that would allow for information to be streamlined to help these students navigate this process.” She adds that since many of the requirements for licensure and certification are parallel, having to duplicate the process can be arduous.

Nahrstedt agrees that additional clarification would be helpful to the field, citing the need for more continuing education at industry conventions or meetings at the state and national levels. But she sees an additional opportunity at the university level. “I also wonder if universities should have more of a responsibility to their alumni to share resources and new information with them to help them navigate. Clinical directors know this information inside and out because they prepare the students for this.”

The desire for increased consistency between bodies governing licensures and certification, however, indicates a longer-term solution that goes beyond education and better communication. And with more extensive supervision requirements for the CA RPE than the ASHA CFY, it’s likely that aligning state licensure to meet ASHA timelines and standards is not a part of the discussion.

At the end of the day, understanding the requirements of the job from the employer directly may be the best course. “I tell my students that they should be very clear that the organization they’re working with knows exactly what the requirements are for them to do their job and do it responsibly,” says Nahrstedt of Cal State San Marcos.

From the licensing board’s perspective, a big part of that conversation should be understanding the legal implications of getting and maintaining one’s license.

“With a licensing board, it’s about maintaining a license to do business with consumer protection at the forefront,” says Paul Sanchez. “If you don’t meet the requirements to practice in California, the implications are more significant.”

Jill Scofield is a Northern California- based freelance writer whose coverage largely focuses on issues affecting higher education, agriculture, membership associations and local government.

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