Common Deficiencies of Personnel Files

Whether you keep paper or electronic personnel files, you must maintain them in a secure and organized manner so they will be ready for your surveyor during your unannounced survey. A good best practice is to audit your personnel files two to four times annually to ensure that the files are complete and up-to-date. 

There are a few items that are commonly marked as personnel file deficiencies. Make sure the following articles are completed, organized and stored in a secure fashion.

The I-9 form:

There are various sections on the I-9 form that need to be completed by either the employee or the designated staff member/employer. The form is divided into sections:

Section One

1. Completed by the employee
2. Signed and dated

Section Two

1. Completed by the organization’s staff member witnessing the documents shown as evidence of List A or of List B and List C
2. Certifies that the information listed was reviewed and is acceptable

Competency assessments:

Organizations ensure that all staff is qualified through the use of competency assessments. These assessments are required “at hire” and annually by the accreditation organization. Competency assessments ensure the staff member instructing customers or clients:

• Has been trained appropriately
• Is able to perform the tasks assigned in the job description

Competency assessments need to be designed for the specific position the employee has, and are completed with a supervisor or peer with the same knowledge base or background. For example, a respiratory therapist (RT) would be reviewed by another RT and a service technician (tech) would be reviewed by another tech.

Separation of any document containing a date of birth:

This is one area that tends to be overlooked when reviewing the personnel files for completeness. Any document containing a date of birth should be in a separate file, such as the Health Information File.

Signed job descriptions:

Job descriptions must be present for every employee within the organization (although owners can be exempt). Job descriptions for the employee’s current job/duties must be in the file and need to be signed and dated. 

All job descriptions must contain:

• Job title
• Reporting requirements
• Expected work hours
• Basic position requirements and listing of major duties/tasks
• Information to comply with ADA requirements, such as physical demands and activities
• Education requirements, including continuing education requirements

Auditing your personnel files on an ongoing basis will help ensure you meet all the requirements for your survey. For additional help, download our Personnel File Audit.