Accreditation documentation requirements for the human resource files are relatively straightforward, yet the human resource (“HR”) standards continue to be some of the most frequently cited standards and generate the most questions from DME customers. HQAA’s recent standards revisions and updates included several of the HR standards. This fact, along with the continued questions and citations for HR standards suggest it was time to revisit the personnel file and review expectations.
Personnel files are basically a record (electronic or paper) of the employee’s relationship and history with the employer. It usually contains job related documents and information regarding the employee’s knowledge, skills, and behavior. Additionally –perhaps, most importantly—it contains documents and information about the employee’s performance and documentation of their training and ongoing assessments of their competence.
Think of the personnel file as a legal document that can be pulled into court and know that laws exist that dictate how the information in the file can be accessed, shared, and used. Regardless of whether you are a larger, more complex organization with a formal human resource department, or a smaller organization where the owner or manager handles the management of human resource documentation, the laws and accreditation standards apply to you!
The survey process for accreditation will certainly include some questions for you regarding the files. Additionally, expect a surveyor to review some of the personnel files. Typically, they will want to review a cross section of staff’s files including clinicians, delivery techs, billing, and customer service personnel. If you provide clinical respiratory services, they will want to look at the file for one or more of the RT’s. If you provide custom rehabilitation services, they will want to look at the file for your ATP. What they look for in each file will be a function of the role/job duties that the employee plays in your organization. For instance, with delivery techs, they will certainly want to see driver’s licenses, and for clinical staff, they will certainly want to see evidence of state licensure for the clinician. Here’s a handy checklist of documents in the personnel file that they will expect to see during review:
- An application and/or resume
- Evidence of reference checks
- Notes or documentation from the job interview
- Background check (if required by the state or the organization’s policies)
- Orientation checklists signed by employee and trainer/manager
- A signed job description listing job duties and requirements
- I-9 forms with supporting documentation (such as passport or driver’s license)
- Any contracts or confirmations that the organization requires signatures for, such as confidentiality statements
- Professional licenses or certifications such as respiratory therapists, pharmacists, pharmacy technicians, ATP’s, or orthotists
- Evidence of ongoing in-service education, including continuing education credits for clinicians and documentation of the annual required topics
- Driver’s license for any staff expected to drive as part of their job duties
- Competency assessments for any staff providing patient care services (e.g.: clinicians and drivers). These assessments should be performed at hire and at least every two years per the newly updated HQAA HR 2 standard
- Performance evaluations done per organization’s policy, but at least once every two years
- A physically separated “healthcare” or “confidential” file for healthcare records to include:
- Hepatitis B vaccination information (can be either evidence of the vaccine or a declination form signed by staff member acknowledging that they were offered the vaccine
- TB testing results (if required by the organization)
- Any health care records such as physical exams for insurance qualification, or “OK to return to work” notes
- Any document that contains date of birth or social security number. While not medical or healthcare related per se, this information should be kept separated and confidential to protect the privacy of the staff member.
Note a few new minor adjustments to the HQAA standards. First of all, the HR 2 requirement for annual competency assessment has been changed. The new requirement is for every other year. This is in line with the requirement for performance evaluations. Often, these are tracked and done by the same person and often at the same time. Now, they are both required every two years, which presumably will make tracking a bit easier. Another change to this standard is that competency assessment is only required for staff that does direct patient care. This includes delivery technicians, respiratory therapists, and staff that sets up or educates patients regarding DMEPOS. Another point worth reinforcing is that competency assessments must be done utilizing similarly qualified individuals. Thus, a respiratory therapist doing clinical services should have their competency assessed by another clinician.
The other rather minor change to the HQAA HR standards is that the standard for ongoing and annual continuing education has dropped the specific hours requirement. The topics are unchanged and include bloodborne pathogens, infection control, safety, HIPAA, and new DMEPOS products. Prior to the standards update, there were specific numbers of hours associated with the required topics. Now, the hours are at the discretion of the organization so long as they cover the required topics.
The HR files can be maintained electronically or on paper, but either way, they’ll need to be secure with limited access. They should be uniform. All paperwork should be signed and dated. The organization should audit the files from time to time to ensure they are complete and up to date.
Ray Kroc, who grew the McDonald’s hamburger chain into the worldwide company that it is, famously said: “You’re only as good as the people you hire.” Think of the HR files as the organization’s proof and evidence that you have hired good people and maintain these important document files carefully.