WHO IS ACCREDITED?

Private Organization Accreditation

CSS Healthcare Services provides Community based health services to the young, the elderly and to Individuals with Developmental Disability. Founded in 1997, we have the ability to offer a variety of quality community-based services to our clients, which has greatly contributed to our growth and success.
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ORGANIZATION TESTIMONIAL

Advantage Credit Counseling Service

Mary Loftus, VP, Agency Service

Our agency is preparing for reaccreditation under the Eighth Edition Standards. The COA site is well organized and very easy to use. Our team of employees working on the reaccreditation process has found the tools index to be very helpful, particularly some of the templates.
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Purpose

A stable, qualified workforce contributes effectively and efficiently to consumer satisfaction and positive service delivery results.

HR 7: Personnel Records

The organization maintains personnel records in compliance with applicable legal and regulatory requirements.

Interpretation: The organization is not required to maintain personnel records for short-term or episodic volunteers who support the organization through administrative, clerical, fundraising, or other functions.

Note: Please see Personnel Records Checklist - Private, Public for additional assistance with this standard.

Note: HR 7 does not apply to independent contractors.  If the organization uses independent contractors see HR 8.

Rating Indicators
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the HR 7 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the HR 7 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the HR 7 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the HR 7 Practice standards. 

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Procedures for maintaining personnel records (all HR 7 standards)
    • Procedures regarding access to personnel records
    • Personnel records
    • Review the Network managing entity’s records for independent practitioners
    • Interview:
      1. HR Director
      2. Supervisory personnel
      3. Personnel at all levels

  • HR 7.01

    Personnel records are updated regularly, and contain:

    1. identifying information and emergency contacts;
    2. application for employment, hiring documents including job postings and interview notes, and reference verification;
    3. job description;
    4. compensation documentation, as appropriate;
    5. pre-service and in-service training records; and
    6. performance reviews and all documentation relating to performance, including disciplinary actions and termination summaries, if applicable.

    Interpretation: An organization may maintain records in separate files according to its own record keeping system as required by law or regulation.

    For example
    , EAP and health records, including health benefits enrollment forms, grievance, complaint, and response documents, immigration status documentation; and EEOC-related records, must be kept separately from other personnel records.

    Note: Network Management entities see HR 7.06.

    Note: Organizations should review state Medicaid plans or other third party reimbursement requirements to familiarize themselves with training requirements and timeframes and ensure appropriate documentation of training hours.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    •  With few exceptions, the organization complies with the standard, but a few records reviewed on newly hired personnel have not yet been completed; or
    • Documentation in a few records need updating.
    3
    Practice requires significant improvement; e.g.,
    • Many personnel files did not include all the relevant elements; job descriptions, pre- and post-service training, interview notes, questions, etc.; or
    • Documents in many files are outdated or missing.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • Personnel records are consistently incomplete or missing required documentation; or
    • There is evidence that personnel files are not maintained in compliance with applicable law or regulation, e.g., different record components are not appropriately separated.

  • HR 7.02

    Personnel records contain health information or reports for annual physical examinations, appropriate to the job position or when required by law.

    NA The organization does not employ persons in positions where health information or physical examinations are appropriate or required by law.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g.,
     
    • In a few instances documentation is outdated or missing but remedial action is being taken.
    3
    Practice requires significant improvement; e.g.,
    • Documentation is outdated or missing from a significant percentage of personnel files.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • HR 7.03

    Access to personnel records is limited to authorized personnel on a need-to-know basis.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g.,
    • Staff seem unclear about authorized access to different components of personnel records, but the organization is addressing the issue.
    3
    Practice requires significant improvement; e.g.
    • The organization has not assessed if its practices regarding file access meets legal requirements; or
    • Supervisors report being confused about access procedures and/or there have been a few incidents of unauthorized access.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • HR 7.04

    Personnel may review, add, and correct information contained in their records, in accordance with applicable law.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • Personnel report that they are able to make additions or corrections, but procedures need some clarification.
    3
    Practice requires significant improvement; e.g.,
    • Personnel are uncertain about procedures, and there is no evidence of management’s effort to clarify the issue.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • HR 7.05

    The organization provides all departing personnel with an opportunity to participate in an exit interview and documents the interview feedback or exit interview declination in the personnel record. 

    Interpretation: This interview enables personnel to address administrative issues related to the transition, as well as to provide feedback on the organization’s strengths and weaknesses.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • Documentation of exit interviews is not comprehensive and/or used for performance improvement.
    3
    Practice requires significant improvement; e.g.,
    • Exit interviews are sporadic and/or occur only at the request of the employee.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • HR 7.06

    The network maintains a record for independent providers that contain:

    1. identifying and contact information;
    2. documentation related to the network’s credentialing process;
    3. documentation of quality monitoring of practitioner performance;
    4. documentation of relevant training; and
    5. performance reviews and all documentation relating to performance, including disciplinary actions and termination summaries, if applicable.

    NA The organization is not a network management entity.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • One of the standard's elements is not fully addressed.
    3
    Practice requires significant improvement; e.g.,
    • Two of the standard's elements are not fully addressed or one elements is not addressed at all.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.
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