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

Brewer-Porch Children's Center

James W. Thompson, Executive Director

The COA standards as applied to the operations at Brewer-Porch Children’s Center at The University of Alabama has given the administration an opportunity to examine best practice and improve the quality of care provided to clients.
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Purpose

The agency’s human resources practices attract and retain a competent and qualified workforce that is capable of supporting the agency’s mission and strategic goals. 

PA-HR 7: Personnel Records

Personnel records contain all relevant documentation and access to personnel records is limited to protect confidentiality.

Note: Please see Retention of Employment Records Tip Sheet - Private, Public for additional assistance with this standard. 

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
    • Policies and/or procedures for: 
      1. Maintaining personnel records 
      2. Accessing personnel records, including explanation of where personnel files are maintained in the agency (PA-HR 7.03)
    State Administered Agency (Regional Office)
    • A description of regional personnel records contents (PA-HR 7.01, PA-HR 7.02)
    All Agencies
    • Personnel records
    • Network only:
      1. Network review of the managing entity's records for independent practitioners (PA-HR 7.05)
    County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
    • Interview:
      1. HR Director
      2. Supervisory personnel
      3. Personnel at various levels including direct service personnel and support personnel
    State Administered Agency (Regional Office)
    • Interview:
      1. Regional HR personnel
      2. Supervisory personnel
      3. Personnel at various levels including direct service personnel and support personnel

  • PA-HR 7.01

    Personnel records are updated regularly, and contain:

    1. identifying information and emergency contacts;
    2. application for employment including resume;
    3. hiring documents including job postings, interview notes, reference verifications, and documentation of completed background checks when available;
    4. job descriptions;
    5. compensation documentation, as appropriate;
    6. pre-service and in-service training records when training hours are documented in the personnel file; and
    7. performance reviews and all documentation relating to performance, including disciplinary actions and termination summaries, if applicable.

    Interpretation: An agency may maintain records in separate files according to its own record keeping system and as required by law or regulation. For example, EAP and health records, including health benefits enrollment forms; grievance, complaint, and response documents; and EEOC-related records, must be kept separately from other personnel records.  

    Interpretation: Network management entities see PA-HR 7.05 for additional requirements.
     

    Note: Agencies 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.


  • PA-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 agency does not employ persons in positions where health information or physical examinations are appropriate or required by law.


  • PA-HR 7.03

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


  • PA-HR 7.04

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


  • PA-HR 7.05

    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 agency is not a network management entity.

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