Standards for private organizations

2020 Edition

Human Resources (HR) 5: Personnel Records

The organization maintains a personnel record for each employee.
2020 Edition

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Purpose

The organization’s human resources practices attract and retain a competent and qualified workforce that contributes to consumer satisfaction and positive service delivery results and supports the achievement of the organization’s mission and strategic goals.
Note: See RPM 5: Security of Information for more information on appropriately limiting access to personnel records to protect confidentiality.

Note: Please see the Personnel Records Checklist for additional guidance on this standard. 
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the HR 5 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the HR 5 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the HR 5 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 5 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Procedures for maintaining personnel records
  • Procedures regarding access to personnel records
  • Network procedures for maintaining independent provider records
No On-Site Evidence
  • Interviews may include:
    1. HR Director
    2. Supervisors
    3. Relevant personnel
  • Review personnel records
  • Review the Network managing entity's records for independent practitioners

 
Fundamental Practice

HR 5.01

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;
  6. health information or reports for annual physical examinations, appropriate to the job position or when required by law; and
  7. 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 records, health benefits enrollment forms, documentation of a grievance/complaint and response documents, immigration status documentation, and EEOC-related records must be kept separately from other personnel records.
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 needs updating.
3
Practice requires significant improvement; e.g.,
  • Many personnel records did not include all the relevant elements; job descriptions, pre- and post-service training, interview notes, questions, etc.; or
  • Documents in many records 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 records are not appropriately maintained, e.g., different record components are not separated.

 

HR 5.02

Personnel may review, add, and correct information contained in their records.
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 5.03

The network maintains a record for independent providers that contains:
  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.
Note: See HR 2.05 for more information on network credentialing processes. 
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 element is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.