Maintaining personnel records for staff members is required to achieve ACHC Accreditation and meet applicable state and federal regulations.

Your organization must keep records, and keep them up to date, for all personnel, including support personnel, licensed clinical personnel, unlicensed clinical personnel, administrative and/or supervisory employees, contracted personnel, independent contractors, volunteers, and students with clinical internships.

Personnel record requirements apply to behavioral health, home care, home health, home infusion therapy, hospice, palliative care, and renal dialysis organizations accredited by ACHC.

Who Is Responsible for Personnel Records?

If your organization does not have a separate human resources department, the responsibility for maintaining personnel records usually is assigned to administration or clinical leadership.

It is important that these designated individuals become familiar with regulatory requirements and develop a systematic way to collect, analyze, and store personnel record information.

Clear and concise policies also must be developed in accordance with personnel record requirements. Policies must be reviewed annually by leadership and made available to staff.

ACHC Requirements

ACHC Accreditation Standards identify materials you need to include in your personnel records. During your accreditation survey, your Surveyor will ask to review personnel records based on the services your organization provides.

Your organization is not required to maintain records on site for contracted staff, but you must be able to access these records and make them available for review during your survey.

Standards specify that your personnel records include, at the minimum, the following items:

• Position application*
• Dated and signed withholding statements*
• I-9 form*
• Personnel credentialing/verification of qualifications
• TB screening
• Hepatitis B vaccination
• Job description
• Motor vehicle license and record check, if applicable
• Criminal background check
• National sex offender registry
• Office of the Inspector General’s (OIG’s) exclusion list
• Personnel policies review or employee handbook*

*Not applicable for contracted staff.

• Annual performance evaluations
• Completion of orientation
• Competency assessments
• Annual on-site observation visit
• Annual in-services/education
• Conflict of interest disclosure form, if applicable
• Confidentiality statement
• CPR, if applicable

Stay Compliant

ACHC recommends that your organization audit personnel files at least annually for documented evidence of required materials. Familiarity with ACHC Standards and consistency in recordkeeping are essential to support accreditation success.

Educational resources, such as the “Personnel Files Survey Checklist,” are available on your customer portal. Download a free copy of the checklist from the ACHC customer portal (under “Resources”) or complete the accompanying form to receive an email with a link to the checklist.

ACHCU, our education division, also offers a wide range of tools and resources to help you prepare for accreditation. Visit achcu.com to learn more.