Standards FAQ Details | Joint Commission
Follow us on Twitter Friend us on Facebook Vimeo linkedIn Share with your Friends Print this Page
Saturday 5:36 CST, February 6, 2016

Standards FAQ Details


Human Resources (HR) (Critical Access Hospitals / Critical Access Hospitals)

Human Resource Standards Applicability to Contracted and Volunteer Personnel
Revised | May 10, 2011
Do the standards in the human resource chapter apply to contracted and volunteer personnel? If yes, how is compliance with the standards surveyed?

A: The standards in the human resource chapter apply to direct, contract, and volunteer personnel providing patient care and/or services on behalf of an organization, regardless of whether the contracted organization is accredited.
Patient care personnel can include, but are not limited to:

  • nursing, therapy, dietary, pharmacy, activities staff, drug and alcohol counselors such as AA counselors, and nursing assistants/aides

Patient services personnel can include but are not limited to:

  • homemakers, companions, sitters, chore workers, drivers, home medical equipment delivery and repair technicians, volunteers transporting patients

Non-patient care or service personnel that would not be included are, for example:

  • volunteers who deliver the mail or flowers, staff the information desk, gift shop or library services, perform patient errands (e.g. writing and mailing letters or obtaining magazines and toiletries from the gift shop), conduct marketing or fund raising activities,

Contracted Personnel: Organizations must manage contracted services and personnel just as they must manage services and personnel who are provided by direct employees. They can either define in the contract or in policy criteria for performance of the contracted service; or, review and adopt the contract organization's policies and practices.
The human resource standards are applicable to any contracted service which provides any element of care or service which is eligible for survey with the following exception:
Home Care: The human resource standards do not apply to delivery of home medical equipment and pharmaceutical products via a contracted common carrier, i.e., UPS, FEDEX, or similar, US Postal Service, local courier companies, etc., where there is no education and setup involved. The standards do apply when provided by a direct employee.
The contract should specify that the contracted organization will provide only staff who are qualified in relation to their education, training, licensure, and competence as defined by the organization.
Volunteers: When volunteers perform patient care or services the organizations must manage volunteer personnel just as they must manage services and personnel who are provided by direct employees
Contract or volunteer Staff Information: The organization should have verified information, (where relevant) of their:

  1. Education and training that is consistent with applicable legal and regulatory requirements and organization policy;
  2. Evidence of license, certification, or registration, when applicable; and
  3. Evidence that individual's knowledge and experience and competence are appropriate for his or her assigned responsibilities as required by the contracting organization.
  4. Orientation to the contracting organization
  5. Evaluations of performance
  6. Health status as required by job responsibilities, as defined by the organization, and as required by law and regulation.
  7. Criminal background check or pre-employment verification of convictions for abuse or neglect, when required by law and regulation
  8. References, when applicable

Evidence of verification may include:

  • appropriate information for each contracted person maintained by the contracting organization
  • copies of appropriate information for each contracted person obtained from the contracted organization/individual
  • the results of an audit of appropriate information for contracted individuals conducted by the contractor. The organization determines whether to include a percentage or all contracted individuals in the audit.
  • the results of an audit of personnel, health, and education records of contracted individuals conducted by the contracted organization. In this case the organization defines the specific information to be included in the audit and whether the audit is to include a percentage or all contracted individuals.

Note: The audit must include an attestation as to the accuracy of the information. A simple attestation letter indicating that the information is current and on file at the organization site, without the audit is not sufficient.

The actual services provided by any contracted organization or individual must meet the intent of all applicable standards in all chapters in the manual that are surveyed for compliance.
Q: Do the standards apply if the contracted organization is Joint Commission accredited?
A: Contracting with a Joint Commission accredited organization does not, in and of itself, assure compliance with the human resource standards. Each organization has it's own specific requirements and is surveyed for compliance with those requirements. When contracting for staff the organization should:

  • define the required qualifications for the contracted staff. This should be delineated in the contract language.
  • review the personnel practices of the contracted organization and the qualifications for their staff to determine compliance with the organization's requirements,
  • if the contracted organization's practices are acceptable the organization can accept those practices for the contracted personnel to be provided

If the contracted organization's practices are not acceptable the organization can define in the contract the specific requirements, or perform the requirements itself

  • develop mechanisms to assure that the contracted organization is complying with the organizations requirements. Examples of mechanisms are outlined above.

It should be noted that the contracted organization may have received recommendations related to the human resources standards. The organization should ensure that the contracted organizations personnel polices and procedures are in compliance with the standards and the contractual requirements.
The location of personnel information for active and former personnel is at the discretion of the organization.