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Contract Staff - Applicability of Human Resource Standards (HAP, CAH, AMB, OBS, NCC)

What are the expectations for complying with the Human Resource (HR) requirements when patient care services are provided via a contractual agreement?

Any examples are for illustrative purposes only.

All standards in the Human Resource (HR) chapter apply to contract staff providing patient care, treatment or services.  A well-written contract should specify that the contract organization will provide only staff who are qualified by education, training, licensure, and competence as defined by the organization. Simply contracting for services provided by another Joint Commission accredited organization does not assure compliance with the HR standards.   
Examples of compliance may include (when applicable):
  • The individual possesses the knowledge, experience and competence appropriate for his or her assigned responsibilities.
  • Current license, certification, or registration confirmed via primary source verification.
  • Meets the educational and experience requirements defined by the organization.
  • Completion of health screenings and criminal background checks as required by law, regulation and organizational policy.
  • Orientation to the policies and procedures, key safety content and specific job duties.

During a survey, the surveyor may ask to review files of contract staff to evaluate compliance. Only the information needed to demonstrate compliance should be provided. Organizations are NOT required to maintain redundant HR files on contracted staff or share the actual results of health screenings or criminal background checks, only that such requirements have been completed.

Through the contractual agreement, organizations determine which entity is responsible for obtaining and maintaining the required HR documentation. Accredited organizations are also required to monitor the provision of the contracted services provided based on the defined performance expectations. The requirements that address contracted services are found in the Leadership (LD) chapter of the accreditation manual at LD.04.03.09.

Examples of clinical contracted services may include, but are not limited to:
  • Dialysis
  • Pharmacy
  • Dietary
  • Environmental Services
  • Laundry Services
  • Agency/traveling staff (nurses, therapists, etc)
  • Mobile imaging (CT, PET, MRI, etc)

Manual: Critical Access Hospital
Chapter: Human Resources HR
Last reviewed by Standards Interpretation: April 27, 2022 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: April 11, 2016 This Standards FAQ was first published on this date.
This page was last updated on April 27, 2022 with update notes of: Review only, FAQ is current Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.

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