Contract Staff - Applicability of Human Resource (HRM) Requirements (BHC)

What are the expectations for complying with the Human Resource (HRM) requirements when care, treatment, or services are provided via a contractual agreement?

Any examples are for illustrative purposes only.

All standards in the Human Resource Management (HRM) chapter apply to contract staff providing care, treatment or services.  A well-written contract should specify that the contract organization will provide only staff who meet the minimum qualifications and competencies to perform specific duties and responsibilities.  Simply contracting for services provided by another Joint Commission accredited organization does not assure compliance with the HRM 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.  Staff is generically defined to include employees, contracted staff, volunteers, and students who provide care, treatment, or service to the individuals served.  All requirements of the HRM chapter are applicable to any of these individuals.  Only the information needed to demonstrate compliance should be provided. Organizations are NOT required to share the actual results of health screenings or criminal background checks, only that such requirements have been completed.

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.
Last updated on June 15, 2020
Manual: Behavioral Health
Chapter: Human Resources Management HRM

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