Contracted Services - Human Resource Record Review During Survey

During a Joint Commission survey of an organization, is the surveyor required to manually verify human resource files/documents for employees, or independent contractors, of a Joint Commission accredited or certified contracted service?

Any examples are for illustrative purposes only

The Joint Commission does not typically request accredited organizations to summon the entire set of personnel files from accredited or certified contracted organizations. Contracted accredited organizations will undergo their own accreditation or certification survey by the Joint Commission and will demonstrate compliance within their personnel records at that time. If personnel records are requested for review, they must be provided in a timeframe sufficient for surveyor review during survey.  The evaluation of the contract itself by the HCO’s leadership, does not substitute for the surveyor’s request to see a specific employee file.   

Please note:  This FAQ applies only to staff and independent contractors of accredited or certified organizations and not to licensed independent practitioners (see also LD.01.03.01 and LD.03.04.01).  

Last updated on June 17, 2020
Manual: Nursing Care Center
Chapter: Human Resources HR

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