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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 practitioners (see also LD.01.03.01 and LD.03.04.01).  

Manual: Assisted Living Community
Chapter: Human Resources HR
First published date: April 11, 2016 This Standards FAQ was first published on this date.
This page was last updated on November 23, 2022 with update notes of: Editorial changes only 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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