Accreditation Commission for Health Care (ACHC), Centers for Medicare & Medicaid Services (CMS), and some individual states have requirements for ambulatory surgery centers (ASCs) to maintain personnel records for each staff member, including part-time and contracted staff.
Often, because of the size of an organization, there is not a separate human resources department, and the responsibility for maintaining personnel records is assigned to administration or nursing leadership. It is important for the designated individual(s) to become familiar with the regulatory requirements and to develop a systematic way to collect, analyze, and store the information needed in these records.
By starting this process with the development of clear and concise policies that are based on the required elements for a complete personnel record, the responsible party builds a strong foundation for success. These policies must be reviewed annually by the leadership and made available to staff.
ACHC Standards outline the required contents of the personnel record. Familiarity with these standards will help the facility ensure compliance. When organizing the record, the responsible party should be aware that consistency is the key to effective recordkeeping.
ACHC Standards
The following ACHC Standards apply to the documentation required in personnel records for deemed and non-deemed ambulatory surgery centers:
The organization must have written job descriptions for all personnel positions, including leadership, contract staff, and employees. Position descriptions include:
Job title.
Duties and responsibilities in accordance with state scope-of-practice laws.
Qualifications for the position, including education, training, experience, skills, license, and/or certification.
Standard: Personnel Record (02.01.04, deemed; 02.01.05, non-deemed)
The organization must maintain personnel records for each member of the staff, including contracted staff.
Personnel records contain basic information received at the time of hire, along with ongoing information, including:
Current license.
Registration, if required.
Competency assessments.
Evidence of new employee orientation.
Documentation of training provided on an annual basis or more often, as indicated.
Standard: Orientation Plan (02.01.05, deemed; 02.01.06, non-deemed)
The organization must have a written orientation plan that orients new employees to the organization and the specific duties they will perform. Organizational training must include:
Ethics and Corporate Compliance.
Patient rights.
Fire safety.
Quality improvement.
Patient confidentiality.
Infection control, including bloodborne pathogens.
Handling of hazardous waste.
Management of an incapacitated or impaired. healthcare provider (non-deemed).
Communication with outside entities (non-deemed).
Standard: Annual Staff Training (02.01.06, deemed; 02.01.07, non-deemed)
There must be documentation of annual training for each employee.
Annual training reviews the seven requirements of orientation. (For elements of training, see also Standard 02.01.05 for deemed surveys.)
The organization conducts an annual employee appraisal to identify the individual’s ability to perform job responsibilities.
Standard: Assessment of Staff Competency (02.01.08, deemed; 02.01.10, non-deemed)
The organization must have an objective process for assessing the competency of each provider of service. Competency assessment must be performed at least annually and at intervals as defined by the organization.
Tips for Compliance
Familiarize yourself with state requirements for the personnel record because additional documentation may be required.
Review your human resources policies on an annual basis.
Be aware of additional requirements that may be in your policy (example: background checks).
Review your training plan to ensure it is updated when policies and regulations change.
Organize the contents of the record in a way that specific documents can be easily located.
Store records in a secure location, and keep records confidential.
Be familiar with retention laws because different parts of the personnel record may vary with regard to mandatory time frames for maintaining documents after an employee leaves.
Consider a checklist or a spreadsheet to help track needed documents for each staff member.
Here to Help
For the most recent Ambulatory Surgery Center Accreditation Standards Manuals from Accreditation Commission for Health Care (ACHC), please contact your Account Advisor or email us at customerservice@achc.org.
Some content presented in “Did You Know?” may consist of timely or topical articles deemed to be of interest to the provider community. These are presented for informational purposes as a service to our readers. The views, opinions, and positions expressed by the authors are theirs alone and do not necessarily reflect the views, opinions, or positions of ACHC, its related entities, or any employee thereof.
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