2024 Edition

Human Resources Introduction

Purpose

The organization’s human resources practices attract and retain a competent and qualified workforce that contributes to consumer satisfaction and positive service delivery results and supports the achievement of the organization’s mission and strategic goals.

Introduction

Since an organization’s workforce performs the tasks and provides the services that fulfill the organization’s mission, its capacity to attract and retain a stable, competent, and qualified workforce is the foundation for achieving positive results for the people and communities it serves. As such, it is incumbent upon Human Resources Management to develop and implement strategies, plans, and programs necessary to attract, motivate, develop, reward, and retain the best people to meet the organization’s goals and objectives.

Interpretation

The HR standards apply to all “personnel” which includes both full-time and part-time employees. Standards that apply to direct service volunteers and independent contractors specifically note their inclusion. COA does not include non-direct service, occasional, or casual volunteers in evaluating an organization’s human resources practices, but organizations should consider the benefits and risks associated with their role.

Note:Please see the HR Reference List for the research that informed the development of these standards.


Note: For information about changes made in the 2020 Edition, please see HR Crosswalk.


2024 Edition

Human Resources (HR) 1: Human Resources Planning

The organization assesses its workforce as part of annual planning and prepares for future needs by:
  1. comparing the composition of its current workforce, including number of employees, skills, demographics, and cultural characteristics, with projected workforce needs; and
  2. determining how to close gaps, when needed, through recruitment, training, leadership development, and/or outsourcing.
Network Interpretation: In addition to the internal HR planning described here, networks must also conduct a network-wide analysis of service providers (NET 3.03, NET 9) in order to ensure full access to needed services.
Examples: To address employment or leadership selection patterns that do not reflect the community served, organizations may establish a plan that includes:
  1. targeted recruitment goals and strategies;
  2. reviewing policies and criteria to identify factors that may pose systemic obstacles to employment or advancement; and
  3. equitable leadership and personnel development programs.

Leadership development programming can include, but is not limited to: trainings, degree or certificate programs, review of relevant professional literature or research, shadowing, additional assignments to develop new skills, leadership mentoring, and exposure to functions outside the individual's current role. Organizations can promote equitable access to leadership development programs by setting transparent, objective, performance-driven eligibility criteria and considering conflicts with job responsibilities when planning activities.

Note: Please see the Workforce Assessment and Planning Tip Sheet for additional guidance on this standard. 

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The workforce assessment is conducted but is not effectively integrated into annual planning; or
  • Strategies for closing identified gaps need improvement.
3
Practice requires significant improvement; e.g.,
  • The organization has not assessed workforce needs for more than two years; or
  • The assessment only addresses some of the programs or services; or
  • The assessment indicates significant gaps but the organization has not taken steps to address them.
4
Implementation of the standard is minimal or there is no evidence that an analysis has been conducted within the past four years.
Self-Study Evidence On-Site Evidence On-Site Activities
  • Assessment of workforce needs
  • Community Demographic Profile
  • A list of administrative and management personnel by department that includes:
    1. name
    2. title
    3. degree held and/or other credentials
    4. role (e.g. employee, volunteer, or contractor)
No On-Site Evidence
  • Interviews may include:
    1. CEO
    2. HR Director
    3. Program/department directors
2024 Edition

Human Resources (HR) 2: Recruitment and Selection

The organization hires appropriately qualified personnel to meet the demand for services and support the achievement of the organization's mission.

Currently viewing: RECRUITMENT AND SELECTION

VIEW THE STANDARDS

Related Standards:

Note: Please see the Personnel Records Checklist for additional guidance on this standard. 

1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the HR 2 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the HR 2 Practice standards; e.g.,
  • With few exceptions, personnel possess the requisite qualifications; or
  • There are a few vacancies, but quality of service or organizational performance is not impacted in any observable way.
3
Practice requires significant improvement, as noted in the ratings for the HR 2 Practice standards; e.g.,
  • There is a pattern of personnel who lack the requisite qualifications, though few in number in any given service; or
  • One or more organizational services cannot meet this standard; or
  • There are significant vacancies in some programs which affect service provision (i.e., high caseloads, or staff unable to meet job expectations).
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the HR 2 Practice standards; e.g.,
  • Personnel consistently do not meet the qualifications for the position and/or for their title.
Self-Study Evidence On-Site Evidence On-Site Activities
  • Recruitment and selection procedures
  • Background check policy
  • Background check procedures
  • Recruitment and selectionpolicies
  • Network credentialing and verification procedures
  • Sample job descriptions from across job categories or positions
  • Relevant portion of governing body minutes when HR selection policies were reviewed and approved
  • Interviews may include:
    1. HR director
    2. Senior managers
    3. Supervisors
    4. Relevant personnel
  • Review personnel records
  • Network interviews may include:
    1. Committee chair or person in charge of the credentialing process
    2. Managing entity staff members responsible for verifications
    3. Clinical supervisors of selected non-accredited contracted providers to verify provision of supervision
  • Review network individual provider and contractor records

 
Fundamental Practice

HR 2.01

Job descriptions and selection criteria:

  1. state the credentials, job expectations, core competencies, essential functions, and responsibilities for each position or group of like positions;
  2. include inclusive language and demonstrate the organization's commitment to equity, diversity and inclusion;
  3. include sensitivity to the service population’s cultural and socioeconomic characteristics; and
  4. are reviewed and updated regularly to evaluate their continued relevancy against the needs and goals of the organization’s programs and persons served.

Examples: Credentials can include, for example:

  1. education;
  2. training;
  3. relevant experience;
  4. competence in required role;
  5. recommendations of peers and former employers; and
  6. any available state registration, licensing, or certification for the respective disciplines.


Examples: Examples of inclusive language in job descriptions can include:

  1. language regarding accommodation for different abilities;
  2. neutral language to eliminate age, cultural, racial, and gender biases; and 
  3. highlighting inclusive benefits that support a diverse workforce directly in the job description. 
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • All but a few job descriptions comply with the standard, e.g., are comprehensive and up-to-date; or
  • One of the standard's elements is not fully addressed.
3
Practice requires significant improvement; e.g.,
  • One of the standard's elements has not been implemented at all;
  • In a significant percentage of cases, the organization does not comply with the standard, e.g., job descriptions are incomplete, vague, or omit qualifications; or
  • Several positions do not have job descriptions.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

HR 2.02

Recruitment and selection procedures include:

  1. notifying personnel of available positions;
  2. verifying past employment and credentials;
  3. providing applicants with a written job description;
  4. giving final candidates the opportunity to speak with currently-employed personnel; 
  5. using standard interview questions that comply with employment and labor laws; and
  6. using diverse interview panels.
Related Standards:

Examples: Diverse panels with representatives from different backgrounds, departments, and seniority levels offer new perspectives, encourage organizations to think broadly and inclusively, and minimize bias. 

1
The organization's practices reflect full implementation of the standard.
2

Practices are basically sound but there is room for improvement; e.g.,

  • Procedures need greater clarity; or
  • Recruitment and selection procedures address the use of diverse interview panels, but staff report it is not always happening in practice; or
  • One of the standard's elements is not fully addressed.
3

Practice requires significant improvement; e.g.,

  • Procedures are very general and/or do not provide useful guidance; or
  • Recruitment and selection procedures do not address using diverse interview panels at all; or
  • Two elements are not fully addressed or one of the elements is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

HR 2.03

Screening procedures include appropriate, legally permissible, and mandated reviews of state criminal history records and civil child abuse and neglect registries for new employees, contractors, volunteers, and student interns who will:
  1. work in residential programs;
  2. provide direct services to, or be alone with, children, the elderly, or other persons determined by the organization to be vulnerable or at risk; or
  3. work with sensitive or confidential information such as personnel and client records.
Related Standards:
Interpretation: The organization is not required to conduct background checks for licensed staff if the organization has verified that background checks are conducted as part of the licensing process. The organization should assess whether there is any risk associated with not conducting background checks on staff not expressly addressed in the standard and consult with legal counsel, as needed. The requirements do not apply to current employees and contractors or to agencies with which the organization contracts for services.
 

Interpretation: The organization should not use criminal history records to deny employment to qualified individuals unless the nature of the conviction is related to the job duties. The organization should consult with legal counsel about any concerns regarding the appropriate use of background information.
 

FEC Interpretation: Due to the nature of services provided, credit counseling organizations are required to conduct criminal history record checks on all staff and volunteers. The child abuse and registry checks are not applicable.
 

OST and ECE Interpretation: Organizations providing OST or ECE services should conduct checks that include: (1) fingerprint-based state and federal criminal history record checks, (2) child abuse and neglect registry checks, and (3) sex offender registry checks. Furthermore, they should conduct these checks on all employees, volunteers with an ongoing role, and contractors who will provide direct services to or be alone with children and youth, including parties who may have been working with the organization before the implementation of background checks. These expectations also apply when organizations contract with outside companies to provide certain services (e.g., transportation services), unless they have verified that background checks are conducted by the outside company (e.g., if the school district that provides transportation already conducts background checks on bus drivers). Organizations should also conduct periodic re-investigations, unless they will be automatically notified by the authority that conducted the initial check if a subsequent violation occurs. 

MS Interpretation: Organizations providing Mentoring Services should conduct criminal history checks and child abuse registry checks on all mentors, where legally permissible. However, the organization should also ensure that the screening process is tailored to the needs and characteristics of target mentees. For example, the screening process should not disqualify prospective mentors if their criminal histories correspond with the lived experiences that uniquely qualify them to the role, such as human trafficking victimization or substance use.
1
The organization's practices reflect full implementation of the standard, e.g.,
  • Practice reflects that the organization understands the legal requirements regarding criminal records checks and review of civil child abuse and neglect registries, and conducts legally permissible reviews for new employees, contractors, volunteers, and student interns.
2
Practices are basically sound but there is room for improvement; e.g.,
•    Procedures for verifying background checks for licensed personnel need strengthening. 
3

Practice requires significant improvement; e.g.,

  • In rare cases background checks are not completed prior to personnel being left alone with vulnerable populations or having access to sensitive or confidential information.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • The organization consistently does not screen personnel per the requirements of the standard; or
  • Screening procedures violate applicable law; or
  • Procedures are vague or non-existent.

 

HR 2.04

An organization that recruits and selects employees with specific cultural traits or other characteristics establishes that such selectivity is:
  1. legally permissible;
  2. reviewed and approved by the organization's governing body, as applicable; and
  3. appropriately considered a bona fide occupational qualification central to meeting the needs of persons served.
Related Standards:
NA The organization does not recruit and select personnel with specific cultural traits or other characteristics.
Examples: An organization under religious auspices might seek legal advice to confirm that it may require employees to belong to a specific religious affiliation if knowledge of and commitment to the values of the religious tradition are necessary to accomplish the activities of the organization.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement.
3
Practice requires significant improvement; e.g.,
  • The organization has not verified that practices are legally permissible, e.g.,
    • Bona fide occupational qualification; and/or
    • Criteria based on religious affiliation.
  • Selection criteria have not been reviewed and approved by the organization’s governing body.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

HR 2.05

The network has a uniform and fairly applied credentialing process that assesses and confirms the qualifications of licensed independent contractors/providers who provide network services and are not employed by a member or community partner that includes:
  1. verification of licensure, education and other relevant training and board certification, where applicable;
  2. experience delivering services to the populations served by the network;
  3. the professional judgment of at least three peer professional references with regard to competence and prior satisfactory levels of performance;
  4. information about pending challenges, provisional status, or previous suspensions or denials of licenses to practice;
  5. publicly available information or official information regarding professional liability actions and litigation relevant to the provision of network services; and
  6. information about prior involuntary termination, reduction of professional staff privileges, or discharge from professional employment obtained from prior staff affiliations or employers.
Related Standards:

NA The organization is not a network management entity and is not assigned the Network Administration (NET) standards. 

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Procedures for verifying credentials need clarifying; or
  • One of the standard's elements is not fully addressed.
3
Practice requires significant improvement; e.g., 
•    Procedures are not well-understood or used appropriately; or
•    Two of the standard's element are not fully addressed or one element is not addressed at all. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

HR 2.06

The network verifies that personnel of network partners and network provider organizations who provide clinical services to network clients:
  1. possess relevant licenses and/or credentials; and
  2. are receiving appropriate supervision.
Related Standards:

NA The organization is not a network management entity and is not assigned the Network Administration (NET) standards. 


NA All partner and subcontracting provider organizations are accredited by COA or a COA-recognized accrediting body.

 

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Procedures related to one of the standard's elements need clarifying.
3
Practice requires significant improvement; e.g., 
•    One of the standard's elements is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.
2024 Edition

Human Resources (HR) 3: Satisfaction and Retention

Human resources practices are equitable and consistently applied and promote a high level of personnel satisfaction and retention.
Related Standards:
Examples: Factors that may contribute to staff satisfaction and retention include:
  1. role clarity;
  2. regular team, organizational, and divisional meetings to promote open communication and collaboration among disciplines and staff levels;
  3. leadership that encourages initiative, creativity, and innovation;
  4. leadership that rewards and recognizes employee contributions;
  5. satisfaction with salary and benefits;
  6. work-life policies and practices, such as flexible work options;
  7. leadership that provides feedback to personnel about their suggestions and recommendations;
  8. reasonable workload;
  9. autonomy;
  10. opportunities for advancement; and
  11. opportunities for career development.

Note: Please see the Personnel Records Checklist for additional guidance on this standard.

1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the HR 3 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the HR 3 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the HR 3 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the HR 3 Practice standards.
Self-Study Evidence On-Site Evidence On-Site Activities
  • Summary results of most recent staff satisfaction survey
  • Summary results of most recent staff retention analysis
  • Table of Contents for personnel policies and procedures manual
  • Personnel grievance procedures
  • Documentation of actions taken to address satisfaction and retention concerns
  • Personnel policies and procedures manual
  • Grievance reports for the past six months
  • Interviews may include:
    1. CEO
    2. Governing Body
    3. HR Director
    4. Relevant personnel
  • Review personnel records

 

HR 3.01

The organization annually measures personnel satisfaction and retention and takes action to address identified satisfaction and retention concerns.
Related Standards:

Interpretation: The aggregation of data reduces the risk of disclosing personal identifiable information in most instances; however, risk of disclosure still exists particularly when data is being disaggregated and unique or easily observable characteristics might allow someone to be identified in the data set. As such, data collection and reporting procedures should include mechanisms for avoiding such disclosure such as data suppression, rounding, reporting in ranges rather than exact counts, combining sub-groups into larger groups, etc.

Examples: Disaggregated data can be useful in addressing identified satisfaction, retention, turnover, hiring, and promotion concerns. Common characteristics used to disaggregate data include:

  1. race and ethnicity/country of origin;
  2. generation status;
  3. immigration/refugee status;
  4. age group;
  5. sexual orientation; and
  6. gender/gender identity
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Satisfaction and/or retention are not formally measured for a few departments and/or programs.
3
Practice requires significant improvement; e.g.,
  • Satisfaction and/or retention are not formally measured for a number of the organization's departments or programs;
  • Staff satisfaction and/or retention has not been formally measured for more than two years; or
  • The organization collects data on staff satisfaction and turnover but does not take action to address concerns; or
  • Retention data has been aggregated but there is no indication of how it is used.
4
The organization does not measure staff satisfaction and/ or retention.

 

HR 3.02

All personnel confirm receipt of a personnel policies and procedures manual that articulates current:

  1. conditions of employment;
  2. benefits;
  3. rights and responsibilities of employees; and
  4. other important employment-related information.

Examples: Policies and procedures that are commonly addressed in a personnel manual include:

  1. the organization's equity statement;
  2. conditions and procedures for layoffs;
  3. emergency and safety procedures;
  4. equal employment policies;
  5. harassment and discrimination;
  6. nepotism and favoritism protections;
  7. grievance process procedures;
  8. insurance protections including unemployment, disability, medical care, and malpractice liability;
  9. performance review system;
  10. promotions;
  11. professional development;
  12. standards of conduct;
  13. time-off policies;
  14. wage policy;
  15. working conditions;
  16. technology/network security and usage policies; and
  17. the use of social media, electronic communications, and mobile devices.
1
The organization's practices reflect full implementation of the standard.
2

Practices are basically sound but there is room for improvement; e.g.,

  • A few of the organization’s procedures are vaguely written or incomplete; or
  • A few staff report not having a copy of, or access to, the manual.
3

Practice requires significant improvement; e.g.,

  • The manual does not include a few important policies or procedures; or
  • A significant number of staff did not confirm receipt of the manual.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

HR 3.03

The organization reviews and updates the personnel policies and procedures manual every two years with an equity, diversity, and inclusion lens to ensure the manual remains up-to-date and promotes equity throughout the organization.

1

The organization's practices reflect full implementation of the standard.

2

Practices are basically sound but there is room for improvement; e.g.,

  • Policies and/or procedures have not been reviewed in the past 2 years, but a review is underway; or
  • There is minimal evidence that the manual has been reviewed through an EDI lens.
3

Practice requires significant improvement; e.g., 

  • Policies and/or procedures have not been reviewed for more than three years; or
  • Evidence that the manual has been reviewed through an EDI lens is not present.
4

Implementation of the standard is minimal or there is no evidence of implementation at all.


 

HR 3.04

The organization establishes personnel grievance procedures, which include:
  1. the right to file a grievance without interference or retaliation;
  2. a description of how grievances are filed, to whom, and who will make a final determination;
  3. timely written notification of the resolution and an explanation of any further appeal, rights, or recourse;
  4. processes for review including a third-party review of the final determination;
  5. documenting responses and actions taken; and
  6. maintaining a copy of the notification of resolution in the personnel record.
Interpretation: Regarding element (d), the third-party review refers to at least one level of review that does not involve the person about whom the complaint has been made or the person who reached the decision under review. If a grievance is raised against the CEO, then the grievance will go directly to the governing body.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • One of the required elements is not fully addressed; or
  • In a few instances staff were not aware of the procedures or did not know how to access them.
3
Practice requires significant improvement; e.g., 
•    Two or more of the required elements are not fully addressed; or one element is not addressed at all; or
•    A significant number of staff members were not aware of the procedures or did not know how to access them. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

HR 3.05

The organization provides all departing personnel with an opportunity to participate in an exit interview and documents their feedback or exit interview declination in the personnel record.
Examples: This interview can provide an opportunity for personnel to share feedback such as administrative issues related to the transition or input on the organization's strengths and weaknesses.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Documentation of exit interviews is not comprehensive and/or used for performance improvement.
3
Practice requires significant improvement; e.g.,
  • Exit interviews are sporadic and/or occur only at the request of the employee.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.
2024 Edition

Human Resources (HR) 4: Performance Review

The performance review process tracks progress towards meeting performance goals, recognizes accomplishments, and emphasizes self-development and professional growth.

Note: Please see the Personnel Records Checklist for additional guidance on this standard.

1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the HR 4 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the HR 4 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the HR 4 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the HR 4 Practice standards.
Self-Study Evidence On-Site Evidence On-Site Activities
  • Performance review procedures
  • Performance evaluation forms/templates
No On-Site Evidence
  • Interviews may include:
    1. HR Director
    2. Supervisors
    3. Relevant personnel
  • Review personnel records

 
Fundamental Practice

HR 4.01

The organization provides every full-time and part-time employee with an annual, written performance review that involves the employee and the supervisor.
Related Standards:
Examples: The organization can promote active participation by personnel in the performance review process by:
  1. designating time to discuss the written review; and
  2. soliciting the individuals' input on his or her accomplishments, challenges, and objectives for future performance and professional development.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Some performance evaluations were not completed within stated timeframes; or
  • A few staff did not receive an evaluation within the most recent evaluation cycle.
3
Practice requires significant improvement; e.g.,
  • Performance evaluations have not been conducted within the last two years; or
  • Evaluations are poorly documented or missing in some personnel files; or
  • The process, including timeframes, differs significantly between departments or programs.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

HR 4.02

Staff performance reviews emphasize self-development and professional growth and include:

  1. specific expectations defined in the job description;
  2. organization-wide expectations for personnel;
  3. objectives established in the most recent review, accomplishments and challenges since the last review period, and objectives for future performance, including developmental and professional objectives;
  4. strategies to continue developing cultural humility;
  5. recommendations for training; and
  6. an assessment of the staff member's knowledge and competence related to the characteristics and needs of service recipients, if applicable.
Related Standards:
Examples: Organization-wide expectations for personnel can include attitudes, knowledge, and skills needed to effectively implement evidence-based practices with fidelity, when applicable.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • In a substantial percentage of cases, the organization complies with the standard; or
  • One of the required elements is not fully addressed.
3
Practice requires significant improvement; e.g.,
  • In a significant percentage of cases, the organization does not address two of the required elements; or
  • The organization does not consistently conduct evaluations across departments and/or programs.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

HR 4.03

Personnel have the opportunity to sign, obtain a copy of, and provide comments on written performance reviews.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Procedures need clarifying; or
  • A few staff report being unaware of their rights as per the requirements of the standard.
3
Practice requires significant improvement; e.g.,
  • Many staff report being unaware of their rights as per the requirements of the standard; or
  • Practice is informal and has not been outlined in procedure; or
  • The procedure is inconsistently applied across departments and/or programs.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.
2024 Edition

Human Resources (HR) 5: Personnel Records

The organization maintains a personnel record for each employee.
Related Standards:

Note: See RPM 5: Security of Information for more information on appropriately limiting access to personnel records to protect confidentiality.


Note: Please see the Personnel Records Checklist for additional guidance on this standard. 

1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the HR 5 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the HR 5 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the HR 5 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the HR 5 Practice standards.
Self-Study Evidence On-Site Evidence On-Site Activities
  • Procedures for maintaining personnel records
  • Procedures regarding access to personnel records
  • Network procedures for maintaining independent provider records
No On-Site Evidence
  • Interviews may include:
    • HR Director
    • Supervisors
    • Relevant personnel
  • Review personnel records
  • Review the Network managing entity's records for independent practitioners

 
Fundamental Practice

HR 5.01

Personnel records are updated regularly and contain:

  1. identifying information and emergency contacts;
  2. application for employment, hiring documents including job postings and interview notes, and past employment verification;
  3. job description signed by the employee;
  4. compensation documentation, as appropriate;
  5. pre-service and in-service training records;
  6. health information or reports for annual physical examinations, appropriate to the job position or when required by law; and
  7. performance reviews and all documentation relating to performance, including disciplinary actions and termination summaries if applicable.
Related Standards:
Interpretation: An organization may maintain records in separate files according to its own record keeping system as required by law or regulation. For example, EAP records, health benefits enrollment forms, documentation of a grievance/complaint and response documents, immigration status documentation, and EEOC-related records must be kept separately from other personnel records.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • With few exceptions, the organization complies with the standard, but a few records reviewed on newly hired personnel have not yet been completed; or
  • Documentation in a few records needs updating.
3
Practice requires significant improvement; e.g.,
  • Many personnel records did not include all the relevant elements; job descriptions, pre- and post-service training, interview notes, questions, etc.; or
  • Documents in many records are outdated or missing.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • Personnel records are consistently incomplete or missing required documentation; or
  • There is evidence that personnel records are not appropriately maintained, e.g., different record components are not separated.

 

HR 5.02

Personnel may review, add, and correct information contained in their records.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Personnel report that they are able to make additions or corrections, but procedures need some clarification.
3
Practice requires significant improvement; e.g.,
  • Personnel are uncertain about procedures, and there is no evidence of management’s effort to clarify the issue.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

HR 5.03

The network maintains a record for independent providers that contains:
  1. identifying and contact information;
  2. documentation related to the network's credentialing process;
  3. documentation of quality monitoring of practitioner performance;
  4. documentation of relevant training; and
  5. performance reviews and all documentation relating to performance, including disciplinary actions and termination summaries, if applicable.

NA The organization is not a network management entity and is not assigned the Network Administration (NET) standards. 

Note: See HR 2.05 for more information on network credentialing processes. 
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • One of the standard's elements is not fully addressed.
3
Practice requires significant improvement; e.g.,
  • Two of the standard's elements are not fully addressed; or
  • One element is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.
2024 Edition

Human Resources (HR) 6: Volunteers

The organization recruits and retains a competent and qualified volunteer pool.
NA The organization does not use direct service volunteers, student professionals, or interns. 
Related Standards:
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the HR 6 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the HR 6 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the HR 6 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the HR 6 Practice standards.
Self-Study Evidence On-Site Evidence On-Site Activities
  • Volunteer/intern supervision procedures
  • Procedures for developing and reviewing volunteer/intern assignments
  • Sample volunteer/intern assignments from across categories
  • Documentation tracking volunteer/intern completion of required trainings
  • Interview:
    1. Personnel responsible for recruitment and supervision of volunteers/interns
    2. Volunteers/Interns
  • Review volunteer/intern records

 

HR 6.01

A written assignment is developed, and periodically reviewed, for each volunteer, student professional, and intern position that includes:
  1. duties;
  2. time commitment;
  3. responsibilities and prohibited activities;
  4. required skill sets, credentials, or trainings; and
  5. lines of supervision and the process for providing ongoing feedback.
Interpretation: Written assignments for student professional and interns should be provided by the placing organization.
Examples: Organizations can support appropriate assignments for prospective volunteers by using an interview process that includes, for example, consideration of their skills, interests, abilities, relevant experience, and availability; and matching those with the available volunteer opportunities at the organization.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Written volunteer/intern assignments require greater clarity; or
  • One of the standard's elements is not fully addressed.
3
Practice requires significant improvement; e.g.,
  • For some volunteer/intern assignments roles and responsibilities are only communicated verbally; or
  • Two of the standard's elements are not fully addressed; or
  • One of the standard's elements is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

HR 6.02

Direct service volunteers, student professionals, and interns are:
  1. directly supervised by licensed or otherwise accountable professionals;
  2. appropriately trained to fulfill their role; and
  3. participate in regular discussions and receive feedback regarding their performance.
Examples: When determining methods and timelines for providing regular feedback, the organization may consider the qualifications and experiences of the volunteer, educational requirements for students, and the complexity and intensity of the assignment.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • With few exceptions volunteers, etc. are supervised as per the standard.
3
Practice requires significant improvement; e.g.,
  • A significant number of volunteers, etc. are not appropriately supervised; or
  • Documentation of supervision is poorly maintained or nonexistent.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.
2024 Edition

Human Resources (HR) 7: Independent Contractors

The organization:
  1. exercises due diligence when contracting with independent contractors; and
  2. routinely monitors compliance with contract requirements.
NA The organization does not use independent contractors.
Related Standards:
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the HR 7 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the HR 7 Practice standards.
3
Practice requires significant improvement as noted in the ratings for the HR 7 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the HR 7 Practice standards.
Self-Study Evidence On-Site Evidence On-Site Activities
  • Procedures for contracting and monitoring contractswith independent contractors
  • Procedures for collecting quality data from contractors
  • Procedures for maintaining independent contractor records
  • Case record content and maintenance procedures that address contractor requirements
  • Sample contracts with independent contractors
  • Documentation of contract compliance,including evidence of competencies/requirements associated with necessary qualifications and trainings
  • Interviews may include:
    1. Relevant personnel
    2. Independent contractors
  • Review independent contractor client records
  • Review independent contractor records

 
Fundamental Practice

HR 7.01

Written contracts with independent contractors:
  1. are time-limited with a specified end date;
  2. define scope-of-work, expectations, and deliverables with specific timeframes;
  3. specify competencies, including necessary qualifications and trainings;
  4. describe protocols for routine communication of relevant information and data, including confidential information;
  5. include requirements for maintaining client records, documentation of services, and organization access to client records;
  6. describe expectations for contractor involvement in the organization's quality improvement process; and
  7. include under what circumstances the contract can be terminated.
Related Standards:
Interpretation: Competencies for independent contractors providing direct services must include the relevant trainings and qualifications, as appropriate to their roles, listed in COA's Administration and Management, service Delivery Administration, and the applicable Service Standards. For example, if the organization is using contractors to deliver mental health services, then contracts must include the qualifications listed in the Personnel section of COA's Mental Health and/or Substance Use Services (MHSU) standards, as well as TS 2. Organizations should obtain documentation from contractors that verifies their competencies, such as degrees or trainings they have received, in order to demonstrate implementation needed to rate the standards within the appropriate sections. 
Examples: Competencies may include education, training, experience, degree requirements, certifications, licenses, and pursuit of CEUs, as applicable.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • One of the standard's elements is not fully addressed.
3
Practice requires significant improvement; e.g.,
  • Two elements are not fully addressed; or
  • One of the elements is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

HR 7.02

Written contracts with independent contractors who provide direct services include criteria for:
  1. service quality;
  2. client satisfaction; and
  3. outcomes that accord with the organization’s expectations.
Related Standards:
NA The organization does not use independent contractors to provide direct services to clients.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • One of the standard's elements is not fully addressed.
3
Practice requires significant improvement; e.g.,
  • Two elements are not fully addressed; or
  • One of the elements is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

HR 7.03

Prior to entering into a contract, the organization verifies in writing that each contractor:
  1. possesses the necessary qualifications;
  2. is licensed and/or has certification, where applicable;
  3. has relevant experience including experience delivering services to the service population, if providing direct services; and
  4. carries professional liability insurance, as required by law or generally accepted business practices.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Procedures need greater clarity; or
  • One of the standard's elements is not fully addressed.
3
Practice requires significant improvement; e.g.,
  • Procedures are very general and/or do not provide useful guidance; or
  • Two elements are not fully addressed; or
  • One of the elements is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

HR 7.04

The organization establishes procedures for how client records are maintained by independent contractors that address:
  1. ownership of records;
  2. information that must be recorded in client records;
  3. organization access to client records for internal and external quality oversight, including review by Medicaid and/or other external funders or regulators, and accrediting bodies;
  4. secure storage;
  5. destruction of records;
  6. whether copies of records may be retained by the contractor; and
  7. maintaining client confidentiality.
Related Standards:
NA The organization does not use independent contractors to provide direct services to clients.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Procedures need greater clarity; or
  • One of the standard's elements is not fully addressed.
3
Practice requires significant improvement; e.g.,
  • Procedures are very general and/or do not provide useful guidance; or
  • Two elements are not fully addressed; or
  • One of the elements is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

HR 7.05

The organization has procedures to:
  1. routinely monitor and document contractor progress toward fulfilling the terms of the contract; and
  2. review contractor performance against identified deliverables prior to contract renewal.
Interpretation: For standards that will be implemented by independent contractors (e.g., CR, BSM, and ASE), the organization must:
  1. provide contractors with a comprehensive policy and procedure manual or include copies of relevant policies and procedures in contracts with independent contractors;
  2. include contract language regarding a contractor's obligation to adhere to organization policies and procedures; and
  3. routinely monitor and document compliance with organization policies and procedures.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Procedures need greater clarity.
3
Practice requires significant improvement; e.g.,
  • Procedures are very general and/or do not provide useful guidance; or
  • Monitoring is sporadic; or
  • Documentation is incomplete or poorly maintained.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

HR 7.06

The organization maintains a record for each independent contractor that contains:
  1. identifying and contact information;
  2. application, resume, and documentation of qualifications;
  3. IRS Form SS-8 or an internal assessment that the individual was properly classified as an independent contractor per Internal Revenue Service guidelines;
  4. a completed IRS W-9 form;
  5. documentation of reference checks;
  6. documentation of qualifications per HR 7.03;
  7. a background check per HR 2.03;
  8. a copy of the contract;
  9. a signed statement that the contractor will adhere to the organization's conflict of interest policies;
  10. a signed confidentiality agreement; and
  11. documentation of quality monitoring of contractor performance.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • With few exceptions, the organization complies with the standard, but a few records reviewed on newly hired contractors have not yet been completed; or
  • Documentation in a few records needs updating.
3
Practice requires significant improvement; e.g.,
  • Documents in several records are outdated or missing.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • Contractor records are consistently incomplete or missing required documentation.
Copyright © 2024 Council on Accreditation