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Personnel Records Review

The Site Visit Team (SVT) will review the selected personnel records in accordance with the following activities within the HDSAI: 23.2 (registration/licensure/certification requirements), 24.3 (orientation, required CE, required trainings), 26.1 (non-discrimination training), 26.3 (cultural competency training), 31.4 (qualification/position description), and 31.5 (annual performance evaluation).

Directions for Gathering Personnel Records (PDF)

Here are the specific items that the SVT should seek when reviewing personnel record materials:

  • Position Description – Position descriptions on file that have been signed, dated and reviewed annually by both employee and supervisor, to be verified through observations by Site Visitors. Position descriptions should include required qualifications for the position. Site Visitors will review the written position descriptions from a randomly selected year since the last site visit.
  • Annual Evaluation / Performance Appraisal – To be accepted as valid documentation, the performance appraisal should have been conducted within a randomly selected year since the last site visit, and is to be signed and dated by the employee and the supervisor conducting the appraisal.
  • Credentials (certification, registration, licensure) – if required by job description or by practice/discipline.
  • Required orientations, trainings or continuing education (may be separate agency log) – if certain trainings are required by position description and/or department policy, the SVT will expect to see evidence of such training in each personnel record selected. It greatly assists the SVT (and cuts down on questions) if you assure the name of your required trainings are consistent from year-to-year and, optimally, if the name corresponds to the training terminology used in the HDSAI. If the name is not the same, providing a cross-walk would be helpful.

2023 Personnel Record Review Worksheet (Word Template)