R03-202. Human Resources

A. A licensee shall:

1. Develop, implement, and comply with written personnel policies and procedures that:

a. Comply with federal and state personnel regulations including the Title VI Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Americans with Disabilities Act of 1990, Health Information Portability and Accountability Act of 1996, and the Federal Regulations on Confidentiality of Alcohol and Drug Abuse Client Records, 42 CFR, Part 2,

b. Address the following:

i. Recruitment, selection, and credentialing of employees, volunteers, interns and students,

ii. Determination of the status of volunteers, students, and other non-paid personnel in relation to employment personnel practices,

iii. Wage and salary guidelines,

iv. Employee benefits including vacation and sick leave,

v. Promotions,

vi. Working hours,

vii. Regulations of conduct including procedures for addressing employees suspected of abusing alcohol or other drugs with dispensation and outcomes identified,

viii. Standards for ethical practices of employees,

ix. Written annual employee performance appraisal or more frequently, if indicated, with evidence that the employee has reviewed and been given the opportunity to respond,

x. Disciplinary actions of employees, including termination,

xi. Employee accidents and safety issues,

xii. Infection control,

xiii. Employee grievance process,

xiv. Maintenance of a “Drug-Free Workplace” environment,

xv. Confidentiality of personnel records delineating the authorized personnel who have access to specific areas of personnel information, and

xvi. Prohibition of harassment.

2. Provide a written description of the agencies Employee Assistance Program.

1. Review policy and procedure manual. Verify the policy addresses A1a-b - 2. Review in employee files for documentation that verify staff has reviewed the drug free workplace policy. 2. Review policy and procedure manual

 

B.         A licensee shall develop, implement, and comply with written position descriptions that:

1.         Reflect the individual’s current performance requirements and duties which include:

a.         Position title,

b.         Tasks and responsibilities of the position,

c.         Required skills, knowledge, training, education and experience,

d.         Lines of authority, and

e.         Supervision.

2.         Are reviewed, signed, and dated by the employee:

a.         At the time of initial employment, or

b.         Within 30 days of a revision to the position description to include the effective date of the revision, or

c.         At the time of a change in position or promotional status, and

d.         Are maintained in the personnel record of each employee.

1. Review policy and procedure manual for current position descriptions. Verify position descriptions contain all the required elements in R03-202 B 1 a-e. 2. Verify positions descriptions are signed and dated at: Initial employment or Within 30 days of a revision of position or When there is a change in position or promotional status

 

C. A licensee shall maintain a personnel record for each employee that contains:

1. An employment application,

2. Starting date of employment and, if applicable, the ending date,

2. Criminal and abuse or neglect background checks, if applicable,

3. Completion of employee orientation including employee review of federal and state confidentiality laws and regulations and agency or program policies and procedures, and

4. A current position description, and

5. An annual written performance appraisal for each full-time and part-time employee that contains:

a. The name, dated signature, and professional credential or job title of the staff member receiving the performance appraisal,

b. The name and title of the individual conducting the performance appraisal,

c. Any disciplinary actions taken, and

6. A written authorization permitting the employee to return to work for a diagnosis described in subsection R03-202 (E)* (2) that is maintained within a confidential or medical section of the personnel file.

1. Review all personnel records to verify the requirements of R03-202 C 1-6 for all current and new employees. 2. Review personnel files and verify that background checks are completed when applicable. *E is an incorrect reference, please refer R03-202 F (2).

 

D. A licensee shall maintain a personnel record for each staff member that contains:

1. Documentation that verifies the staff member’s:

a. Education and training,

b. Job experience,

c. Professional license, registration, certification and/or counselor credential,

d. Completion of training or education required for the position or plan to obtain professional credential.

1. Review personnel records for all current and new employees to verify the requirements of R03-202 D 1 a-d.

 

 

E. An agency that utilizes students, interns and/or volunteers shall provide information on federal and state confidentiality laws and regulations to these individuals and maintain documentation that the information was provided.

1. Review documentation to verify students, interns and/or volunteers have been provided information.

 

F. A residential treatment program shall ensure that:

1. Within 30 days of employment and annually thereafter, an employee submits one of the following as evidence of freedom from infectious pulmonary tuberculosis:

a. A written report of a negative Mantoux skin test result which was administered within six months before the report is submitted, or

b. If the employee has had a positive skin test for tuberculosis, a written statement from a medical professional dated within six months before the statement is submitted indicating that the employee is free from infectious pulmonary tuberculosis, or

c. If the medical professional determines infection is present, the employee is referred to appropriate services for treatment.

2. If an employee has been diagnosed with pulmonary tuberculosis, the employee must provide written authorization from a medical professional that indicates the staff member or employee is permitted to return to work and that documentation is maintained according to R03-202(C)(5)*.

1. Review confidential or medical section of employee file. Verify TB test was completed within 30 days of employment and annually thereafter. Verify negative test results were administered within six months before it is submitted. OR Verify written statement from medical professional meeting requirement OR Verify doctor’s report and/or orders meeting requirement. 2. Verify written authorization meeting this requirement. *C (5) is an incorrect reference, please refer R03-202 C (6).

 

G. A licensee shall ensure that personnel record documentation required in R03-202(C) and (F) is maintained:

1. Throughout an individual's period of employment, and

2. For two years after the termination date of the individual's employment.

1. Review current personnel records. Records shall be from January 2008 to current. 2. Review policy and procedure manual and/or verification of storage location. Personnel records of staff terminated before January 2008 will not be reviewed for licensing purposes.