INTRODUCTION In the social and human services field, an organization's workforce is its greatest asset. Since employees and volunteers perform the tasks and provide the services that fulfill the organization's mission, 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. The significance of Human Resources Management is that the capacity to attract and retain a stable, qualified workforce is the foundation for achieving positive results for the people the organization serves. Human Resources Management also holds important implications for risk management. Sound, consistently applied human resources practices help reduce the risk of employment litigation and costs. Sound practices help protect another of the organization's most important assets: its reputation in the community. Interpretation: The term "workforce" covers full-time and part-time employees as well as volunteers. The use of these terms is governed by the following guidelines: - Direct service, clerical, professional, or management volunteers are considered to be part of an organization's personnel and will be included in the accreditation self-study; - If the organization does not use volunteers in its management, direct service, or any other ongoing activity, standards that only refer to volunteers do not apply to the organization; and - COA will not consider occasional or "casual" volunteers in its evaluation of an organization's compliance. For example, a volunteer who is present a few times to assist in addressing direct mail campaign envelopes or a similar activity has no ongoing role. In contrast, a volunteer custodian, cook, or secretary who works on a regularly scheduled basis has an ongoing role and will be considered in evaluating an organization's human resource practices. Interpretation: Network personnel can include: a. employees of the network management entity, including administrative personnel and direct service providers; b. employees of network partner organizations who provide direct network services, if the network is a membership network; c. employees of subcontracting network provider organizations; and d. independent, individual providers. Note: Please see Volunteers, Interns, and Consultants: Applicability of Page 1
COA Standards to Non-Employee Personnel - Private, Public, Canadian for additional assistance with this standard. Note: Please see HR Reference List for a list of resources that informed the development of these standards. Table of Evidence Self-Study Evidence - Describe how your organization manages its human resources: Does your organization have a separate HR department? If not is there a dedicated HR position, or is human resource management the responsibility of an individual with additional non-hr responsibilities? Does your organization outsource some of its human resources functions? If so which ones? - Describe any challenges that your organization may have faced with regard to recruiting and/or retaining qualified staff. Has your organization implemented any solutions that have proven effective? (E.g., there is a shortage of MSW's in your area, or funding cuts have made it difficult to pay for direct service staff with advanced degrees for your foster care program...). - Provide any additional information that would increase the Peer Team's understanding of how your organization's human resource practices contribute satisfaction and positive service delivery - A list of administrative and management personnel that includes: a. name; b. title; c. degree held and/or other credentials; d. FTE; e. length of service at the organization; and f. time in current position. Please organize the list by department - An organization chart that includes all the organization's departments or divisions and programs On-Site Evidence No On-Site Evidence On-Site Activities No On-Site Activities Page 2
(FOC) HR 1: Work Environment The organization provides an equitable work environment that is supportive of organizational productivity, diversity, and stability. Table of Evidence Self-Study Evidence - Discrimination policy - Harassment policy On-Site Evidence - Nepotism policy On-Site Activities - Interview: a. CEO b. HR Director c. Supervisory personnel d. Direct service personnel e. Persons served HR 1.01 The organization does not unlawfully discriminate against any person or category of persons. Related: RPM 1, RPM 2.01 (FP) HR 1.02 Policy prohibits personnel from engaging in any form of harassment, as defined by applicable federal, state, or local law. Related: RPM 1, RPM 2.01 Interpretation: Implementation of the standard requires appropriate training for staff on the organization's harassment policy. The policy should allow personnel to bypass any person in the reporting process who is also the alleged harasser. Types of harassment that are, or may be, prohibited by law include harassment on the basis of age, gender, sexual orientation, Page 3
color, race, creed, national origin, ancestry, religious persuasion, marital status, political belief, physical or mental disability, pregnancy, military or veteran status, or retaliation, which includes opposing participation in any complaint process at the Equal Employment Opportunity Commission (EEOC) or other human rights agency. HR 1.03 Organizational policy: a. prohibits preferential treatment; and b. addresses nepotism with regard to hiring, supervision, and promotion. Related: ETH 2 Interpretation: This standard permits the hiring of relatives, provided that relatives are qualified and do not work within the same hierarchy of supervision. For example, implementation of this standard may be demonstrated through a supervisory structure where a third party, such as an advisory group member or consultant assumes responsibility for the day-to-day supervision of a staff member's work. Page 4
(FOC) HR 2: Human Resources Planning The organization assesses the type and number of personnel needed to accomplish its mission, goals, and objectives. Related: AG 2.05, NET 9.02 Interpretation: Human resources planning should occur in conjunction with strategic planning (GOV 6), budget development (FIN 5), and training and professional development (TS 1 and TS 2). Note: Please see Workforce Assessment and Planning Tip Sheet - Private, Public, Canadian, Network for additional assistance with this standard. Table of Evidence Self-Study Evidence No Self-Study Evidence On-Site Evidence - Assessment of workforce needs - Analysis of workforce composition - EEO plan (as necessary) - Documentation of actions taken - Annual Network-wide Analysis report On-Site Activities - Interview: a. CEO b. HR Director c. Supervisory personnel HR 2.01 The organization assesses its workforce as part of annual planning and prepares for future needs by: a. comparing the composition of its current workforce, including number of employees, skills, and demographics, with projected workforce needs; and b. determining how to close gaps, when possible, through recruiting, training or outsourcing. Related: RPM 5.01, GOV 7.03 Page 5
NA The organization is a network management entity. HR 2.02 The organization analyzes employment patterns, and when the cultural characteristics of personnel do not generally reflect those of its defined service population, the organization implements a plan that: a. establishes goals for recruitment, employment, and promotion; and b. includes timetables for correction. Interpretation: All organizations are expected to analyze employment patterns. If the analysis indicates that the organization's employment patterns are not reflective of the community, the organization is required to develop a plan that includes the elements in the standard. Interpretation: For networks, the analysis is conducted annually, and is network-wide, covering all employees, partner organizations, provider organizations and independent providers providing direct services to persons and families for whom the network is responsible. Note: Please enter demographic information on the organization's personnel on the Community Demographic Profile. Page 6
(FOC) HR 3: Recruitment, Selection, and Deployment The organization hires enough qualified personnel to meet the demand for services. Related: MS 2.02 Table of Evidence Self-Study Evidence - Recruitment and selection policies/ procedures - Policy and procedures regarding background checks - Network credentialing and verification procedures On-Site Evidence - Job Descriptions (CEO, CFO, Directors and sample of direct service personnel) - Personnel records - Relevant portion of governing body minute - Copies of attorney, administrative agency or court opinions that indicate the organization's recruitment practices comply with applicable laws and regulations with regard to protected characteristics - Policy and procedures describing the use of volunteers - Network Individual provider and contractor files, re: required information and verifications of current licenses or credential - Network records of actions to approve practitioners - Enabling legislation/ regulations pertaining to background checks On-Site Activities - Interview: a. CEO b. HR Director c. Senior managers d. Supervisory personnel e. Direct service personnel f. Students, as applicable g. Volunteers h. Personnel responsible for recruitment and supervision of volunteers - Network Interview: a. Committee chair or person in charge of the credentialing process Page 7
HR 3.01 b. Managing entity staff members responsible for verifications c. Clinical supervisors of selected non-accredited contracted providers to verify provision of supervision Job descriptions and selection criteria: a. state the qualifications, job expectations, essential functions, and responsibilities for each position or group of like positions; b. include sensitivity to the service population's cultural and socioeconomic characteristics; and c. are reviewed and updated regularly. HR 3.02 Recruitment and selection procedures include: a. notifying personnel of available positions; b. verifying references and credentials of personnel and independent contractors; c. providing applicants with a written job description; d. giving final candidates the opportunity to speak with currently-employed personnel; e. retaining hiring records in accordance with legal requirements; and f. using standard interview questions that comply with employment and labor laws. Related: TS 1.03, MS 4.01 Interpretation: Credentials include education, training, relevant experience, competence in required role, recommendations of peers and former employers, and state registration, licensing, or certification for the respective disciplines, if any. The retention of hiring records, which can include postings or other advertisements, applications, and interview notes, shows consistency in recruitment and hiring decisions, and protects the organization in the event of an Equal Employment Opportunity Commission (EEOC) or related complaint. (FP) HR 3.03 Page 8
Screening procedures include appropriate, legally permissible, and mandated reviews of state criminal history records and civil child abuse and neglect registries for new employees, consultants, independent contractors, volunteers, and student interns who will: a. work in residential programs; b. 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 c. work with sensitive or confidential information such as personnel files and case records. Related: MS 4.01, RC 11.04, SVE 12.07, YD 16.06 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. 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 appropriate. The requirements do not apply to current employees and contractors or to agencies with which the organization contracts for services. 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. Note: For more information, please see Volunteers, Interns, and Consultants: Applicability of COA Standards to Non-Employee Personnel - Private, Public, Canadian. HR 3.04 An organization that recruits and selects personnel with specific cultural traits or other characteristics establishes that such selectivity is: a. legally permissible; b. reviewed and approved by the organization's governing body, as applicable; and c. appropriately considered a bona fide occupational qualification. Interpretation: When recruitment and hiring criteria include consideration of Page 9
specific protected characteristics, such as gender, religion, and national origin, the organization should seek legal advice as to whether these characteristics are bona fide occupational qualifications that are critical to the organization's normal operation. In addition, an organization under religious auspices should 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. NA The organization does not recruit and select personnel with specific cultural traits or other characteristics. HR 3.05 Organizations that deploy volunteers to provide direct services specify their roles and responsibilities. Related: RPM 2.01, TS 3.05, HR 5 NA The organization does not use volunteers to provide direct services. HR 3.06 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: a. verification of licensure, education and other relevant training and board certification, where applicable; b. experience delivering services to the populations served by the network; c. the professional judgment of at least three peer professional references with regard to competence and prior satisfactory levels of performance; d. information about pending challenges, provisional status, or previous suspensions or denials of licenses to practice; e. publicly available information or official information regarding professional liability actions and litigation relevant to the provision of network services; and f. information about prior involuntary termination, reduction of professional staff privileges, or discharge from professional employment obtained from prior staff affiliations or employers. Related: HR 7.06 Page 10
NA The organization is not a network management entity. HR 3.07 The network verifies that personnel of network partners and network provider organizations who provide clinical services to network clients: a. possess relevant licenses and/or credentials; and b. are receiving appropriate supervision. NA All partner and subcontracting provider organizations are accredited by COA or a COA-recognized accrediting body. NA The organization is not a network management entity. Page 11
(FOC) HR 4: Satisfaction and Retention The organization promotes a high level of personnel satisfaction and retention. Interpretation: The organization can consider factors that have been associated with staff satisfaction and retention, including: role clarity, recognition of employee contributions, satisfaction with salary and benefits, reasonable workload, autonomy, opportunities for advancement, and career development. The organization should also take the opportunity to retain high performing staff by providing support, opportunities, and resources to prepare personnel within the organization to assume leadership roles. Note: Please see Staff Turnover Rate Worksheet - Private, Public, Canadian for additional assistance with this standard. Table of Evidence Self-Study Evidence - Personnel grievance procedures - Aggregated personnel satisfaction and retention information On-Site Evidence - Meeting minutes and/or schedules - Methods/protocols employed by the organization to obtain personnel participation/input and for providing feedback to personnel about their recommendations/suggestions - Grievance reports - Relevant minutes related to retention rates and improvement action, if necessary On-Site Activities - Interview: a. CEO b. Governing Body c. HR Director d. Personnel at all levels HR 4.01 The organization promotes open communication and collaboration among disciplines and staff levels by: Page 12
a. holding regular team, organizational, and divisional meetings, as appropriate to the organization; and b. providing feedback to personnel about their suggestions and recommendations. Related: FPS 11.08, YD 17.10 HR 4.02 The organization encourages initiative, creativity, and innovation and rewards and recognizes the contributions of personnel. Related: TS 1.02, CCI 8.02 HR 4.03 The organization annually establishes personnel satisfaction and retention goals and measures: a. rate of personnel turnover; and b. personnel satisfaction. Related: PQI 4.04, YD 17.07 HR 4.04 The organization takes action to address identified staff satisfaction and retention concerns. Interpretation: The organization can be alert to Work/Life policies and practices that have been shown to increase employee productivity, job satisfaction, and retention, including: flexible work options and personal and family support. HR 4.05 The organization establishes personnel grievance procedures, which include: a. the right to file a grievance without interference or retaliation; b. a description of how grievances are filed, to whom, and who will make a final determination; Page 13
c. timely written notification of the resolution and an explanation of any further appeal, rights, or recourse; d. processes for review, including a third-party review of the final determination; e. documenting responses and actions taken; and f. maintaining a copy of the notification of resolution in the personnel record. Related: YD 17.07 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. Page 14
(FOC) HR 5: Human Resource Practices Human resource practices are equitable, consistently applied, and in compliance with applicable laws and regulations. Related: HR 3.05 Interpretation: For networks, the analysis is conducted annually, and is network-wide, covering all employees, partner organizations, provider organizations and independent providers providing direct services to persons and families for whom the network is responsible. Table of Evidence Self-Study Evidence - Table of Contents for Personnel Manual - Procedures for conducting an annual audit of human resource practices On-Site Evidence - Reports from the most recent HR audit including documentation of corrective action, as needed - Personnel Manual - Personnel records - Review and analysis reports of compensation/benefits On-Site Activities - Interview: a. CEO b. Governing Body regarding CEO c. HR Director d. Supervisory personnel e. Personnel at all levels (FP) HR 5.01 The organization conducts an annual audit of its human resource practices that ensures: a. compliance with applicable employment and labor laws; and b. human resource practices support achievement of the organization's mission and strategic goals. Page 15
Related: RPM 1, RPM 2.01 Interpretation: Organizations must be prepared to justify how the audit process ensures compliance with applicable employment and labor laws. This should include consultation with third-party human resource professionals such as attorneys, human resource vendors, and professional associations, as needed given the organization's internal expertise. Interpretation: Applicable employment and labor laws include, but are not limited to, those governing fair employment practices, use of contingent workers, compensation and benefits, maintenance of personnel records, retention of hiring records, background checks, and collective bargaining. Some of the major federal laws in the United States that govern employer/employee relations include: Titles VI and VII of the Civil Rights Act of 1964 (as amended by the Equal Employment Opportunity Act of 1972 and the Civil Rights Act of 1991), the Fair Labor Standards Act (FLSA), Section 503 of the Rehabilitation Act of 1973, the Equal Pay Act, the Age Discrimination in Employment Act of 1967, the Americans with Disabilities Act (ADA), the Family and Medical Leave Act (FMLA), the Occupational Safety and Health Act (OSHA), the Consolidated Omnibus Budget Reconciliation Act (COBRA), the National Labor Relations Act, as well as the regulations implementing all of the above statutes, and Executive Order 11246. Typically, state or local law or regulation, when more stringent, supersedes federal regulation. Organizations are expected to review and monitor their compliance with federal, state, and local laws and regulations. Research Note: Evidence suggests that employment related complaints, charges, and lawsuits are on the rise, making human resource practices a significant source of liability risk for organizations. Small and mid-sized organizations are increasingly seeking out third-party professionals such as attorneys, human resource vendors, and professional associations as a matter of best practice to ensure their compliance with applicable laws and regulations. Note: See HR 5.04 for more information on reviewing the organization's use of contingent workers, including independent contractors, leased workers, volunteers, and temporary employees. HR 5.02 All personnel receive, and confirm in writing, receipt of an up-to-date employee policies and procedures manual that articulates current: Page 16
a. conditions of employment; b. benefits; c. rights and responsibilities of employees; and d. other important employment-related information. Related: ETH 2, TS 2.01, ETH 4, ETH 5 Interpretation: Policies and procedures can be written or electronic and address: a. conditions and procedures for layoffs; b. emergency and safety procedures; c. equal employment policies; d. nepotism and favoritism protections; e. grievance process procedures; f. insurance protections including unemployment, disability, medical care, and malpractice liability; g. performance appraisal system; h. promotions; i. professional development; j. standards of conduct; k. time-off policies; l. wage policy; m. working conditions; and n. technology/network security and usage policies. HR 5.03 Total compensation and benefits are reviewed regularly in relation to industry practices. Related: YD 17.07 HR 5.04 To ensure compliance with legal requirements the organization annually reviews its use of contingent workers, including independent contractors, leased workers, volunteers, and temporary employees, with respect to tax law, wage and hour laws, and other applicable employment and labor laws. Related: RPM 1, RPM 2.01, NET 3, NET 7 Page 17
NA The organization does not use contingent workers, including independent contractors, leased workers, volunteers, and temporary employees. Page 18
HR 6: Performance Review The organization holds both supervisors and supervised personnel accountable for performance and facilitates open, two-way communication as a means to encourage performance improvement. Related: TS 3.03, TS 3.05 Table of Evidence Self-Study Evidence - Performance evaluation forms/templates or description of ongoing review process On-Site Evidence - Personnel records - Performance review procedures - Contract policy and procedures - Contracts On-Site Activities - Interview: a. HR Director b. Supervisory personnel c. Direct service personnel d. Personnel at various levels e. Independent contractors HR 6.01 The organization has a standardized process for providing every full-time and part-time employee and volunteer with a written performance review at regular intervals that involves the employee or volunteer and the supervisor. Related: RPM 2.01, TS 3.03 Interpretation: Performance reviews should be conducted in-person where possible. Casual volunteers do not need to participate in the organization's performance review process. Interpretation: When determining the timelines for the performance review, the organization may consider the qualifications and experience of the worker and the supervisor, and the complexity and intensity of the service. Page 19
Timelines should be communicated to staff and clearly stated in the organization's policies, procedures, and/or employee manual. HR 6.02 The performance review process assesses job performance, recognizes accomplishments, provides constructive feedback, and emphasizes self-development and professional growth, in relation to: a. specific expectations defined in the job description; b. organization-wide expectations for personnel; c. objectives established in the most recent review, accomplishments and challenges since the last review period, and objectives for future performance; d. developmental and professional objectives; e. recommendations for further training, skill building, and other resources that may contribute to improved job performance; and f. knowledge and competence related to the characteristics and needs of service recipients, if applicable. Related: TS 2, TS 3.03 Research Note: Research suggests that adding narratives to the review is more effective in capturing job performance than numerical ratings alone. HR 6.03 The organization promotes a work environment that supports active participation by personnel in the performance review process. Interpretation: Staff members should have the opportunity to sign, obtain a copy of, and provide comments on all written reviews. HR 6.04 The organization monitors the quality of services provided by independent contractors. Related: HR 7.06 Interpretation: Mechanisms used to monitor quality may include quarterly quality improvement review, evaluation of services, or another assessment performed by a third party. Page 20
NA Services are not provided by independent contractors. Page 21
HR 7: Personnel Records The organization maintains personnel records. Related: RPM 5, RPM 6, MS 8.01 Interpretation: The organization is not required to maintain personnel records for short-term or episodic volunteers who support the organization through administrative, clerical, fundraising, or other functions. Note: Please see Personnel Records Checklist - Private, Public for additional assistance with this standard. Table of Evidence Self-Study Evidence No Self-Study Evidence On-Site Evidence - Personnel records - Procedures regarding access to personnel records - Review the Network managing entity's records for independent practitioners On-Site Activities - Interview: a. HR Director b. Supervisory personnel c. Personnel at all levels HR 7.01 Personnel records are updated regularly, and contain: a. identifying information and emergency contacts; b. application for employment, hiring documents including job postings and interview notes, and reference verification; c. job description; d. compensation documentation, as appropriate; e. pre-service and in-service training records; and f. performance reviews and all documentation relating to performance, including disciplinary actions and termination summaries, if applicable. Interpretation: An organization may maintain records in separate files Page 22
according to its own record keeping system. The organization complies with this standard as long as all required information is maintained systematically and in a manner that complies with federal and state laws regarding the required contents of personnel files and confidentiality. In addition, EAP and health records, including health benefits enrollment forms, grievance, complaint, and response documents, and EEOC-related records, must be kept separately from other personnel records. Note: Network Management entities see HR 7.06. Note: Organizations should review state Medicaid plans or other third party reimbursement requirements to familiarize themselves with training requirements and timeframes and ensure appropriate documentation of training hours. HR 7.02 Personnel records contain health information or reports for annual physical examinations, appropriate to the job position or when required by law. NA The organization does not employ persons in positions where health information or physical examinations are appropriate or required by law. HR 7.03 Access to personnel records is limited to authorized personnel on a need-to-know basis. HR 7.04 Personnel may review, add, and correct information contained in their records, in accordance with applicable law. HR 7.05 Personnel who leave the organization voluntarily have the opportunity to participate in an exit interview. Interpretation: This interview enables personnel to address administrative issues related to the transition, as well as to provide feedback on the organization's strengths and weaknesses. Page 23
HR 7.06 The network maintains a record for independent providers that contain: a. identifying and contact information; b. documentation related to the network's credentialing process; c. documentation of quality monitoring of practitioner performance; d. documentation of relevant training; and e. performance reviews and all documentation relating to performance, including disciplinary actions and termination summaries, if applicable. Related: HR 3.06, HR 6.04 NA The organization is not a network management entity. Page 24