What Surveyors Check in Personnel Files
When a surveyor opens an employee file, they work through a predictable list. Here is exactly what they look for, category by category — and the missing items that cause the most citations.
1. Identifying Information
- Government-issued photo ID
- Social Security number or ITIN on record
- Current address and emergency contact
2. Hiring & Employment Eligibility
- Completed employment application
- Verified employment history and job-related references
- Signed job description matching assigned duties
- I-9 employment eligibility verification with supporting documents
- W-4 and signed payroll / direct-deposit authorization
3. Licenses & Certifications
- Current professional license copy (RN, LPN) with verification of good standing
- Nurse aide certification or competency evaluation (CNA, HHA, PCA)
- Position-specific certifications required by the role
- Expiration dates tracked so nothing lapses mid-employment
4. Background & Exclusion Screening
- Criminal background check completed before direct patient contact
- State and/or FBI fingerprint results where required
- Abuse / neglect registry check
- Monthly OIG LEIE and SAM.gov exclusion screening with dated logs
5. Health & Safety
- TB screening / test results (current)
- Required immunizations or declination forms
- Current CPR / First Aid certification
- Fit-for-duty or pre-employment physical where required
6. Training & Competency
- Documented new-hire orientation
- Initial training hours meeting your state minimum
- Annual continuing-education / in-service hours with dated completion
- Signed competency evaluations for each clinical role
7. Signed Acknowledgments
- HIPAA / privacy policy acknowledgment
- Employee handbook acknowledgment
- Bloodborne pathogen, infection control, and safety policy sign-offs
- Patient rights and abuse-reporting policy acknowledgment
8. Ongoing Documentation
- Performance reviews and probationary evaluations
- Disciplinary records, if any
- Supervisory visit notes on the required schedule
- Document-expiration tracking and a clean audit trail
The #1 reason agencies get cited
It is almost never a missing employee — it is a missing document. A lapsed license, an overdue TB test, an incomplete I-9, or a gap in monthly OIG screening. The credential may exist, but if it is not current and in the file, it is a citation. Tracking expiration dates is what keeps you audit-ready.
Personnel File FAQ
What is the most common personnel-file citation?
Missing or expired documents — most often a lapsed license, an overdue TB test or CPR card, an incomplete I-9, or missing monthly OIG exclusion screening. Surveyors cite the gap even when the underlying credential exists but is not documented in the file.
How far back do surveyors look in employee files?
Surveyors review the entire current personnel file and expect a continuous, dated record from hire through the present — orientation, annual training, re-screenings, and supervisory visits. Gaps in the timeline are treated as non-compliance.
How often must staff be screened against the OIG exclusion list?
Monthly. The OIG Special Advisory Bulletin recommends Medicare/Medicaid-participating providers screen all employees and contractors against the OIG LEIE and SAM.gov exclusion lists every month, and keep dated proof of each screening.
Do I need a signed job description in every file?
Yes. Surveyors check that each employee has a signed job description that matches the duties they actually perform, confirming the worker is qualified and authorized for their assigned tasks.
See Which Files Have Gaps — Free
AsiliGuide tracks every document on this list and flags what is missing or expiring before a surveyor does.
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