ACHC Accreditation Tool – Personnel File Audit Tool

Accreditation & Compliance Survey Preparation Checklist

Agency Information
Agency Name:
Office Location / Branch:
Administrator / Director:
Survey Preparation Date:
Prepared By:
Section 1: Office / Administrative Compliance

Instructions: Mark each item as: ✔ Completed  |  ◑ In Progress  |  ✘ Not Completed

Facility accessibility compliance (ADA or local equivalent)
Status:
Comments:
Compliance with zoning / licensing regulations
Status:
Comments:
Operating hours, contact details, and emergency contact posted
Status:
Comments:
Workplace safety signage (smoke-free, safety notices)
Status:
Comments:
Agency license / registration displayed
Status:
Comments:
Privacy notice / data protection policy available
Status:
Comments:
Mission / vision statement displayed or documented
Status:
Comments:
Client / service user rights document available
Status:
Comments:
Complaint / grievance procedure available
Status:
Comments:
Regulatory or compliance posters displayed
Status:
Comments:
Insurance documentation (general/professional liability)
Status:
Comments:
Emergency exit plan displayed
Status:
Comments:
Emergency exit signage installed
Status:
Comments:
Emergency / disaster preparedness plan available
Status:
Comments:
Alternate operating location identified
Status:
Comments:
Emergency staffing / contingency plan
Status:
Comments:
Fire drill conducted and documented
Status:
Comments:
Fire safety inspection certificate
Status:
Comments:
Fire extinguisher maintenance logs
Status:
Comments:
Office supplies / operational inventory maintained
Status:
Comments:
After-hours communication system in place
Status:
Comments:
Waste disposal plan (general / specialized)
Status:
Comments:
Hazardous materials handling procedures
Status:
Comments:
Secure storage of records (physical/electronic)
Status:
Comments:
Data security / cybersecurity measures
Status:
Comments:
PPE availability (if applicable)
Status:
Comments:
Safety Data Sheets (SDS) available
Status:
Comments:
Operational forms and documentation accessible
Status:
Comments:
Organizational chart updated
Status:
Comments:
Emergency communication tree maintained
Status:
Comments:
Vendor contracts active and reviewed
Status:
Comments:
Confidentiality / data protection agreements
Status:
Comments:
Financial records / operating budget maintained
Status:
Comments:
Legal formation documents available
Status:
Comments:
Corporate governance documents (bylaws/agreements)
Status:
Comments:
Policy & procedure manual reviewed annually
Status:
Comments:
Emergency / disaster policies reviewed
Status:
Comments:
Employee handbook available
Status:
Comments:
Staff identification system (ID badges, etc.)
Status:
Comments:
Client onboarding / intake packet ready
Status:
Comments:
Section 2: Personnel Records Compliance
Personnel File Structure
Primary Personnel File Maintained: Yes No
Confidential File Maintained: Yes No
Personnel Compliance Checklist
Employee orientation completed before service delivery
Status:
Comments:
Role-specific competency / training verification
Status:
Comments:
Background checks completed
Status:
Comments:
Regulatory exclusion checks
Status:
Comments:
Professional licenses / certifications verified
Status:
Comments:
Conflict of interest disclosures signed
Status:
Comments:
Employee roster maintained and updated
Status:
Comments:
Health screenings (if required)
Status:
Comments:
Personnel file audits conducted
Status:
Comments:
Continuing education records maintained
Status:
Comments:
Performance evaluations documented
Status:
Comments:
Section 3: Health & Safety Screening (If Applicable)
Baseline Health Screening
Screening conducted prior to service delivery: Yes No
Screening Type:
Results:
Clearance Status:
Ongoing Monitoring
Periodic screenings documented:
Incident-related evaluations recorded:
Clearance updates maintained:
Section 4: Compliance Review Summary
Overall Compliance Status:
  • Fully Compliant
  • Minor Gaps Identified
  • Major Compliance Issues
Key Deficiencies Identified:
Corrective Action Plan:
Target Completion Date:
Section 5: Authorization
Prepared By:
Signature:
Date:
Administrator / Director Approval:
Signature:
Date: