Personnel Requirements

Policy 381-200  · Volume 1 · Governance & Administration  · Issued: 10/07/2025  · Updated: 10/14/2025
Active
This policy deals with Harbor’s staffing and clinical oversight requirements for delivering safe, compliant personal care and respite services. It explains Harbor’s staffing plan expectations, pre-assignment verification of personnel qualifications (including background checks and required PCA/CNA credentials), and RN-led competency assessments before an aide’s first client assignment. The policy also covers ongoing RN supervision (at least every 90 days), required annual in-service training (minimum 12 hours), and the personnel-file documentation Harbor maintains to demonstrate compliance.

1. Policy Objective

Harbor shall maintain sufficient numbers of qualified personnel to safely and effectively deliver services, including personal care and respite services, and shall ensure that all personnel meet applicable qualification, training, orientation, competency, supervision, and documentation requirements before providing services to clients. Harbor shall maintain ongoing clinical oversight through registered nurse supervision, plan-of-care review, supervisory visits, annual in-service training, and complete personnel records in accordance with Virginia home care licensure regulations. (; ; )

Requirements
  • 1.1 Harbor shall design and implement a staffing plan that reflects the types of services offered and provides qualified staff in sufficient numbers to meet client care needs. (; Ref: 5.1)
  • 1.2 Harbor shall ensure that employees and contractors are licensed, certified, or qualified as required by applicable law and regulation, and Harbor shall maintain a mechanism to verify professional credentials. (; ; Ref: 5.2)
  • 1.3 Harbor shall provide each employee a written position description containing the job title, duties and responsibilities, job title of the immediate supervisor, and minimum entry-level qualifications, and shall maintain a mechanism to advise employees of changes to their position description. (; ; Ref: 5.2)
  • 1.4 Harbor shall provide orientation to all new employees and contractors that addresses required regulatory topics before independent client service is performed. (; Ref: 5.3)
  • 1.5 Harbor shall develop and implement a process for evaluating employee performance, including identification of individual staff development needs and plans. (; ; Ref: 5.3)
  • 1.6 Harbor shall provide opportunities for staff development and shall record participation in staff development activities. (; Ref: 5.5)
  • 1.7 All individuals entering a client’s home on behalf of Harbor shall be readily identifiable by name tag, uniform, or other visible means. (; Ref: 5.6)
  • 1.8 Harbor shall maintain an organized system to manage personnel records, protect confidentiality, safeguard records from loss or unauthorized use, and retain records for at least three years after termination of employment. (; ; ; Ref: 6)
  • 1.9 Health-related information shall be maintained separately within the personnel file. (; Ref: 6)
  • 1.10 Home attendants shall be able to speak, read, and write English and shall meet at least one qualifying pathway permitted by before assignment to clients. (; Ref: 5.2)
  • 1.11 The RN Supervisor shall assess each aide’s skills and competencies before the aide’s first client assignment and shall document the assessment. (; Ref: 5.4)
  • 1.12 For personal care services, Harbor shall ensure that a written plan of care is developed, provided to the client, reviewed with the assigned aide, and supervised as often as necessary based on client needs, with intervals not to exceed 90 days. (; ; ; Ref: 5.4)
  • 1.13 Harbor shall ensure that an RN or LPN is available during all hours that personal care services are being provided. (; Ref: 5.4)
  • 1.14 Each aide providing personal care services shall complete at least 12 hours of in-service training annually. (; Ref: 5.5)
  • 1.15 Criminal background and barrier crime screening shall be completed and documented before employment or client assignment, as applicable. (; Ref: 5.2)
1.1 Definitions
  • Staffing Plan means the written document describing the types of services offered, staffing levels, and availability of qualified personnel necessary to meet client needs. ()
  • Position Description means the written job description required for each employee containing the job title, duties and responsibilities, immediate supervisor, and minimum qualifications. ()
  • Home Attendant means personnel providing personal care services who satisfy the qualifications in .
  • RN Supervisor means the registered nurse designated to supervise personal care services, assess aide competency, oversee plans of care, and conduct supervisory visits. ()
  • Orientation means initial training provided to new employees and contractors on required organizational and regulatory topics before independent assignment. ()
  • Competency Assessment means the RN Supervisor’s evaluation of an aide’s skills, knowledge, and ability to perform assigned care tasks safely before the aide’s first client assignment. ()
  • Plan of Care means the written plan developed by the RN Supervisor for each personal care client that includes the six required elements under . ()
  • Supervisory Visit means the RN Supervisor’s visit to the client’s home conducted as often as necessary based on client need, with intervals not to exceed 90 days. ()
  • In-Service Training means ongoing training for aides after initial hire, totaling at least 12 hours per calendar year. ()
  • Barrier Crimes means criminal offenses listed in the Code of Virginia that may disqualify an individual from employment in a licensed home care organization. ()
  • Personnel Record means the organized record maintained for each employee containing the items required by .
Implementation Guidance
  • A1 Harbor should use a standardized personnel file checklist and onboarding workflow so no employee or contractor is assigned before all required documents are complete. (; ; )
  • A2 recognizes six qualifying pathways for home attendants, not just PCA certificate holders or CNAs. These include individuals who have completed a nursing education program, are enrolled in a nursing program with at least one clinical course completed, passed an approved competency evaluation, or completed a Board of Nursing-approved nurse aide program. Harbor shall not reject qualified applicants solely because they do not hold a PCA certificate. ()
  • A3 The 90-day supervisory visit interval is a maximum. The RN Supervisor determines visit frequency based on client need and assessment. Clients with higher needs may require more frequent visits. ()

2. Scope & Application

This policy applies to the Governing Body, Administrator, RN Supervisor, all employees, and all contractors who provide or support services under Harbor’s home care organization license, including direct care staff, office staff, and clinical personnel. It applies to Harbor’s personal care and respite services regardless of payer source. (; ; )

Requirements
  • 2.1 All employees shall receive a current written position description and applicable orientation before independent assignment. (; ; Ref: 5.2; Ref: 5.3)
  • 2.2 Personnel providing direct care shall not be assigned to clients until qualification requirements, background screening, and competency requirements are verified and documented. (; ; Ref: 5.2; Ref: 5.4)
  • 2.3 Contractors providing direct care or clinical services shall meet applicable qualification and documentation standards. (; ; Ref: 7)
  • 2.4 All Harbor personnel entering client homes shall comply with Harbor’s identification requirements. (; Ref: 5.6)
Implementation Guidance
  • A4 No aide — whether employee or contractor — shall be assigned to a client until the personnel file contains verified qualifications, cleared background screening, and a completed RN competency assessment. (; ; )

3. Regulatory Basis

This policy implements applicable Virginia home care licensure requirements relating to staffing plans, credential verification, position descriptions, employee orientation, performance evaluation, staff development, identification, personnel records, home attendant qualifications, RN supervision of personal care services, plans of care, supervisory visits, RN/LPN availability, in-service training, and criminal background screening. (; ; ; ; ; )

Implementation Guidance
  • A5 Harbor shall review this policy and its citation mapping at least annually to ensure operational requirements remain aligned with current regulation. (; Ref: 8)

4. Roles & Responsibilities

4.1 Governing Body
  • 4.1.1 The Governing Body shall ensure Harbor is staffed and equipped to provide services safely and in accordance with applicable law. ()
  • 4.1.2 The Governing Body shall review and approve the staffing plan and ensure adequate resources are available to maintain qualified RN supervision of personal care services. (; ; ; Ref: 5.1)
4.2 Administrator
  • 4.2.1 The Administrator shall develop, implement, and maintain the written staffing plan, reviewing it at least annually and when client volume or service needs materially change. (; Ref: 5.1)
  • 4.2.2 The Administrator shall verify credentials and qualifications for each employee and contractor before assignment and shall maintain personnel files with all required documentation. (; ; ; Ref: 5.2; Ref: 6)
  • 4.2.3 The Administrator shall ensure each employee receives an applicable position description and orientation. (; ; Ref: 5.2; Ref: 5.3)
  • 4.2.4 The Administrator shall ensure background screening is completed and cleared before employment or assignment. (; Ref: 5.2)
  • 4.2.5 The Administrator shall implement a performance evaluation process that includes staff development planning. (; ; Ref: 5.3)
  • 4.2.6 The Administrator shall ensure aide in-service training is tracked and completed at minimum annually. (; Ref: 5.5)
4.3 RN Supervisor
  • 4.3.1 The RN Supervisor shall assess and document each aide’s competency before the aide’s first client assignment. (; Ref: 5.4)
  • 4.3.2 The RN Supervisor shall complete an initial assessment for each personal care client and develop a written plan of care containing all required elements. (; Ref: 5.4)
  • 4.3.3 The RN Supervisor shall determine supervisory visit frequency based on client need; the interval between visits shall not exceed 90 days. (; Ref: 5.4)
  • 4.3.4 The RN Supervisor shall be available or ensure an LPN is available during all hours that personal care services are being provided. (; Ref: 5.4)
  • 4.3.5 The RN Supervisor shall identify individual aide training needs through competency assessments and supervisory visits and ensure completion of at least 12 hours of in-service training annually. (; Ref: 5.5)
4.4 Direct Care Staff (Home Attendants)
  • 4.4.1 Direct care staff shall meet all qualification standards before assignment and shall provide services only within their authorized role and plan of care. (; )
  • 4.4.2 Direct care staff shall complete required orientation, in-service training, and competency remediation as assigned. (; )
  • 4.4.3 Direct care staff shall report changes in client condition to the RN Supervisor promptly. ()
Implementation Guidance
  • A6 When one individual serves in multiple roles, all responsibilities for each role remain in effect and shall be completed and documented separately as applicable. ( Ref: 6)

5. Procedures

5.1 Staffing Plan
  • 5.1.1 The Administrator shall maintain a written staffing plan describing the types of services offered, the number and qualifications of staff needed, supervisory ratios, and backup coverage. (; Ref: 6)
  • 5.1.2 The staffing plan shall be reviewed at least annually and revised when client volume, service mix, or supervisory capacity materially changes. (; ; Ref: 6)
5.2 Hiring and Qualification Verification
  • 5.2.1 Harbor shall provide each employee a written position description containing the job title, duties and responsibilities, title of the immediate supervisor, and minimum entry-level qualifications before the employee assumes responsibilities. (; Ref: 6)
  • 5.2.2 Harbor shall maintain a mechanism to verify professional credentials and qualifications required for each role. (; Ref: 6)
  • 5.2.3 For home attendants, Harbor shall verify the individual can speak, read, and write English and meets at least one of the following qualifying pathways permitted by : (a) completed a nursing education program for RN or LPN licensure; (b) enrolled in a nursing education program with at least one clinical course completed; (c) holds current Virginia Nurse Aide certification; (d) completed a Board of Nursing-approved nurse aide education program; (e) satisfactorily completed a 40-hour PCA curriculum; or (f) passed a competency evaluation meeting applicable federal criteria. (; Ref: 6)
  • 5.2.4 Harbor shall complete criminal background and barrier crime screening before employment or client assignment and shall document and retain results. (; Ref: 6)
  • 5.2.5 No direct care staff member shall be assigned to a client until all qualification verifications, screenings, and the RN competency assessment are complete and documented. (; ; Ref: 5.4; Ref: 6)
5.3 Orientation and Performance Evaluation
  • 5.3.1 Harbor shall provide orientation to each new employee and contractor before independent assignment that includes, at minimum, all of the following: (; Ref: 6)
    1. Organizational objectives;
    2. Organizational philosophy;
    3. Confidentiality;
    4. Client rights;
    5. Applicable personnel policies;
    6. Emergency preparedness;
    7. Infection prevention and control;
    8. Cultural awareness; and
    9. Applicable laws and regulations.
  • 5.3.2 Harbor shall document orientation completion including topics covered, date, and individual acknowledgment. (; Ref: 6)
  • 5.3.3 Harbor shall evaluate employee performance on a defined schedule and shall document results. (; Ref: 6)
  • 5.3.4 Performance evaluations shall identify individual staff development needs and include a development plan. (; Ref: 6)
  • 5.3.5 Harbor shall provide opportunities for staff development and record each individual’s participation. (; Ref: 6)
5.4 RN Competency Assessment, Plan of Care, and Supervisory Visits
  • 5.4.1 Before the first client assignment, the RN Supervisor shall assess each aide’s ability to perform assigned personal care tasks safely and shall document results using a competency evaluation form. (; Ref: 6)
  • 5.4.2 If competency deficiencies are found, the aide shall receive additional training before assignment; reassessment shall be documented before the aide is cleared. (; Ref: 6)
  • 5.4.3 For each personal care client, the RN Supervisor shall complete an assessment and develop a written plan of care that includes, at minimum, all of the following: (; Ref: 6)
    1. The client’s needs;
    2. Functional limitations;
    3. Activities permitted;
    4. Any special dietary needs;
    5. Specific services to be provided; and
    6. Frequency of services.
  • 5.4.4 The written plan of care shall be retained in the client’s record. A copy shall be provided to the client and the plan shall be reviewed with the assigned aide before services begin. (; Ref: 6)
  • 5.4.5 The RN Supervisor shall conduct supervisory visits as often as necessary based on client needs and the RN’s assessment. The interval between visits shall not exceed 90 days. (; Ref: 6)
  • 5.4.6 During each supervisory visit the RN Supervisor shall observe care delivery as appropriate, evaluate aide performance, review and update the plan of care as needed, and document findings and follow-up actions. (; Ref: 6)
  • 5.4.7 Harbor shall ensure that an RN or LPN is available during all hours personal care services are being provided. (; Ref: 4.3)
5.5 Annual In-Service Training
  • 5.5.1 Each aide providing personal care services shall complete at least 12 hours of in-service training per calendar year. (; Ref: 6)
  • 5.5.2 Training topics shall address client care, safety, infection prevention and control, emergency procedures, reporting responsibilities, Harbor policy updates, and competency needs identified through supervision or evaluation. (; Ref: 6)
  • 5.5.3 In-service training may be completed in conjunction with on-site supervisory visits when documented appropriately. ()
  • 5.5.4 Harbor shall maintain a training log showing hours, topics, dates, and individual completion. (; Ref: 6)
5.6 Identification in Client Homes
  • 5.6.1 All Harbor personnel entering a client’s home shall be readily identifiable by name tag, uniform, or other visible means. ()
Implementation Guidance
  • A7 Harbor should maintain a personnel file checklist as the first page of each file. The checklist should confirm the presence of: position description, credential verification, background check, orientation acknowledgment, competency assessment, in-service training log, and performance evaluations. (; Ref: 6)
  • A8 Harbor maintains an in-service training tracker for each aide showing annual hours and topics. This tracker shall be available during VDH surveys and DMAS audits. (; Ref: 6)

6. Documentation Requirements

Documentation related to this policy shall be maintained in Harbor’s administrative and personnel records and shall include, at minimum, the following when applicable:

  • Written staffing plan reviewed and approved at least annually. (; Ref: 5.1)
  • Written position descriptions for each employee with documentation of updates when changed. (; ; Ref: 5.2)
  • Credential verification and qualification documentation. (; ; ; Ref: 5.2)
  • Criminal background and barrier crime screening documentation, cleared before employment. (; Ref: 5.2)
  • New hire orientation records showing topics completed, date, and individual acknowledgment. (; Ref: 5.3)
  • Employee performance evaluations and documented staff development plans. (; ; Ref: 5.3)
  • Records of staff development opportunities provided and individual participation. (; Ref: 5.3)
  • RN competency assessment for each aide before first client assignment. (; Ref: 5.4)
  • Client assessment and written plan of care, including documentation that the plan was provided to the client and reviewed with the assigned aide. (; ; Ref: 5.4)
  • RN supervisory visit notes with findings and follow-up actions. (; Ref: 5.4)
  • Annual in-service training records showing hours, topics, dates, and individual completion. (; Ref: 5.5)
  • Personnel records for each employee containing: identifying information; employment history; qualifications; results of efforts to secure job-related references; performance evaluations; disciplinary actions if any; adverse licensing actions if any; and other elements required by . (; Ref: 5.2)
  • Health-related information maintained separately within the personnel file. ()
  • Personnel records retained for at least three years following termination of employment. ()
6.1 Forms & Tools
Section 6 Requirement Form(s) / Tool(s) Used
Maintain written staffing plan Annual Staffing Plan and Coverage Matrix
Maintain position descriptions Job Description Form (per role)
Credential and qualification verification License/Certification Verification Checklist
Background and barrier crime screening Criminal Background and Barrier Crime Screening File
New hire orientation New Hire Orientation Checklist and Acknowledgment
Performance evaluation and staff development Employee Performance Evaluation Form
Staff development records Training and Staff Development Log
RN competency assessment RN Aide Competency Evaluation Form
Client plan of care RN Client Assessment and Plan of Care Form
RN supervisory visit documentation RN Supervisory Visit Note
Annual in-service training tracking Aide In-Service Training Tracker
Personnel file completeness Personnel File Master Checklist
Implementation Guidance
  • A9 Harbor may maintain personnel files electronically or in paper form in a secure location. Files shall be organized consistently so required items can be located quickly during surveys. Health-related information shall be maintained separately within the file. (; ; Ref: 6)

8. References & Regulatory Citations

Regulation Regulatory Requirement (Summary) How Used in This Policy / Internal Cross-References
Staffing plan; credential verification mechanism; position descriptions (4 required elements); employee notification of changes; new hire orientation (9 required topics); performance evaluation; staff development needs and planning; staff development records; identification in client homes; personnel record confidentiality and management; personnel record required elements; positive drug test reporting; record retention (3 years post-termination); safeguarding records; health information separation within file. Sections 1, 2, 4, 5, 6
Home attendant qualifications — English language requirement; six qualifying credential and education pathways. Sections 1, 2, 4, 5, 6
RN designation for personal care supervision; personal care service components; six-element written plan of care; plan distribution to client and aide review; supervisory visit frequency based on need, not to exceed 90 days; RN/LPN availability during all service hours; 12-hour annual in-service training requirement. Sections 1, 4, 5, 6, 7
Criminal background checks and barrier crime screening before employment. Sections 1, 2, 4, 5, 6
Written policies and controlled documentation requirements; personnel record documentation standards. Sections 1, 6, 8
Governing Body responsibility to ensure the organization is staffed and equipped to provide services. Section 4.1

Harbor shall maintain this policy as a controlled document within the policy and procedure manual and shall make it available for audits, oversight, payer review, and licensing survey activities. ()

Controlled document if viewed online. Uncontrolled if printed.