Standard HR.1.20 for staff, students and volunteers
who work in the same capacity as staff who provide care, treatment,
and services, at EP 5 states criminal background checks are verified
when required by law and regulation and organization policy.
This means that if state law, regulation or organization policy requires
background checks on all employees, volunteers and students, JCAHO
expects them to be done on all three categories.
If state law requires background checks on only specified types of
health care providers (e.g. nursing assistants/child care workers),
then JCAHO would require background checks on only those specified
in state law (unless organization policy goes beyond state law).
If state law requires background checks on all "employees",
the organization should seek an opinion from the state on what categories
of health care workers are considered "employees". If the
state clearly does not consider volunteers or students to be employees,
then JCAHO would not require background checks on them (unless organization
policy goes beyond state law and requires it).
If state law is ambiguous as to the definition of employee, the organization
can define the scope of background checks to fit its own definition.
As such, they may include or exclude students and volunteers, and
JCAHO would survey to hospital policy.
In the absence of a state law on criminal background checks, each
organization can develop its own expectations, e.g., and organization
elects to screen employees and not students/volunteers. JCAHO would
evaluate compliance with the organization's internal policy only.
There would be no JCAHO expectation that an organization check categories
of providers beyond what is required in their own policy, which must
comply with law and regulation.