North Carolina Home Care Agency Personnel File Requirements: the 10A NCAC 13J Checklist (2026)

Health Care Personnel Registry search completed before hire, with the date and time specific confirmation number or the printed verification result filed as the note of access the statute requires (DHSR's search page says: 'Record the confirmation number (or print the verification results) for your business files')

All unlicensed staff with direct access to clients or their property: in-home aides, companions and sitters, and any other unlicensed staff whose work gives them the opportunity for direct contact with clients or their property · Before hiring; note each access

G.S. 131E-256(b)(3), (c), (d2) · NC licensed home care agency (all)

Evidence that the registry result showed no substantiated finding: the agency may not hire, directly or by contract, anyone with a substantiated finding under G.S. 131E-256(a)(1); a pending allegation entry is not a legal bar, so how the agency treats one is a policy choice

All direct hires and contract staff · Before hiring

10A NCAC 13J .1003(c) · NC licensed home care agency (all)

Opt in, on the same search, to DHSR's email notices of registry status changes for the next 12 months, and search again before that window closes

Each person searched · At the pre-hire search; again before 12 months pass

DHSR Health Care Personnel Registry, Verify Registry Listings (updated July 16, 2026) · Recommended (not required by rule)

Signed consent to a criminal history record check; an applicant who refuses may not be employed, and a current employee who refuses may not be moved into a position that requires entering the patient's home

Every position that requires entering the patient's home, including licensed nurses and therapists, and any current employee moving into one from a position that does not · Before conditional employment begins

G.S. 131E-265(a), (f)(1) · NC licensed home care agency (all)

For an SBI State and national check (less than five years of North Carolina residency): the fingerprints and signed consent form sent with the request. The national check 'shall include a check of the applicant's or current employee's fingerprints', and the SBI request must carry the fingerprints and a consent form signed by the individual; five years or more of residency requires a State check. Recommended, not required: a note of the residency facts relied on (the statute does not say how residency is documented; keeping that record is a recommendation, not a requirement)

Every position that requires entering the patient's home · With the request; conditional employment may not begin before the agency has the consent 'or the completed fingerprint cards as required in G.S. 143B-1209.20'

G.S. 131E-265(a), (f)(1); G.S. 143B-1209.20 · NC licensed home care agency (all)

Verification that each licensed or registered staff member and contractor is "currently licensed or registered in accordance with applicable laws of the State of North Carolina" (RN, LPN, therapist, therapy assistant, social worker, respiratory therapist); DHSR checklists call this 'License Verification'

Licensed and registered staff, including contract personnel · Before the first assignment, and kept current

10A NCAC 13J .0906(b), .1003(f)(8), .1111(a)(5) · NC licensed home care agency (all)

Record that competency for each assigned client care task was verified by agency supervisory personnel, by the method the agency's written policy defines, before the task was assigned; the rule says meeting competency 'includes a demonstration of tasks to the health care practitioner', and DHSR's FAQ says competencies 'must be verified by a demonstration'

All home care services personnel, licensed and unlicensed · Before the task is assigned

10A NCAC 13J .1003(f)(9), .1110(a)-(b); DHSR Home Care FAQ Q57 (Revised 5/30/25) · NC licensed home care agency (all)

Dated proof that the check was requested from the State Bureau of Investigation under G.S. 143B-1209.20 (State or national) or, for a State check only, from a private entity that regularly conducts criminal history record checks using public records obtained from a State agency

Every position that requires entering the patient's home · Within five business days of the conditional offer; for a person working conditionally, not later than five business days after conditional employment begins

G.S. 131E-265(a), (f)(2), (h) · NC licensed home care agency (all)

The result of the check: for a national check, the DHHS Criminal Records Check Unit notice stating whether the information may affect employability (the national record itself is never shared with the agency); for a State check, the result from the SBI or the private entity. Keep verification that a check was completed ready to produce on request, and treat the criminal history information as confidential

Every position that requires entering the patient's home · On receipt; the Unit notifies the agency within five business days of receiving the national record

G.S. 131E-265(a) · NC licensed home care agency (all)

A dated note showing the seven statutory factors were considered when the check revealed a relevant offense conviction (level and seriousness, date, age at conviction, circumstances, nexus to the job duties, record since the crime, subsequent relevant offense); the statute requires the consideration but not a written record of it, and 'The fact of conviction of a relevant offense alone shall not be a bar to employment'

Any applicant whose check reveals a conviction of a relevant offense as defined in G.S. 131D-40(d) · Before the hiring decision

G.S. 131E-265(b), (d); G.S. 131D-40(d) · Recommended (not required by rule)

Proof of orientation under the agency's written orientation policy (13J names no hour count or content list; DHSR's survey checklists list 'Proof of Orientation' as a personnel record item)

All employees · On the schedule the agency's written orientation policy sets (13J sets no timing; a nurse aide I qualifying under 21 NCAC 36 .0403(a)(1) must also have completed 'an orientation program specific to the employing facility'; the four-month enrollment route in .0403(a)(2) does not mention orientation)

10A NCAC 13J .1003(d); DHSR Home Care Initial Survey Checklist (Rev 9/21) · NC licensed home care agency (all)

An application or resume that lists education, training and previous employment that can be verified, including job title (DHSR's service-line checklists also list employee name, job title and date of hire)

All employees · At hire

10A NCAC 13J .1003(f)(1) · NC licensed home care agency (all)

A written job description for the position stating qualifications and specific responsibilities, with a record of the employee's acknowledgment (DHSR checklists ask for a 'Signed Job Description')

All employees; a job description must exist for every position · At hire, and again when the position changes

10A NCAC 13J .1003(e), (f)(2) · NC licensed home care agency (all)

Reference checks or verification of previous employment (the rule sets no number of references; DHSR checklists list 'Reference Check(s)')

All employees · At hire

10A NCAC 13J .1003(f)(3) · NC licensed home care agency (all)

Performance evaluation according to agency policy and at least annually; the rule says evaluations 'may be confidential pursuant to Rule .0905', and that rule (on multiple premises) accepts a statement signed by the employee's supervisor attesting to completion where a business or government policy precludes disclosure

All employees · At least annually

10A NCAC 13J .1003(f)(7), .0905(2) · NC licensed home care agency (all)

In-service education and attendance records showing the hours and topics the agency's own written in-service policy requires (13J sets no minimum; DHSR says the policy 'should specify the number of in-service hours')

All employees covered by the agency's in-service policy · On the schedule the policy sets

10A NCAC 13J .1003(d); DHSR Home Care FAQ Q54 (Revised 5/30/25) · NC licensed home care agency (all)

Documentation by the health care practitioner of any follow-up corrective action taken after a supervisory visit finding, kept in the employee's record

Any in-home caregiver whose supervisory visit findings call for corrective action · When a supervisory visit finding requires follow-up

10A NCAC 13J .1110(e) · NC licensed home care agency (all)

Unlicensed direct-access staff only: When an allegation of abuse, neglect, misappropriation, drug diversion or fraud, or an injury of unknown source, involves health care personnel (unlicensed staff with direct access to clients or their property, G.S. 131E-256(c)): the report to DHSR, evidence the allegation was investigated, and the results sent to DHSR

Unlicensed staff with direct access to clients or their property (health care personnel under G.S. 131E-256(c)) who are the subject of an allegation · Report within 24 hours of the agency becoming aware; results within five working days of the initial notification

10A NCAC 13O .0101(7), .0102; G.S. 131E-256(c), (g) · NC licensed home care agency (all)

Verification of an active listing on the DHSR Nurse Aide I Registry for any in-home aide assigned to a client whose plan of care requires extensive assistance; an aide serving only limited-assistance clients need not be listed

In-home aides whose client's plan of care requires extensive assistance (totally dependent or hands-on help more than half the time, plus one of the three criteria in .0901(7)) · Before assignment to that client; confirm the listing is active, not merely that it once existed

10A NCAC 13J .1107(b), .0901(7), (18) · NC home care agency: in-home aide services

Before an aide performs nursing care activities delegated by a licensed nurse, regardless of title: completion of a facility-specific orientation and verified DHSR Nurse Aide Registry listing, or the agency's assurance that the aide is enrolled in a State-approved NA I program to be completed within four months of the employment date, with only demonstrated tasks assigned under supervision meanwhile

Aides performing delegated nursing care activities · Before the aide performs nursing care activities; the four-month window runs from the employment date

21 NCAC 36 .0403(a)(1)-(2); 21 NCAC 36 .0402(a) · NC home care agency: in-home aide services

For an aide whose nurse aide listing is from another state: the North Carolina Nurse Aide I Registry listing, obtained through DHSR's reciprocity process, before the aide does work that requires a listing (the licensure rule and the Board of Nursing rule both name the North Carolina registry)

Aides moving from another state's nurse aide registry · Before assignment to work that requires a listing

10A NCAC 13O .0301(a)(2); 10A NCAC 13J .1107(b); 21 NCAC 36 .0403(a)(1) · NC home care agency: in-home aide services

Registered nurse verification of six core personal care skills: assisting with mobility including ambulation, transfers and bed mobility; bath or shower; toileting; dressing; eating; and continence needs

In-home aides not listed on the nurse aide registry who were hired after April 1, 2009 (for a listed aide the registry verification stands in for this item) · Before assignment

10A NCAC 13J .1003(g) · NC home care agency: in-home aide services

Before an aide functions as a nurse aide II (an NA I performing up to four agency-selected NA II tasks under 21 NCAC 36 .0404(f) is covered by the next row instead): completion of a Board-approved NA II course plus an orientation specific to the employing agency, a current NA I listing with no substantiated findings on the NA I Registry or the Health Care Personnel Registry, and a record that the agency 'inquired of the Board' and confirmed the Board Nurse Aide II Registry listing (the DHSR online search does not cover the Board's registry)

Aides functioning as nurse aide IIs (a client who needs at least one task at the nurse aide II level and is totally dependent or needs hands-on assistance more than half the time meets the extensive assistance definition in 10A NCAC 13J .0901(7)) · Before the aide works as a nurse aide II

21 NCAC 36 .0403(b)(1)-(3), .0404(a); 10A NCAC 13J .0901(7) · NC home care agency: in-home aide services

Documentation of Board-approved module training and competency evaluation for each nurse aide I the agency approves to perform up to four selected NA II tasks; the approval is specific to the agency and does not transfer to another healthcare setting

Nurse aide I staff performing selected NA II tasks under the four-task option · Before the aide performs the selected task

21 NCAC 36 .0404(f)(1)-(3) · NC home care agency: in-home aide services

Records of each aide's paid, RN-delegated and RN-supervised nurse aide hours, so the agency RN can complete DHSR's Online Employment Verification Form at the aide's 24-month NA I renewal and the Board's online employment verification at the NA II biennial renewal (DHSR does not count sitter work, orientation without aide duties, or work the RN 'cannot support with written documentation or facility records')

Nurse aide I and nurse aide II staff and the RN who supervises them · Ongoing; NA I renewal every 24 months, NA II biennially

21 NCAC 36 .0404(g)(2); DHSR Nurse Aide I Registry Renewal page and FAQ (accessed 2026-10-13) · Recommended (not required by rule)

Supervisory visit records with the date, findings and signature of the person performing the visit, from the health care practitioner's visit to each client's residence every 90 days and the annual visit while the caregiver is providing care; the rule places them in agency records, usually the client record, so index them by aide

Unlicensed in-home caregivers · Every 90 days per client, and annually while the aide is present

10A NCAC 13J .1110(c)-(d) · NC home care agency: in-home aide services

HCCBG or SSBG participants (10A NCAC 13J .1107(g)), and agencies providing In-Home Aide Services for Older Adults funded with county social services allocations (10A NCAC 06X .0101): documentation of each aide's competence at the service level regularly provided, including verification of knowledge of all content areas and correct performance of all tasks at that level, and Nurse Aide I listing for any aide performing Level III Personal Care tasks (the DAAS rule still says the registry is 'with the NC Board of Nursing'; DHSR maintains it)

Agencies that participate in the Home and Community Care Block Grant or Social Services Block Grant through DAAS, and agencies providing In-Home Aide Services for Older Adults funded with allocations to county departments of social services · Competence for each specific task documented before the aide performs it independently (06A .0304(c)); full level competency: Level III Personal Care within four months of employment at that level, other levels within one year

10A NCAC 13J .1107(g); 10A NCAC 06X .0101; 10A NCAC 06A .0304(a)-(c), .0306 · NC home care agency: in-home aide services

HCCBG or SSBG participants (10A NCAC 13J .1107(g)), and agencies providing In-Home Aide Services for Older Adults funded with county social services allocations (10A NCAC 06X .0101): supervisory home visit records showing at least two visits in the aide's first month, then at least quarterly for Levels I and II or every sixty days for Levels III and IV, with some visits while the aide is providing care, and a written aide selection policy that limits aides to persons 18 or older or emancipated minors

Agencies that participate in the Home and Community Care Block Grant or Social Services Block Grant through DAAS, and agencies providing In-Home Aide Services for Older Adults funded with allocations to county departments of social services · First month of employment, then on the level's cadence

10A NCAC 13J .1107(g); 10A NCAC 06X .0101; 10A NCAC 06A .0307(b)-(c), (e), .0308(1) · NC home care agency: in-home aide services

Proof of the agency director's qualification route: a health care practitioner under G.S. 90-640(a); or at least two years of supervisory or management experience in home care or another provider licensed under G.S. 131E or 122C; or a bachelor's degree in health, business or public administration science plus at least one year of supervisory or management experience in home care or other licensed health care program. Persons acting as director before October 1, 2006 are grandfathered. Add a resume: DHSR's initial checklist asks for one 'only for Agency Director'

Agency director · At designation

10A NCAC 13J .1001(b); DHSR Home Care Initial Survey Checklist (Rev 9/21) · NC licensed home care agency (all)

Written designation of the person responsible for supervising each type of home care service provided directly or by contract (one person may supervise more than one service and may also be the director), and written documentation of the responsibilities and authority of the director and supervisor

Agency director and each designated service supervisor · Before the service is provided

10A NCAC 13J .1001(c)-(d) · NC licensed home care agency (all)

Copy of the written notice to DHSR when the director position becomes vacant, with the replacement's name; DHSR asks for the documents showing the new director qualifies (for example resume, licenses, credentials)

Agency director · Within five working days of the vacancy

10A NCAC 13J .1001(e); DHSR Home Care FAQ Q38 (Revised 5/30/25) · NC licensed home care agency (all)

Documentation that each licensed in-home caregiver (RN, LPN, therapist, assistant) meets the rules of the occupational licensing board and demonstrated competency for assigned client care tasks to the health care practitioner, supervised by the method and frequency the agency's policy defines for licensed staff

In-home caregivers subject to occupational licensing laws · Before assignment; supervision per agency policy

10A NCAC 13J .1110(a), (c) · NC licensed home care agency (all)

Record of training in infusion services or special training in the drug and nutritional therapies the agency offers, as identified in agency policy, for the RN providing or supervising infusion nursing (the DHSR infusion checklist lists 'Infusion Therapy Training')

RNs providing or supervising infusion nursing services · Before infusion services are provided

10A NCAC 13J .1108(a) · NC home care agency: infusion nursing services

For respiratory staff, including contractors: an active license, certification or registry plus proof of education and experience sufficient for the safe delivery of service

Staff providing clinical respiratory or ventilation services · Before the service is provided, and kept current

10A NCAC 13J .1109(a) · NC home care agency: clinical respiratory or ventilation services

Written agreement, signed by both parties, for any contracted service, providing for verification that each individual is appropriately licensed or registered, supervision of contract personnel where applicable, and assurance that contract personnel meet the same requirements as agency personnel; the agency keeps ultimate responsibility, and the contract agency carries its own criminal check duty

Contract personnel and the agencies that supply them · Before contracted services begin; reviewed and updated, if necessary, annually

10A NCAC 13J .1001(f), .1111(a)(5)-(7), (c); G.S. 131E-265(a1) · NC licensed home care agency (all)

Documentation that each companion and sitter is competent to perform the client care tasks or activities assigned, under a supervisor the agency's policy designates (non-hands-on care services do not require training or verification of skills by a registered nurse)

Companion, sitter and respite personnel of a licensed home care agency · Before assignment

10A NCAC 13J .1504(1), .1501(2) · NC home care agency: companion, sitter, respite

Supervisory records showing client contact every three months, a supervisory visit to the client's residence at least every six months, and at least an annual visit while the companion or sitter is in the home, each with the date, findings and signature. Rule .1504 applies 'In addition to the requirements in Rule .1110,' whose 90-day practitioner visit in .1110(c) reaches in-home caregivers not subject to occupational licensing; the sources reviewed here do not say how DHSR reconciles the two cadences for companions, though its Initial Home Care Survey Checklist cites .1504(2) for companion sitter supervision

Companion, sitter and respite personnel of a licensed home care agency · Quarterly contact; six-month visit; annual visit with the worker present

10A NCAC 13J .1504(2), (4), .1110(c); DHSR Home Care Initial Survey Checklist (Rev 9/21) · NC home care agency: companion, sitter, respite

Both screening layers: the Health Care Personnel Registry search with its record of access (these are unlicensed staff with direct access to clients and their property) and the signed consent to a criminal history record check (G.S. 131E-265(a) reaches any position at a licensed home care agency 'that requires entering the patient's home'; the duty does not turn on whether the service is a home care service under G.S. 131E-136(3)g.). The seven-year multi-state check in G.S. 131E-138(h)(3) binds home assistance services providers, which are licensed separately under G.S. 131E-138(a), not home care agencies

Companion, sitter and respite personnel of a licensed home care agency · Before hiring, and before conditional employment begins

G.S. 131E-256(c), (d2); 10A NCAC 13J .1003(c); G.S. 131E-265(a); G.S. 131E-138(a), (h)(3) · NC home care agency: companion, sitter, respite

Where the agency relies on the Section .1500 director standard (which applies 'Notwithstanding' Rule .1001): proof the director is a high school graduate or GED holder and is either a health care practitioner under G.S. 90-640(a) or has one year of experience in home care, companion, sitter or respite services, or another provider licensed under G.S. 131E or 122C (DHSR's FAQ applies this standard 'For agencies licensed to provide Companion, Sitter, and Respite services only.' Section .1500 took effect January 1, 2010; the sources reviewed here do not say how DHSR applies .1503 since S.L. 2023-150 made companion, sitter and respite-only providers home assistance services providers under G.S. 131E-136(1b)-(1c))

Director of an agency licensed for companion, sitter and respite services only (DHSR Home Care FAQ Q37); an agency that also provides other home care services meets 10A NCAC 13J .1001(b) · At designation

10A NCAC 13J .1503(1); DHSR Home Care FAQ Q37 (Revised 5/30/25); G.S. 131E-136(1b)-(1c) · NC home care agency: companion, sitter, respite

Written designation of the person responsible for supervising non-hands-on care services provided directly or by contract (may also be the director; the rule names no professional credential)

Supervisor of companion, sitter or respite services · Before the service is provided

10A NCAC 13J .1503(2) · NC home care agency: companion, sitter, respite

A written policy decision on TB screening, Hepatitis B documentation and pathogen training for companions and sitters: the rule requires those items for hands-on care employees, while DHSR's initial survey checklist describes its bloodborne pathogen, TB and Hepatitis B policies as 'required for all in-home caregivers'

Companion, sitter and respite personnel of a licensed home care agency · At hire, under whatever the policy decides

10A NCAC 13J .0901(10), .1003(b), (f)(4)-(6); DHSR Home Care Initial Survey Checklist (Rev 9/21) · Recommended (not required by rule)

Documentation of the home health aide's qualification route: a training and competency evaluation program; a competency evaluation program; a state-approved nurse aide training and competency evaluation program with current listing in good standing on the state nurse aide registry; or a qualifying state licensure program

Home health aides · Before the aide furnishes services

42 CFR 484.80(a)(1) · Medicare-certified HHA (42 CFR 484)

Training records showing at least 75 hours of classroom and supervised practical training, with at least 16 classroom hours preceding at least 16 supervised practical hours, covering the required subject areas

Home health aides qualified by training · Before the aide furnishes services

42 CFR 484.80(b)(1)-(4) · Medicare-certified HHA (42 CFR 484)

If the agency trains its own aides: evidence that classroom and supervised practical training was performed by a registered nurse with at least 2 years of nursing experience, at least 1 of them in home health care, or by others under that RN's general supervision

Aide training instructors · Before training begins

42 CFR 484.80(e) · Medicare-certified HHA (42 CFR 484)

Competency evaluation performed by a registered nurse, with the five specified subject areas evaluated by observing the aide with a patient or pseudo-patient, any 'unsatisfactory' rating recorded, and retraining plus a subsequent evaluation completed before the aide performs that task without direct RN supervision

Home health aides · Before the aide furnishes services; again after any unsatisfactory rating

42 CFR 484.80(c)(1), (3)-(5) · Medicare-certified HHA (42 CFR 484)

Documentation of at least 12 hours of in-service training in each 12-month period, supervised by a registered nurse

Home health aides · Each 12-month period

42 CFR 484.80(d) · Medicare-certified HHA (42 CFR 484)

Dates of compensated aide service sufficient to show there has been no continuous 24-month period without compensated services, which would require the aide to complete another program before providing services

Home health aides · Ongoing

42 CFR 484.80(a)(2) · Medicare-certified HHA (42 CFR 484)

Record of the annual on-site visit to observe and assess each aide while performing care for patients who also receive skilled services, or the semi-annual on-site observation for aide-only patients

Home health aides · Annually, or semi-annually for aide-only patients

42 CFR 484.80(h)(1)(iv), (h)(2)(ii) · Medicare-certified HHA (42 CFR 484)

Retraining and a new competency evaluation for the deficient and all related skills whenever a deficiency in aide services is verified during an on-site visit

Home health aides · When a deficiency is verified

42 CFR 484.80(h)(3) · Medicare-certified HHA (42 CFR 484)

For an administrator who began employment on or after January 13, 2018: proof the person is a licensed physician, a registered nurse, or holds an undergraduate degree, and has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. If the same person also serves as the 13J agency director, the 10A NCAC 13J .1001(b) standard applies to that role as well.

HHA administrator · At hire

42 CFR 484.115(a)(2); 10A NCAC 13J .1001(b) · Medicare-certified HHA (42 CFR 484)

Qualification evidence for the clinical manager (licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker or registered nurse), each RN (graduate of an approved school of professional nursing, licensed in the state) and each LPN (completed a practical nursing program, licensed in the state, working under a qualified RN)

Clinical manager, RNs and LPNs · At hire

42 CFR 484.115(c), (e), (k) · Medicare-certified HHA (42 CFR 484)

Proof the PCS aide is a high school graduate or equivalent, or is 18 years of age or older

Aides providing Medicaid PCS · At hire

NC Medicaid Clinical Coverage Policy 3L, 6.1.1 · NC Medicaid PCS provider (Policy 3L)

Documentation in the aide's personnel record of training in beneficiary rights; confidentiality and privacy practices; personal care skills for bathing, dressing, mobility, toileting and eating; documentation and reporting of beneficiary accidents and incidents; recognizing and reporting signs of abuse and neglect; and infection control (content areas, not hours)

Aides providing Medicaid PCS · Before the aide provides PCS

NC Medicaid Clinical Coverage Policy 3L, 6.1.2(a)-(c), (e)-(g) · NC Medicaid PCS provider (Policy 3L)

For aides serving beneficiaries who receive hours under Session Law 2013-306: training or experience in caring for individuals with a degenerative disease characterized by irreversible memory dysfunction, backed by the provider's attestation to NC Medicaid (form NC Medicaid-3085)

Aides serving beneficiaries with S.L. 2013-306 hours · Before assignment to those beneficiaries

NC Medicaid Clinical Coverage Policy 3L, 6.1.2(d) · NC Medicaid PCS provider (Policy 3L)

Evidence that the criminal background check was conducted 'before they are hired as specified in licensure requirements' and that the aide is not listed on the Health Care Personnel Registry with a substantiated finding (G.S. 131E-265(f) permits conditional employment once consent is obtained and the request goes out within five business days; 3L does not address that provision)

In-home aides providing Medicaid PCS · Before hire

NC Medicaid Clinical Coverage Policy 3L, 7.10(c)(1)-(2); G.S. 131E-265(f) · NC Medicaid PCS provider (Policy 3L)

Screen the check result against the Section 6.0 list (controlled-substance felonies, felony or misdemeanor health care fraud, felony abuse, neglect, assault, battery, criminal sexual conduct, fraud or theft against a minor or vulnerable adult, patient abuse, cruelty or torture, and registry-listed abuse misdemeanors and substantiated allegations); PCS furnished by an aide with a listed conviction cannot be billed to Medicaid

In-home aides providing Medicaid PCS · Before billing for the aide's services

NC Medicaid Clinical Coverage Policy 3L, 6.0 · NC Medicaid PCS provider (Policy 3L)

An individual file on each in-home aide documenting training, background checks and competency evaluations, with evidence that the aide meets the 10A NCAC 13J qualifications and is supervised as 13J requires

In-home aides providing Medicaid PCS · Maintained throughout employment

NC Medicaid Clinical Coverage Policy 3L, 7.10(c)(3)-(4) · NC Medicaid PCS provider (Policy 3L)

New employee orientation record covering state rules pertaining to home care agencies and the requirements of the 3L policy, with comprehensive records of all staff orientation and training activities

All new in-home aides and other agency employees of a PCS provider · At hire; records kept for all orientation and training

NC Medicaid Clinical Coverage Policy 3L, 7.10(d)(1), (4) · NC Medicaid PCS provider (Policy 3L)

Records of the ongoing staff development program and of competency training and evaluation for in-home aides, and of attendance by agency directors, administrative personnel, RN nurse supervisors and other managers at NC Medicaid regional and online training programs

In-home aides, directors, RN supervisors and other managers of a PCS provider · Ongoing

NC Medicaid Clinical Coverage Policy 3L, 7.10(d)(2)-(3), (5) · NC Medicaid PCS provider (Policy 3L)

RN Supervisor visit documentation (date, arrival and departure time, purpose, findings and signature) for the visit to each beneficiary's residence every 90 calendar days with a seven-day grace period, two of them within 365 days while the aide is scheduled to be present, including the evaluation of the aide's performance

In-home aides providing Medicaid PCS and the RN Supervisor · Every 90 calendar days per beneficiary; two visits per 365 days with the aide scheduled

NC Medicaid Clinical Coverage Policy 3L, 7.10(b) · NC Medicaid PCS provider (Policy 3L)

Where an aide performs Nurse Aide I or Nurse Aide II tasks: documentation that the training, competency evaluation and other qualifications in 21 NCAC 36 .0403(a) or (b) are met and that the task is specified on the beneficiary's service plan

In-home aides performing NA I or NA II tasks for PCS beneficiaries · Before the task is performed

NC Medicaid Clinical Coverage Policy 3L, 6.1.6; 21 NCAC 36 .0403(a)-(b) · NC Medicaid PCS provider (Policy 3L)

Form I-9: Section 1 completed and signed by the employee at the time of hire (with the preparer or translator certification if someone assisted), and Section 2 completed and signed by the employer after physically examining, or examining under the alternative procedure in paragraph (b)(1)(ix), the identity and employment authorization documents

All W-2 employees · Section 1 at hire; Section 2 within three business days of the hire

8 CFR 274a.2(b)(1)(i)(A), (b)(1)(ii)(A)-(B) · Federal employment law (all employers)

E-Verify record of the verification of each new hire's work authorization

Employers with 25 or more employees in North Carolina (an individual whose term of employment is less than nine months in a calendar year is not an employee for this purpose) · After hiring

G.S. 64-26(a); G.S. 64-25(3)-(4) · NC employment law

Written notice given at the time of hiring of the promised wages and the day and place for payment, and written notice at least one pay period before any change in promised wages

All employees · At hiring; before any wage change

G.S. 95-25.13(1), (3) · NC employment law

Payroll or other records with each employee's name, address, date of birth, occupation, rate of pay and compensation earned each week

All employees of an employer subject to the ADEA · Each week's compensation recorded; retention periods are in the Retention rows

29 CFR 1627.3(a) · Federal employment law (covered employers)

If the agency is a HIPAA covered entity: documentation that each new workforce member was trained on the privacy policies and procedures within a reasonable period after joining, and documentation of any sanction applied

Workforce members of a covered entity (HIPAA applies to covered entities only) · Within a reasonable period after the person joins; sanctions when applied

45 CFR 164.530(b)(2)(i)(B), (b)(2)(ii), (e)(2) · Federal law: HIPAA covered entities only

Documented check of the OIG List of Excluded Individuals and Entities at hire and on a schedule the agency's policy sets: no Medicare, Medicaid or other federal health care program payment will be made for any item or service furnished by an excluded individual (no rule reviewed here sets a screening schedule, so the schedule is an agency-policy choice; see the OIG exclusion screening guide)

All staff and contractors of an agency that bills Medicare or Medicaid · At hire, then on the agency's schedule

42 CFR 1001.1901(b)(1) · Recommended (not required by rule)

Baseline TB skin test result, with evidence of noninfectious status before assignment in a client's home for anyone who tests positive, filed as the TB screening record ((f)(4) cross-refers to 'Paragraph (a)' although the test requirement sits in Paragraph (b)). The rule says 'skin test' and does not mention a blood assay (IGRA), which 10A NCAC 41A .0205 allows for the settings it names, so confirm with DHSR before substituting one; DHSR's Initial Home Care Survey Checklist asks for 'Proof of TB Skin Test or Chest X-ray'

Hands-on care employees · Before assignment in a client's home

10A NCAC 13J .1003(b), (f)(4); 10A NCAC 41A .0205(b)-(c); DHSR Home Care Initial Survey Checklist (Rev 9/21) · NC licensed home care agency (all)

For individuals who previously tested positive: a baseline and then annual verification that they are free of TB symptoms, obtained from the local health department, a private physician or a health nurse employed by the agency (the Tuberculosis Control Branch provides Form DHHS 3405, Record of Tuberculosis Screening, free of charge)

Hands-on care employees with a prior positive skin test · Baseline, then annually

10A NCAC 13J .1003(b) · NC licensed home care agency (all)

Repeat TB test results for employees the agency's risk assessment identifies as at risk for exposure, at the intervals the rule ties to 'OSHA standards'; write the interval and the standard relied on into the TB policy

Employees the agency's risk assessment identifies as at risk · At the intervals 'prescribed by OSHA standards' (the rule's words); state the interval and the standard relied on in the TB policy

10A NCAC 13J .1003(a)-(b) · NC licensed home care agency (all)

Record that the hepatitis B vaccination series was made available at no cost, after the required training, unless the employee already had the complete series, is immune by antibody test or has a medical contraindication

Employees with occupational exposure as defined in 29 CFR 1910.1030(b) · Within 10 working days of initial assignment

29 CFR 1910.1030(f)(1)(ii)(A), (f)(2)(i) · Federal OSHA: employers with occupationally exposed employees (29 CFR 1910.1030)

Documentation of Hepatitis B immunization or declination, in accordance with the agency's exposure control plan

Hands-on care employees · 13J sets no timing; file it under the exposure control plan (29 CFR 1910.1030(f)(2)(i) requires the vaccine to be made available within 10 working days of initial assignment)

10A NCAC 13J .1003(f)(5) · NC licensed home care agency (all)

Any declination signed on the mandatory Appendix A statement, and the later vaccination record if the employee accepts the vaccine while still covered by the standard

Employees with occupational exposure who decline the vaccine · At declination; vaccination made available whenever the employee later accepts

29 CFR 1910.1030(f)(2)(iii)-(iv) and Appendix A · Federal OSHA: employers with occupationally exposed employees (29 CFR 1910.1030)

Airborne and bloodborne pathogen training for hands-on care employees, including annual updates, in compliance with 29 CFR 1910 and the agency's exposure control plan (the one recurring training interval 13J states; 29 CFR 1910.1030 covers bloodborne pathogens only, so the airborne element comes from 13J)

Hands-on care employees · At initial assignment, then annually

10A NCAC 13J .1003(f)(6) · NC licensed home care agency (all)

Bloodborne pathogens training at initial assignment to tasks with occupational exposure and at least annually, within one year of the previous training, at no cost and during working hours

Employees with occupational exposure · At initial assignment; annually within one year of the previous training

29 CFR 1910.1030(g)(2)(i)-(ii), (iv) · Federal OSHA: employers with occupationally exposed employees (29 CFR 1910.1030)

Training record showing the dates of the sessions, the contents or a summary, the names and qualifications of the persons conducting the training, and the names and job titles of all attendees (a sign-in sheet without the content summary and trainer qualifications falls short)

Employees with occupational exposure · At each training session

29 CFR 1910.1030(h)(2)(i) · Federal OSHA: employers with occupationally exposed employees (29 CFR 1910.1030)

OSHA medical record for each employee with occupational exposure: name, hepatitis B vaccination status with dates, results of post-exposure examinations, testing and follow-up, the employer's copy of the healthcare professional's written opinion, and the information provided to that professional; after an exposure incident, the documented route and circumstances, with the written opinion given to the employee within 15 days of the evaluation

Employees with occupational exposure · Established at initial assignment; updated after any exposure incident

29 CFR 1910.1030(h)(1)(i)-(ii), (f)(3), (f)(5) · Federal OSHA: employers with occupationally exposed employees (29 CFR 1910.1030)

Keep TB results, vaccination records and post-exposure records in a separate confidential medical section: OSHA requires the medical records to be kept confidential and not disclosed without the employee's express written consent, but it does not require a physically separate file, so the separation is a practice choice

All employees with health records on file · From the first entry

29 CFR 1910.1030(h)(1)(iii) · Recommended (not required by rule)

If the agency performs invasive procedures as defined (the definition includes the use of needles to puncture skin): training of its health care workers in the written infection control policy, and the Department-approved infection control course for the designated on-site staff member at each noncontiguous facility

Health care workers of an agency that performs invasive procedures, and the designated infection control staff member · On adoption of the policy and at hire; course completion for the designated staff member

10A NCAC 41A .0206(a)(2), (b) · NC public health rule: health care organizations that perform invasive procedures

The personnel record for each home care employee, and the in-service education and attendance records, kept for at least one year after termination from agency employment and available on the agency premises for inspection by the Department when requested

All employees, including terminated · At least one year after termination

10A NCAC 13J .1003(d), (f) · NC licensed home care agency (all)

For a multi-site agency that centralizes records: the ability to bring the portions of personnel records subject to review to the inspected site on 72 hours' advance notice

Agencies operating more than one licensed premises · Within 72 hours of the Department's request

10A NCAC 13J .0905(2)-(3) · NC licensed home care agency: multiple premises

Any aide-related entries the agency files in the client record follow the client-record clock: not less than five years from the most recent discharge, or until three years after a minor client's 18th birthday (13J requires only that supervisory visit documentation be kept 'in the agency's records', with no stated period, 10A NCAC 13J .1110(d))

Aide-related entries an agency chooses to file in client records · Five years from the most recent discharge

10A NCAC 13J .1401(f), .1110(d) · NC licensed home care agency (all)

OSHA medical records, including hepatitis B vaccination status, kept for at least the duration of employment plus 30 years (records of an employee who worked less than one year need not be kept beyond employment if given to the employee at termination); bloodborne pathogens training records kept 3 years from the training date

Employees with occupational exposure · Employment plus 30 years for medical records; 3 years for training records

29 CFR 1910.1030(h)(1)(iv), (h)(2)(ii); 29 CFR 1910.1020(d)(1)(i), (d)(1)(i)(C) · Federal OSHA: employers with occupationally exposed employees (29 CFR 1910.1030)

Form I-9 retained three years after the date of hire or one year after the date employment is terminated, whichever is later (practice tip, not a rule: note the three-year date at hire and set the final purge date at termination)

All W-2 employees, including terminated · Three years after hire or one year after termination, whichever is later

8 CFR 274a.2(b)(2)(i)(A) · Federal employment law (all employers)

E-Verify record of work authorization retained while the employee is employed and for one year thereafter

Employers with 25 or more employees in North Carolina · While employed plus one year

G.S. 64-26(b) · NC employment law

Personnel and employment records (applications, hiring, promotion, demotion, transfer, lay-off, termination, pay rates, training selection, reasonable accommodation requests) kept one year from the record or the action, whichever is later; one year from termination for an involuntary termination; and all relevant records until final disposition once a charge is filed

Employers subject to Title VII, the ADA or GINA · One year; until final disposition of any charge

29 CFR 1602.14 · Federal employment law (covered employers)

Payroll records kept 3 years; job applications, promotion, demotion, transfer, discharge, test papers and physical examination results used in a personnel action kept 1 year from the action; time and earning cards with daily starting and stopping times, and wage rate tables, kept at least 2 years

ADEA employers: payroll 3 years and the listed personnel records 1 year (29 CFR 1627.3); FLSA employers: payroll 3 years and time cards and wage rate tables 2 years (29 CFR 516.5-516.6) · 3 years for payroll; 1 year for the listed personnel records; 2 years for time cards

29 CFR 1627.3(a), (b)(1); 29 CFR 516.5(a); 29 CFR 516.6(a)(1)-(2) · Federal employment law (covered employers)

If the agency is a HIPAA covered entity: privacy training and sanction documentation retained six years from its creation or the date it was last in effect, whichever is later

Workforce members of a covered entity · Six years

45 CFR 164.530(j)(2) · Federal law: HIPAA covered entities only