Your complete workflow guide inside Kipu Compliance — for every stage, from onboarding your first hire to running a survey-ready personnel file operation.
Log in immediately when:
- New hire starting
- Staff member terminated
- License or credential expiring
- Background check result received
- New location or level of care added
- Audit or survey date confirmed
- Regulatory change affecting HR docs
- UCR score drops unexpectedly
| 📁 86 HR Documents | 🎓 ~60 Competencies | 🎒 NAADAC/NBCC-Accredited LMS | 👤 Live UCR Per Staff Member |
|---|---|---|---|
| Personnel files, license verification, onboarding, payroll, and HR compliance — all pre-built | Role-based assessments across Nursing, Clinical, Operations, HR, Medical, and more | Training catalog meets CARF, TJC, CMS, and SAMHSA standards — role-assigned automatically | Every HR requirement per staff member tracked live by role and date of hire — one place, always current |
| HR Documents | Competencies | Recently Added & Updated | Training Completion Target |
|---|---|---|---|
| 86 Pre-built, regulation-mapped personnel docs | ~60 Role-based staff assessments by job function | 6+ HR docs & competencies added or revised | ≥90% Recommended minimum per Employee Summary |
The User Compliance Report (UCR) - Open It on Every Login
Tracks every HR document & competency per staff member, by role and date of hire.
| 📊 User Compliance Report (UCR) Left Nav → UCR | 📋 HR Documents Report — Full Staff Sweep Reports → HR Documents Report |
|---|---|
|
|
Documented Elsewhere Status is Available in the UCR for HR Docs & Competencies
Marks an HR Document or Competency as completed outside of Kipu Compliance — for records maintained in an external HRIS, legacy paper files, or another platform. The item receives Elsewhere status and counts as Compliant when the Document Date satisfies the applicable time requirement. A late Document Date still generates Not Compliant. In the UCR, the Related User field defaults to the UCR user and cannot be edited — preventing accidental reassignment. Best used as a transition bridge, not a long-term workaround.
| Where to Access (HR) | UCR-Specific Behavior | Permissions Required | What to Fill In | Score Impact | Admin Setup |
|---|---|---|---|---|---|
| UCR → HR Doc or Competency Actions dropdown · HR Doc Answer Index pages · Competency Answer Index | Related User field defaults to the UCR user and cannot be edited — prevents accidental reassignment to the wrong staff member | Document Elsewhere role per location + Create permission for HR Documents or Competencies. Both required — neither alone is sufficient. | Document Date (actual completion date, required) · Description — where the doc is stored (required) · External URL (optional) · PDF up to 10MB (optional) | ELSEWHERE = Compliant if Document Date is within the time requirement. Late = Not Compliant. Counted in compliance % the same as completed items. | Assign Document Elsewhere role via Company Admin (orange side) per location. Users without this role will not see the option in the Actions menu. |
86 HR Documents — Organized by Category
Use Ctrl+F / Cmd+F in the system to search by name · All documents are pre-built and regulation-mapped
| 🔍 Pre-Hire & Screening | 📋 Onboarding & Orientation | ✅ Acknowledgements & Policies | 🔬 License & Certification Verification |
|---|---|---|---|
Background consent must be standalone per FCRA — never bundled with the application. |
I-9 must be stored in a separate binder — not in the personnel file. |
Annual P&P Acknowledgement is distinct from Employee/Contractor Acknowledgements — both are required. |
PSV verifies licenses & certifications directly with the issuing source — OIG, NPDB, DEA, and state licensing boards. |
| 👔 Performance & HR Management | 📚 Training Records | 🏥 Health, Safety & Incidents | ⚖️ Payroll & Contractor |
|---|---|---|---|
|
Supervision logs (Clinical, Nursing, Medical, Direct Service) live in HR Documents but are owned and completed by the department director — HR monitors completion via the UCR, not submits them. |
|
|
Daily — Morning check: staff document status, approvals, and red items
Every day / every other day at minimum.
Check Dashboard — Required Approvals & Compliance To-Dos
Open the Dashboard and review the Required Approval and Compliance To-Dos boxes. HR-specific forms waiting for your action — background screenings, PSVs, clinical supervision sign-offs, competency approvals — surface here first. Use Load Data under the For You tab to see all pending HR forms. Clearing these daily prevents queues that become visible to auditors.
Navigate to: Dashboard → Required Approval
Open the UCR — scan for Not Compliant and Late items
Look for any Not Compliant / Late items requiring immediate action, and note Upcoming items on the horizon. HR requirements are driven by each employee's date of hire — a new hire's 30-day window can flip overnight. Also check any Elsewhere entries — a late Document Date still generates Not Compliant even with Elsewhere status.
Navigate to: Left Nav → UCR
Filter UCR by Department Manager — surface accountability gaps
Use the Department Manager filter to view compliance status by team or department. This tells you whether a gap is a systemic department issue (the manager needs to act) or an individual miss (coaching conversation). Same data — completely different response. Holding managers accountable through the UCR is what keeps HR from being the only person chasing completions.
Navigate to: UCR → Department Manager
Weekly — Training completion, competency oversight & user activity review
Load Training Center Employee Summary — identify incomplete or overdue trainings
Navigate to the Training Center — you must have the Manager of Training Center role in your profile to access this view. Load the Employee Summary at the bottom of the page to see training completion rates across all staff. Target: ≥90% completion. The LMS is NAADAC/NBCC accredited and meets CARF, TJC, CMS, and SAMHSA standards — training assignments are role-based, not uniform for all staff.
Navigate to: Left Nav → Training Center → Employee Summary
Create tasks for outstanding trainings & export the report
For staff with overdue training, use the Create Task button directly from the Employee Summary — the task links to their record and creates a documented follow-up trail. Export the report to Excel for your records. This export is audit-ready evidence: it shows who was behind, when you identified it, and that you acted.
Navigate to: Training Center → Create Task / Export
Review User Activity for recent compliance actions
Check the User Activity tab. As HR, you can select any user from the dropdown to view their individual activity log — including every email and notification sent to them. Use this to verify that follow-ups were actually delivered when a staff member claims they never received a reminder. This is your paper trail for "I told them."
Navigate to: Left Nav → User Activity
Review competency assessor coverage
Confirm that at least two assessors are assigned per competency set across all role groups: Nursing, Clinical, Operations, HR, Medical, Admissions, Leadership. A single-assessor setup breaks the moment that person is out or resigns. Missing assessor assignments are why competency items appear stalled in the UCR — check before escalating to support.
Navigate to: Left Nav → Competencies → Settings
Monthly — HR document sweep & license verification
Run the HR Documents Report — full staff sweep
Navigate to Reports → HR Documents Report for a cross-staff view of all 86 HR document completions. Priority items: PSV · Background Screening Results · Annual Policy Acknowledgement · State License Re-verification · NPDB Re-verification. This is the same view accreditors construct when requesting personnel file documentation — run it monthly so nothing surprises you during a survey.
Navigate to: Reports → HR Documents Report
Primary Source Verification (PSV) status check
Verify that active licensed staff PSVs are current. PSV covers OIG · NPDB · DEA · State licensing boards — all verified directly with the issuing source, not relying on documents the employee provides. Multi-State PSV handles clinicians licensed across multiple states, with an accompanying per-employee, per-state data report.
Navigate to: UCR → HR Documents → PSV | Multi-State PSV (New)
Review Access Manager for inactive or terminated users
Check the Access Manager for any staff who should be disabled. Accounts cannot be deleted in KCOM — only disabled or re-enabled. Prompt deactivation of terminated users is an access control compliance requirement; delayed deactivation is a recurring audit finding and a data security risk. Use the Employee Resignation / Termination Checklist to confirm all offboarding steps are complete.
Navigate to: Left Nav → Access Manager
Confirm supervision logs are being completed by department directors
Supervision logs (Clinical, Nursing, Medical, Direct Service Personnel) live in HR Documents but are owned and completed by the department manager. HR's role is to verify via the UCR that these are being submitted on schedule and flag any that are late.
Navigate to: UCR → HR Documents → Supervision
Monthly — New hire onboarding & workforce monitoring
Verify new hire document completion timelines
Review all employees added in the last 30–90 days against the UCR. HR requirements are driven by date of hire — confirm pre-hire documentation (Background Screening Consent, Background Results, Health & TB Screen, I-9) and onboarding stages (Day 1 → Day 30 → Day 90) are progressing on schedule. A missed 30-day window creates a Not Compliant item that ages visibly in the UCR.
Navigate to: UCR → Filter by Date of Hire
Influenza & COVID vaccination tracking (Oct–Mar, Seasonal)
During flu season, track staff vaccination status and declination reasons using the Influenza & COVID-19 Vaccination Form and Vaccination Update. TJC no longer requires proof of vaccination but requires documented tracking of why staff are not vaccinated — the declination data feeds the Annual Influenza Program. Aggregate this data by department to identify targeted education opportunities.
Navigate to: HR Documents → Vaccination
Review employee satisfaction & safety culture survey data
Check the Employee Satisfaction Survey and Employee Workplace Safety & Security Survey aggregate data from the HR Documents section. Low engagement scores often precede compliance failures and staff turnover — treat them as an early warning system. Present trend data to leadership monthly; organizations that monitor this proactively have lower turnover and fewer audit surprises.
Navigate to: HR Documents → Surveys
Review Bloodborne Pathogen Exposure Reports
Check for any new Bloodborne Pathogen Exposure Reports filed this month. OSHA requires timely documentation of needlestick and OPIM exposure incidents. Confirm that each report captures the nature of exposure, source information, post-exposure protocol initiated, and medical follow-up arranged. Delayed documentation is an OSHA recordkeeping violation.
Navigate to: HR Documents → BBP Exposure
Quarterly — Performance management, PI data contribution & personnel file audit
Contribute HR data to Quarterly QA/QI Committee
Pull training completion rates, competency assessment results, supervision documentation status, and any staff grievance or HR-related incident data. CARF requires quarterly QA/PI analysis and review of workforce-related satisfaction and performance data. HR data is one of the most frequently under-represented inputs to PI committees — your data tells the workforce story.
Navigate to: Training Center Export / Reports
Review driving records for all transportation staff (CARF)
If your organization provides client transportation, complete the Driving Record Update HR document for all staff authorized to drive clients or operate facility vehicles. CARF requires regular MVR review for all drivers. Annual is the minimum; many organizations review quarterly to catch violations before they become a liability or insurance issue.
Navigate to: HR Documents → Driving Record Update
Review open Employee Performance Improvement Plans (PIPs)
Check the status of all open Employee PIPs. PIPs should have defined check-in schedules documented in the form — follow up on those milestones quarterly at minimum. Open PIPs that aren't actively managed become a liability exposure. If performance hasn't improved and no documented check-ins exist, the PIP provides no protection in an EEOC or termination dispute.
Navigate to: HR Documents → Employee PIP
Run a personnel file audit rehearsal
Select 5 random personnel files and walk through them as a TJC or CARF surveyor would. For each file: Is the job description current? Is PSV documented? Are annual acknowledgements signed? Is licensure current and verified? Are supervision logs complete? Use the HR Audit Tool for a structured checklist. Document findings — the exercise only has value if it produces a corrective action.
Navigate to: HR Documents → HR Audit Tool
Annual — HR document cycles staggered through the year. Leadership review is always last.
Do not batch — space across Q1 through Q4.
Q1 — Health & Safety Competency & De-Escalation (All Staff)
All staff complete the Health & Safety Competency and Verbal De-Escalation Competency annually. Assign through Training Center Rules. Schedule Q1 to allow remediation time before mid-year audits. Both updated to include Telehealth / Brick & Mortar / Both service type fields. CARF requires documented completion for all staff.
Navigate to: Training Center Rules
Q1 — Compile Annual Influenza Program data
Aggregate flu season vaccination and declination data collected Oct–Mar into the Annual Influenza Program. TJC requires compiled workforce-level data — not just individual forms filed during the season. This is what accreditors ask to see.
Navigate to: HR Documents → Vaccination
Q2 — Annual Acknowledgement / Review of Policies & Procedures
All staff attest to annual review of all org policies and procedures (TJC HR.01.02; CARF 1.I). Confirm completion in the UCR for every active staff member. This is distinct from the Employee/Contractor Acknowledgements form — both are required and both will be reviewed during a survey.
Navigate to: UCR → HR Documents | TJC HR.01.02
Q2 — Background Screening recertifications & mid-year CEU check
Review which staff are due for recurring background check requirements — frequency and scope vary by state and role. Update Background Screening Results in the UCR. Also verify licensed staff are on track for licensure renewal CEU requirements using the CEU Tracker — catching gaps in Q2 prevents a year-end scramble.
Navigate to: UCR → HR Documents
Q3 — Annual QI Review, Contracted Services Evaluation & Peer Reference
HR compiles workforce data — turnover, training completion, competency pass rates — to contribute to the org-wide Annual QI Review & Plan. Complete the Contracted Services Evaluation for all contract staff and vendors (TJC LD.04.03; CARF 1.F). Coordinate Peer Reference / Recommendation Form completion for practitioners with prescribing privileges — required for TJC telehealth-accredited facilities for licensing and privileging decisions.
Navigate to: HR Documents / Reports
Q4 — Performance Reviews of Executive Leadership ⭐ (Always Last)
Complete last — this is a formal written review of executive leadership performance required by CARF. It reflects the full year of compliance posture and workforce outcomes. Coordinate with the board as applicable. Completing this before year-end data is fully in means it won't capture everything — do it last for a reason.
Navigate to: HR Documents → Performance Review | CARF · Last
Q4 — Self-Assessment of Board of Directors & Employment Agreement renewals
Facilitate the periodic self-assessment of board members (CARF) and document results. Review employment agreements for executive and clinical leadership — confirm contract terms, compensation, and confidentiality clauses are current. Q4 is also peak license renewal season for many states; confirm all licensed staff have renewed and update State License Re-verification forms in the UCR before year-end.
Navigate to: HR Documents / UCR
HR Manager Workflow Guide · Updated March 2026 · NAADAC/NBCC LMS
Comments
0 comments
Article is closed for comments.