How To: Keep All Staff Files Up to Date for ARMHS Audits and Recertifications

On every page in each staff person’s file, the staff person’s name must be identified. In each staff person’s file, the following documents are needed:

•  A background check that is completed during the hiring process
•  Date of hire
•  Date that the staff person first began providing services
•  Job title and summary of staff responsibilities
•  Qualifications that substantiate their job title
•  An official transcript and/or copy of a degree with an official transcript (if applicable)
•  Copy of most recent health-related license (if applicable)
• Treatment Supervision (if applicable)
•  Treatment supervision plan (if applicable)
•   Documentation of Training
•   Initial training 
•  30 hours training (if applicable)
•  Training after 90 days (if applicable) 
•  Annual Training
•  Continuing Education/Ongoing Training
•  Performance review
•  Any alleged and substantiated violations by the staff person of Company policies and the Company’s response

1. Background Checks

DHS requires that background checks be conducted during the hiring process for certain professions in which the staff person will be working directly with and providing care to vulnerable adults and children. A background check should be done after the job has been offered to the prospective employee, contingent on their background study results, but before the individual begins providing services to clients. According to Minn. Stat. 245I.07(a), the documentation related to the staff person’s background study will go in their personnel file if they are hired. 

For ARMHS employees, employers are not required to use NetStudy 2.0 for background checks and can instead use any reputable background study service. Prior to conducting the background study, information will need to be gathered from the prospective employee and they will need to sign a form that they understand the background study and consent to the release of their information. 

2. Date of Hire

According to Minn. Stat. 245I.07(a), each staff person needs to have their date of hire in their personnel file. 

3.Date that Staff Person Began Providing Services to Clients

According to Minn. Stat. 245I.07(a), each staff person needs to have the date that the staff person’s specific duties and responsibilities became effective, including the date that the staff person began having direct contact with clients. In almost all cases, this date will be the same, so it is sufficient to just have the date that the staff person began providing direct contact services to clients. 

4. Job Title and Summary of Job Responsibilities

Minn. Stat. 245I.07(a), states that each staff file must have a description of the staff person’s job title and responsibilities. A good place to look for this is the Minnesota statute that corresponds with their job title. Each job title has a list of qualifications after it. Another place is the job posting for the position. 

5. Qualifications that Substantiate their job title

Reference Minnesota Statute 245I.04 for the official list of qualifications needed for each job title. DHS also has a form that details the different qualifications or see ARMHS Recertification Checklist for a breakdown. 

6. An Official Transcript and/or Copy of their Degree with Official Transcript

Official transcripts will need to be requested from the staff person’s school to be sent to the Program office. Transcripts and degrees should be scanned in as opposed to a picture taken of them and then uploaded.  

7. Copy of Most Recent Health-Related License

If staff member is a licensed professional, then their staff personnel file must include a copy of their most recent health-related license. This allows Company to stay abreast of licensure expiration dates and ensure that each staff person renews their license prior to its expiration date. Staff people must not be allowed to work or be scheduled to work without an up-to-date license. 

8. Treatment Supervision

All staff persons who provide services to clients and who are not mental health professionals or certified rehabilitation specialists need treatment supervision. The treatment supervision must follow a person’s written supervision plan (see below). Sessions of treatment supervision must focus on each client the staff person serves, the client’s needs, and the ability of the staff person to provide services to each client. The following topics should be covered during treatment supervision in regard to the staff person’s current caseload:

• A review and evaluation of the interventions that the staff person delivers to each client;
• Instructions on alternative strategies if a client is not achieving treatment goals;
• A review and evaluation of each client’s assessments, treatment plans, and progress notes for accuracy and appropriateness;
• Instruction on the cultural norms or values of the client and communities that the license holder serves and the impact that a client’s culture has on providing treatment;
• Evaluation of and feedback regarding a direct services person’s areas of competency; and 
• Coaching, teaching, and practicing skills with a staff person. 

The treatment supervisor must provide treatment supervision in a way that allows for immediate feedback. The methods of supervision that allow for this are in-person, telephone, or interactive video chat. 

Treatment supervision can be done by a fellow staff member, clinical supervisor, or treatment director who is a mental health professional or a certified rehabilitation specialist. A treatment supervisor can also be a contracted worker but it is the responsibility of the Program to ensure that all of its staff people who needs supervision receive it, therefore the Program would be who contracts with the treatment supervisor.

The Supervising Clinician should be available via phone for urgent consultations for both staff and clients. A supervisee is expected to contact the supervisor for urgent consultation when the supervisee identifies an issue or question that they do not feel comfortable addressing, they don’t have sufficient experience to appropriately handle, or the issue is outside of the supervisee’s scope of practice. 

If a mental health practitioner or a clinical trainee is providing treatment supervision to a mental health rehabilitation worker or a mental health behavioral aide, then the mental health practitioner or the clinical trainee’s treatment supervision needs to occur at least monthly and address the following topics, in addition to the other topics listed above that apply to all treatment supervision:

• Identification and planning for general needs of the recipient population served;
• Identification and planning to address provider entity program needs and effectiveness;
• Identification and planning for provider entity staff training and personnel needs and issues; and 
• Planning, implementation, and evaluation of provider entity quality improvement program. 

If a staff person who is receiving treatment supervision happens to be employed by two different licensed Programs at the same time, each Program is responsible for providing treatment supervision to the staff person. 

Regarding frequency or minimum hours of supervision, the statute is not specific about this detail. It is therefore a recommendation that treatment supervision happen at least monthly. If the treatment supervision sessions are individual, the sessions should last about an hour, possibly longer if more needs to be covered during the session, to adequately cover all the elements of a treatment supervision session. If the treatment sessions are in a group setting, then the sessions could be anywhere from two to four hours, depending on the amount of people in the group. 

The only staff positions that the law specifies frequency for supervision are for mental health rehabilitation workers, mental health behavioral aides, and one specific category of qualifications for mental health practitioners. 

For mental health rehabilitation workers and mental health behavioral aides must receive direct observation from a mental health professional, clinical trainee, certified rehabilitation specialist, or mental health practitioner, while the mental health rehabilitation worker or mental health behavioral aide is providing treatment services. The direct supervision needs to occur at least once every two weeks for the first six months of the staff person’s employment and once per month following. The observing staff person must sign off on the progress note for the treatment service that was observed. 

If the mental health rehabilitation worker meets qualifications for their job based upon having a high school diploma, or equivalent, and is fluent in the non-English language or competent in the culture of the ethnic group to which at least 20% of the mental health rehabilitation worker’s client belong, then they need to have individual supervision every month and direct observation every two weeks for the first 2,000 hours of their employment. 

If a mental health practitioner has 2,000 hours of experience providing services to clients with mental illness, substance use disorder, traumatic brain injury, or a developmental disability, but does not have the education requirements and is not fluent in the non-English language of the ethnic group for which at least 50% of the individual’s clients belong, then they must receive treatment supervision once per week until they meet the requirement of 4,000 hours of experience providing direct services to clients.  

9. Treatment Supervision Plan

A written treatment supervision plan must be developed by the treatment supervisor and the staff person who will be supervised. It must be completed within 30 days of the new staff person’s first day of employment. The license holder (Program) must review and update each staff person’s treatment supervision plan on an annual basis. Each plan must include:

• The name and qualifications of the staff person receiving treatment supervision;
• The names and licensures of the treatment supervisor(s) who are supervising the staff person; 
• How frequently the treatment supervisor(s) must provide treatment supervision to the staff person; and
• The staff person’s authorized scope of practice, including a description of the client population that the staff person serves, and a description of the treatment methods and modalities that the staff person may use in providing services to clients. 

Form A is a blank treatment supervision plan that includes the necessary elements. 

Form B is a treatment supervision plan filled in with mock sample answers. Please use for reference only. 

10. Documentation of Training

Minn. Stat. 245I.05, Subd. 2, requires that license holders must provide training to their staff persons and document that the training was provided to each staff person. The following information needs to be documented for each staff person’s training:

• The topics of the training;
• The names of the trainee;
• The name and credentials of the training;
• The license holder’s method of evaluating the trainee’s competency upon completion of training;
• The date of the training; and
• The length of the training in hours and minutes.

See Form C below.

If the staff person is a licensed behavioral health professional, Company does not need to document their continuing education training. 

When a new staff person is hired, they will need all of the training listed in the “Initial Training” section below as well as the “30 Hours of Additional Training” section below. Staff persons cannot carry over these training qualifications/hours from a previous employer.

Staff persons can, however, carry over the training listed in the section below “Training in 90 Days” if the training was completed within the last two years through an employee training session or program. If the training was completed through an equivalent postsecondary education, and it was completed within the last four years, the staff person is exempt from doing the same training again. 

11. Initial Training

According to Minn. Stat. 245I.05, Subd. 3, each staff person, regardless of their job title, must receive training in the following areas when they are first hired and before they start providing services to clients: 

• Vulnerable Adult Maltreatment (see Minn. Stat. 245A.65, Subd. 3)

• Client Rights and Protections (see Minn. Stat. 245I.12)
• Minnesota Health Records Act, including client confidentiality, family engagement, and client privacy (see Minn. Stat. 144.294)
• Emergency Procedures that the staff person must follow when responding to a fire, inclement weather, a report of a missing person, and a behavioral or medical emergency
• Specific Activities and Job Functions for Staff Person; Program Polices and Procedures
• Professional Boundaries
• Specific Needs of Each Client to Whom Staff Person Will be Providing Services 

Some of these topics will be included in the staff person’s orientation, particularly the Program Policies and Procedures.

Within 72 hours of a staff person first providing direct contact services to a client, they must have education on:

• The Maltreatment of Minor Reporting Requirements and Definitions (see Minn. Stat. 260E)

12. 30 Additional Hours of Initial Training

Certain mental health practitioners will require an additional 30 hours of training before they provide direct contact services to clients. Those staff persons include:

• Mental Health Practitioners who have 30 hours of semester hours or 45 quarter hours in behavioral sciences or related fields and have 2,000 hours of experience providing services to clients with a traumatic brain injury or a developmental disability;
• Mental Health Practitioners who are fluent in the non-English language of the ethnic group to which at least 50% of the individual’s clients belong; 
• Mental Health Practitioners who have at least 4,000 hours of experience delivering services to individuals with a traumatic brain injury or a developmental disability; or
• Mental Health Practitioners who have at least 2,000 hours of experience delivering services to individuals with a traumatic brain injury or a developmental disability and are receiving treatment supervision at least once per week until they reach 4,000 total hours of experience 

The training that they need the additional 30 hours in includes:

• Mental illness;
• Client recovery and resiliency;
• Mental health de-escalation techniques;
• Co-occurring mental illness and substance use disorders; and
• Psychotropic medications and medication side-effects.

13. Training Within 90 Days 

Within 90 days of first providing direct contact services to adult clients, mental health practitioners, mental health certified peer specialists, and mental health rehabilitation workers must receive training about the following topics:

• Trauma-informed Care and Secondary Trauma
• Person-Centered Individual Treatment Plans, including seeking partnerships with family and other natural supports
• Co-occurring Substance Use Disorders
• Culturally Responsive Treatment Practices 

14. Annual Training

All staff persons who provide direct contact services to clients need to receive training on the following topics on an annual basis:

• Vulnerable Adult Maltreatment (see Minn. Stat. 245A.65, Subd. 3)

• Client Rights and Protections (see Minn. Stat. 245I.12)
• Minnesota Health Records Act, including client confidentiality, family engagement, and client privacy (see Minn. Stat. 144.294)
• Emergency Procedures that the staff person must follow when responding to a fire, inclement weather, a report of a missing person, and a behavioral or medical emergency
• The Maltreatment of Minor Reporting Requirements and Definitions (see Minn. Stat. 260E)

15. Continuing Education/Ongoing Training

Program must ensure that all staff persons who are not mental health professionals must receive 30 hours of training, every two years. Training topics must be based upon the program’s needs and the staff person’s areas of competency. These training topics can be done by the Program, a guest speaker, or a training program that the Program purchases. 

16. Performance Review

Annual Performance reviews can be done either at the same time of year for all employees (so long as it is consistent year to year), regardless of their hire date, or they can be done annually at or around (within a month) the employee’s original date of hire. If annual reviews are done at the same time of year for all employees, then for the first annual review, it may cover less than a year’s time. 

Every Program and Company does performance reviews a little bit differently. Some have the staff persons evaluate themselves based upon certain competencies and then their supervisor evaluates them on the same areas, and some chose to have only the supervisors evaluate the staff persons. 

Performance reviews are an excellent time to discuss any ongoing issues a staff person may be having in behavior or performance and to lay out a plan of improvement. It is also an ideal time to discuss job expectations and to set goals for the coming year. The elements that should be in a performance review in some capacity include:

• The staff person’s strengths and what they are doing well in at their job;
• The staff person’s weaknesses or areas that have been an issue or could use improvement;
• Goals that have been achieved or need improvement from the last performance review;
• A rating system that allows for all performance reviews to be consistent between staff persons;
• The time period that the review covers. Most times this will be annual, but at times it may be more frequent; and
• Goals to be worked on for the next year.

A good place to find areas of strength to measure the staff persons by is to look at the Program philosophy, mission or vision statement, or the Program values. Then rate how each staff person is embodying and displaying those concepts in their work. 

Goals will be specific to each Program, however, they can be anything such as education or trainings that staff people are to complete in the next year, personal goals for a staff person, or ways the Program can improve in some way and the manner in which each staff person can assist in achieving it. 

Supervisory staff should meet with each staff person to discuss their performance review, that has been prepared prior to the meeting, to explain the rationale for each rating and go over the agreed upon goals for the coming year. Both parties should sign and date the performance review and the staff person should receive a copy. The original or a copy must also go into each staff person’s personnel file. 

17. Any Alleged or Substantiated Violations by the Staff Person of Company Policies and the Company’s Response

If there are incidents in which an employee has violated a Company Policy or there have been complaints about a staff person violating Company policies or conducting themselves in an unethical manner, these should be documented in the staff person’s file along with the measures that have been taken by the Program to address it and rectify it. Copies of Performance Improvement Plans or Corrective Action Plans should all be in each staff personnel file. 

Staff Personnel File Cover Sheet (Form A)

 

Name: ______________________________________________________________________

Job Title: ____________________________________________________________________

Job Responsibilities: ___________________________________________________________

____________________________________________________________________________

Date of Hire: ____________________________ 

Date of When Staff Person Began Having Direct Contact with Clients: ___________________

Checklist for the Following Documents: 

• Background Check
• Copy of Professional License (if applicable)    Date of Renewal: ___________________
• Initial Training (to be completed before providing direct contact services to clients):
• • Vulnerable Adult Maltreatment 
  • Client Rights and Protections
  • Minnesota Health Records Act, including client confidentiality, family engagement, and client privacy
  • Emergency Procedures that the staff person must follow when responding to a fire, inclement weather, a report of a missing person, and a behavioral or medical emergency
  • Specific Activities and Job Functions for Staff Person; Program Polices and Procedures
  • Professional Boundaries
  • Specific Needs of Each Client to Whom Staff Person Will be Providing Services 

• Training Topic to be Completed Within 72 Hours of First Providing Direct Contact Services:

Maltreatment of Minor Reporting Requirements

• 30 Hours Training Topics – Applicable for Mental Health Rehabilitation Workers, Mental Health Behavioral Aides, and some Mental Health Practitioners (to be completed before providing direct contact services to clients):

Mental Illness

Client Recovery and Resiliency

Mental Health De-Escalation Techniques

Co-Occurring Mental Illness and Substance Use Disorders

Psychotropic Medications and Medication Side Effects

• Training Topics to be Completed Within 90 days of First Providing Direct Contact Services to Adult Clients – Applicable for clinical trainees, mental health practitioners, mental health certified peer specialists, and mental health rehabilitation workers:

Trauma-Informed Care and Secondary Trauma

Person-Centered Individual Treatment Plans, including seeking partnerships with family and other natural supports

Co-Occurring Substance Use Disorders

Culturally Responsive Treatment Practices

• Annual Training Topics:

Vulnerable Adult Maltreatment 

Maltreatment of Minor Reporting Requirements

Client Rights and Protections

Minnesota Health Records Act, including client confidentiality, family engagement, and client privacy

Emergency Procedures that the staff person must follow when responding to a fire, inclement weather, a report of a missing person, and a behavioral or medical emergency

Completion Year: ________________________

Completion Year: ________________________

Completion Year: ________________________

Completion Year: ________________________

Completion Year: ________________________

• 30 Hours of Ongoing Training Every Two Years – Applicable to all staff persons who provide direct contact services to clients, except mental health professionals

Completion Year: ________________________

Completion Year: ________________________

Completion Year: ________________________

 

 

 

 

 

TREATMENT SUPERVISION PROVIDED BY (LIST NAME(S) AND LICENSURE OF STAFF AUTHORIZED TO PROVIDE SUPERVISION OR SEE ATTACHED ADDENDUM)

FREQUENCY OF TREATMENT SUPERVISION (SOME STAFF POSITIONS AND SERVICE LINES REQUIRE SPECIFIC SUPERVISION. THIS WOULD BE IN ADDITION TO THOSE REQUIREMENTS.) Every first Tuesday of the month will be group supervision via Google Meet from 4:30pm-7:00pm. Quarterly, supervisee and supervisor will have a one-hour individual session; time and date to be mutually agreed upon. It will be either in person or via Google Meet. Supervisee is also to contact Supervisor via his cell phone (612) 555-5591 if there is a client crisis or emergency that requires supervision or guidance.

DESCRIPTION OF THE CLIENT POPULATION THAT THE STAFF PERSON SERVES Supervisee serves adult men and women in the Minneapolis and St. Paul metro area that meet qualifications for ARMHS services based upon their mental health. At this time, the population is diverse and is not specific to any particular races, cultures, religions, or languages.

DESCRIPTION OF TREATMENT METHODS AND MODALITIES THE STAFF PERSON MAY USE TO PROVIDE SERVICES TO THE CLIENT (MAY INCLUDE OPTIONS SUCH AS INDIVIDUAL PSYCHOTHERAPY, GROUP DBT SKILLS, GROUP IMR OR E-IMR, SKILLS TRAINING, MOTIVATIONAL INTERVIEWING, ETC.) Person-Centered; Focusing on behavior and behavioral changes through awareness of thoughts, attitudes, emotions and actions; Cognitive Behavioral; Accountability (Humanistic); Integrative;  Skills Training; Motivational Interviewing

 

Continuing Education Training Session (Form D)

 

Topic of Training: ______________________________________________________

Presenter (and qualifications): _____________________________________________

Date and Time: _________________________________________________________

Clock Hours: ____________________________

Learner Outcomes 

Upon completion of the training, the participant will be able to:

1. Identify…
2. Recognize…
3. Discuss…

Statement of attendance:

This is to certify that I, ___________________________________ (name of participant) have 

completed this educational training on _______________________ (date) and attended for the 

entire session. 

Signature: __________________________________________________________________

OR

This is to certify that I, ___________________________________ (name of participant) have 

completed this educational training on ____________________________ (date) and I scored at 

least _______% on the quiz given after the training that covered subjects from the training. 

Signature: __________________________________________________________________