MMHA 6220 Week 11 Employee Handbook Audit Example

Nine Handbook Sections Against This Term's Policies: An Audit Matrix for Bellwood Valley Home Health That Finds a Leave Conflict, a Missing Right to Leave Unsafe Visits and a Pay Secrecy Rule

Student Name

Walden University

MMHA 6220: Human Resource Management in Healthcare

Instructor Name

Month Day, Year

Nine Handbook Sections Against This Term's Policies: An Audit Matrix for Bellwood Valley Home Health That Finds a Leave Conflict, a Missing Right to Leave Unsafe Visits and a Pay Secrecy Rule

Purpose and Method

This audit compares each section of the Bellwood Valley Home Health employee handbook, last revised in 2021, with the policies drafted this term: leave, workplace violence prevention, sanction and background screening, fitness for duty, pay transparency, telework and employee assistance. The agency, like its handbook, is a composite created for coursework. Each handbook section was read against the related policy, and every inconsistency was recorded as one of four finding types.

Conflict: the handbook says something that contradicts a current policy. Gap: the handbook is silent on something employees need to know. Stale language: the handbook describes a practice, standard or recommendation that has changed. Missing acknowledgment: the handbook or a policy lacks a current signed employee acknowledgment.

The audit read the handbook as an aide would, start to finish, and also searched it for terms used in each policy, such as intermittent, exclusion and telework, to catch passages that addressed a topic under a different heading.

Severity is rated high where the finding could mislead employees about legal rights or safety, medium where it could cause inconsistent practice, and low where it is a matter of clarity.

Audit Matrix

Table 1

Handbook Audit Matrix

Each finding has one owner, who is responsible for the revision and for its review date.

The Three Most Urgent Revisions

First, remove the pay confidentiality rule. Federal labor law protects most employees when they act together on working conditions, and talking about wages with coworkers counts (29 U.S.C. § 157). A handbook rule asking nonsupervisory employees to keep wages confidential can itself be unlawful, even if never enforced, and it contradicts the pay transparency policy's statement that employees may discuss their pay. The fix is simple: delete the sentence and add the transparency policy's language.

Second, add the right to leave unsafe visits. The workplace violence policy gives every employee in the field the right to end a visit and leave without penalty, but employees learn their rights from the handbook, and the handbook is silent. An aide who believes she will be disciplined for leaving a threatening situation may stay. The handbook should state the right in the first paragraph of its field safety section, along with the check-in procedure.

Third, revise the leave section. The handbook describes leave as a single bank used in full days. Under federal regulations, leave for a serious health condition can be used in pieces, or as a shortened schedule, whenever medically necessary (29 C.F.R. § 825.202). An employee reading the handbook may believe she must take a full day for a two-hour appointment, or that intermittent leave is unavailable. The section should describe intermittent leave and refer employees to HR.

The tuberculosis testing language is also stale and should be revised in the same cycle, since the 2019 national recommendations dropped routine yearly testing for staff who have no known exposure and no ongoing occupational risk (Sosa et al., 2019); requiring it adds cost and testing burden without the benefit the rule assumes.

Implementation

Revisions will be issued in two stages. The three high-severity findings will be corrected within 30 days through a handbook addendum, sent to every employee along with a plain-language summary of one page and a request to sign that it was received. The medium and low findings will be corrected in a full revised handbook within 90 days, reviewed by counsel before release. Clinical managers will receive a short briefing on the changes so they can answer questions in the field, since aides and nurses rarely read handbook updates at a desk.

Two findings need more than a wording change. The right to leave unsafe visits will only matter if employees believe it, so the director of clinical services will discuss it at every team meeting in the first month and report how many visits were ended under it each quarter. The pay confidentiality rule must be removed from every place it appears, including the offer letter template, where the audit found the same sentence.

Review Calendar

Table 2

Annual Review Calendar With Owners

Reviews are spread over the calendar so no one month bears the whole load.

Disclaimer

This audit identifies inconsistencies between the handbook and the agency's own current policies and notes where the handbook appears out of date. It does not certify that the handbook or any policy complies with federal, state or local law, accreditation standards or payer requirements. Before the revised handbook is issued, the agency's employment counsel should review it, particularly the leave, pay and screening sections, where state law may add requirements.

References

Intermittent leave or reduced leave schedule, 29 C.F.R. § 825.202 (2024).

Rights of employees, 29 U.S.C. § 157 (2018).

Sosa, L. E., Njie, G. J., Lobato, M. N., Bamrah Morris, S., Buchta, W., Casey, M. L., Goswami, N. D., Gruden, M., Hurst, B. J., Khan, A. R., Kuhar, D. T., Lewinsohn, D. M., Mathew, T. A., Mazurek, G. H., Reves, R., Paulos, L., Thanassi, W., Will, L., & Belknap, R. (2019). Tuberculosis screening, testing, and treatment of U.S. health care personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019. MMWR Morbidity and Mortality Weekly Report, 68(19), 439-443. https://doi.org/10.15585/mmwr.mm6819a3