As long as I have known, the TJC standard has always been that volunteers should mirror employee practices - I believe most specifically for those in direct patient care. However, I think each organization responds to this based on their interpretation of what direct patient care means.
In Meeting Volunteer Competency Requirements, published several years ago by C&R Publications: "The JCAHO issueds a Standards Clarification in October 2000, which was updated in February 2001, and again March 2002, that states volunteers must meet the same rigorous HR standards as regular staff, including verification of orientation, training, and competency.
The clarification, called "Human Resources Standards Applicability to Contracted and Volunteer Personnel", states that the standards in the human resource chapter apply to direct, contract, and volunteer personnel providing patient care and /or services on behalf of an organization,...
The HR standards apply, according to the JCAHO clarification, to contracted or volunteer patient care personnel such as nurses, therapy, dietary, pharmacy, activities staff, drug and alcohol counselors...and nursing assistants or aides. The standards also apply to patient services personnel such as homemakers, companions, sitters, chore workers, drivers, and home medical equipment deliver and repair technicians.
The standards definition says that examples of non-patient care or service personnel who would be exempt from the requirements include: "volunteers who deliver the mail or flowers, staff the information desk, gift shop or library services, perform patient errands (eg. writing and mailing letters or obtaining magazines and toiletries from the gift shop), conducting marketing or fund raising activities, or provide simple wheelchair transport services.""
So my own interpretation is the standards apply to those who actually put hands on a patient. I mirror the HR practices only in that I have policies that state what I do and why I do it and I reference HR policies when appropriate. I orient, but I do not send them to hospital orientation. I do background checks on all but no drug screens. I have documented department trainings, but these documents are not official CBOs. I do not do annual evaluations.
I am also aware of hospitals who follow the HR standards to the letter.