Section 350.670  Personnel Policies

a)         Each facility shall develop and maintain written personnel policies that are followed in the operation of the facility.  These policies shall include, at a minimum, each of the requirements of this Section.

b)         Employee Records

1)         Employment application forms shall be completed for each employee and kept on file in the facility.  Completed forms shall be available to Department personnel for review.

2)         Individual personnel files for each employee shall contain date of birth; home address; educational background; experience, including types and places of employment; date of employment and position employed to fill in this facility; and (if no longer employed in this facility) last date employed and reasons for leaving.

3)         Individual personnel files for each employee shall also contain health records, including the initial health evaluation and the results of the tuberculin skin test required under Section 350.675, and any other pertinent health records.

4)         Individual personnel records for each employee shall also contain performance evaluation records.

c)         Prior to employing any individual in a position that requires a State license, the facility shall contact the Illinois Department of Financial and Professional Regulation to verify that the individual's license is active. A copy of the verification shall be placed in the individual's personnel file.

d)         The facility shall check the status of all applicants with the Health Care Worker Registry prior to hiring.  Information on the Health Care Worker Registry will include:

1)         Whether the individual is active on the Registry;

2)         Whether the individual has findings of abuse, neglect, or misappropriation of property;

3)         The date of the individual’s most recent criminal history records check;

4)         Whether the individual has a conviction for a disqualifying offense pursuant to Section 25 of the Health Care Worker Background Check Act; and

5)         Whether the individual has a waiver.

e)         All facilities shall conduct required registry checks on employees at the time of hire and annually thereafter during employment. In addition to the Health Care Worker Registry, the facility shall check the Department of Children and Family Services' State Central Register and the Illinois Sex Offender Registry. A person may not be employed if he or she is found to have disqualifying convictions or substantiated cases of abuse or neglect. At the time of the annual registry checks, if a current employee's name has been placed on a registry with disqualifying convictions or disqualifying substantiated cases of abuse or neglect, then the employee must be terminated. Disqualifying convictions or disqualifying substantiated cases of abuse or neglect are defined for the Department of Children and Family Services Central Register by the Department of Children and Family Services' standards for background checks in 89 Ill. Adm. Code 385.  Disqualifying convictions or disqualifying substantiated cases of abuse or neglect are defined for the Health Care Worker Registry by the Health Care Worker Background Check Act and within the Act and this Part. A facility's failure to conduct the required registry checks will constitute a Type "B" violation.  (Section 3-206.04(a) of the Act)

f)         All personnel shall have either training or experience, or both, in the job assigned to them.

g)         Orientation and In-Service Training

1)         All new employees, including student interns, shall complete an orientation program covering, at a minimum, the following:  general facility and resident orientation; job orientation, emphasizing allowable duties of the new employee; resident safety, including fire and disaster, emergency care and basic resident safety; the importance of nutrition in general healthcare; and understanding and communicating with the type of residents being cared for in the facility.  Before being assigned to provide direct care to residents, all new direct care staff, including student interns, shall complete an orientation program covering the facility's policies and procedures for resident care services.  The employee's training and competency shall be documented.

2)         All employees, except student interns, shall attend in-service training programs pertaining to their assigned duties at least annually.  These in-service training programs shall include the facility's policies, skill training and ongoing education to enable all personnel to perform their duties effectively.  The in-service training sessions regarding personal care and nursing services shall include information on the prevention and treatment of decubitus ulcers.  In-service training concerning dietary services shall include information on the effects of diet in treatment of various diseases or medical conditions and the importance of laboratory test results in determining therapeutic diets.  Written records shall be kept of program content for each session and of personnel attending each session.

3)         All facility employees who deal directly with residents shall be trained on the individual requirements and behavioral issues of residents who may come under their care, to ensure the safety and dignity of each client.  The employees' training and competency shall be documented.

h)         Employees shall be assigned only duties that are directly related to their job functions, as identified in their job descriptions.  Exceptions may be made in emergencies.

i)          Personnel policies shall include a plan to provide personnel coverage for regular staff when they are absent.

j)          Every facility shall have a current, dated weekly employee time schedule posted where employees may refer to it.  This schedule shall contain the employee's name, job title, shift assignment, hours of work and days off. The schedule shall be kept on file in the facility for one year after the week for which the schedule was used.

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)