Section 518.1550  Personnel Services

a)         An organized personnel department or service shall be established and designed to meet the needs of the personnel.

b)         Personnel policies and practices that adequately support freestanding emergency center services and quality of patient care shall be established and maintained.

c)         Sufficient, qualified personnel shall be employed to properly operate the various departments and the adjunct services requiring technical skill, such as laboratory, x-ray, pharmacy, nursing, etc.

d)         Sufficient service personnel shall be employed to properly operate service departments.

e)         Qualified personnel shall mean those persons who hold necessary licenses for the activities they perform.  If no license is required, qualified personnel shall mean those persons who are registered or certified by the Department, the Illinois Department of Financial and Professional Regulation, the Council on Medical Education of the American Medical Association or Agencies or Committees established in collaboration with the Council, other accrediting agencies approved by the Department, or an acceptable equivalent experience.

f)         Personnel policies shall be written and available to all personnel.

g)         Personnel policies shall be reviewed and/or revised periodically, but no less frequently than once every two years.  The date of review or revision shall be indicated on the personnel policies.

h)         The personnel service shall have available organizational charts that identify all departments and/or services.

i)          All positions shall be authorized by the Board, either directly or through delegation to the administrator.

j)          A job description shall be written for each position in the freestanding emergency center, including minimum qualifications.

k)         Personnel records

1)         Accurate, current and complete personnel records shall be maintained for each employee during his/her term of employment and for the years thereafter as may be necessary to satisfy other State or federal requirements.

2)         A standard of content shall be established for personnel records, which shall contain at least the following:

A)        Application form and/or resume with current and background information sufficient to justify the initial and continuing employment of the individual;

B)        Verification of license, if the position requires a license.  A licensed person shall be employed only after verification of the license is obtained;

C)        A record regarding the employee's specialized education, training, and experience;

D)        Verification of identity;

E)        Employment health examination and subsequent health services rendered to the employees as are necessary to ensure that all employees are physically able to perform their duties;

F)         Record of orientation to the job;

G)        Continuance of education; and

H)        Current information relative to periodic work performance evaluations.

l)          Employees shall not be assigned duties that exceed their education, training, experience, and qualifications.

m)        Orientation and in-service training programs shall be provided so that personnel may maintain skills and learn new developments.

n)         Personnel health requirements

1)         Each FEC shall establish an employee health program that includes the following:

A)        An assessment of the employee's health and immunization status at the time of employment;

B)        Policies regarding required immunizations; and

C)        Policies and procedures for the periodic health assessment of all personnel. These policies shall specify the content of the health assessment and the interval between assessments and shall comply with the Control of Tuberculosis Code (77 Ill. Adm. Code 696).

2)         Personnel absent from duty because of any communicable disease shall not return to duty until examined for freedom from any condition that might endanger the health of patients or employees.

o)         Personnel services may be provided by the owning or controlling hospital, provided that standards are specific to the FEC and are established in accordance with this Section.

p)         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.

q)         The facility shall check the status of all applicants with the Health Care Worker Registry prior to hiring.

(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)