Section 280.2040  Personnel Policies

a)         The hospice shall develop and maintain written personnel policies that are followed in the operation of the program.  These policies shall include policies and procedures regarding the use of volunteers.

b)         Employment application forms shall be completed on each employee and kept on file in the program's central office.  The file shall contain, at a minimum, home address; telephone number; Social Security number; educational background; documentation of current professional certification, licensure or registration, as applicable; past employment history, including dates, positions held, reasons for leaving.  The date of employment and position held shall be documented in each file.

c)         Each employee shall have an accurate written job description.  Employees shall be assigned only duties directly related to their job functions, as identified in the job descriptions.  Exceptions may be made when unplanned events, such as severe weather, limit staffing temporarily.

d)         Where applicable, every hospice program employee must be licensed, certified, or registered in accordance with federal, State and local laws.  (Section 8(n) of the Act)

e)         All personnel shall have either training or experience, or both, in the job assigned them.  The hospice program shall provide an ongoing program for the training and education of its employees, appropriate to their responsibilities, including training in Alzheimer's care in accordance with 77 Ill. Adm. Code 973.

f)         All new employees shall complete an orientation program covering, at a minimum:

1)         The program's philosophy and goals; and

2)         Job orientation, emphasizing allowable duties of the new employee, safety, and appropriate interactions with patients and families.

g)         All employees shall attend in-service training programs pertaining to their assigned duties at least annually.  Written records of program content and personnel attending each session shall be maintained.

h)         The hospice shall document all arrangements for each consultant's services in a written agreement setting forth services to be provided.

i)          The hospice shall retain professional and supervisory responsibility for all services provided under arrangements and shall ensure that all services are:

1)         Authorized by the hospice;

2)         Furnished in a safe and effective manner by qualified personnel; and

3)         Delivered in accordance with the patient's plan of care.

j)          The hospice program shall utilize the services of trained volunteers in accordance with the standards for certification under the Medicare program set forth in the Conditions of Participation in 42 CFR 418.  (Section 8(j) of the Act)

1)         Volunteer application forms shall be completed on each volunteer and kept on file in the program's central office.  The file shall contain, at a minimum, home address; telephone number; educational and employment background relating to the volunteer position; and documentation of current professional certification, licensure or registration relating to the volunteer position.  The date of acceptance as a volunteer and position held shall be documented in each file.

2)         Each volunteer shall have an accurate written job description.  Volunteers shall only be assigned duties directly related to their job functions, as identified in the job description.

3)         All volunteers shall have training or experience in the job assigned them.

4)         All volunteers shall complete an orientation program covering, at a minimum:

A)        The program's philosophy and goals; and

B)        Job orientation, emphasizing allowable duties of the volunteer, safety, and appropriate interactions with patients and families.

(Source:  Amended at 44 Ill. Reg. 12582, effective July 2, 2020)