Section 340.1375  Personnel Requirements

 

a)         Supervision of Nursing Services

 

1)         The facility shall have a director of nursing service (DONS) who shall be a registered nurse.

 

A)        This person shall have knowledge and training in nursing service administration and restorative and rehabilitative nursing. This person shall also have some knowledge and training in the care of the type of residents for which the facility cares.

 

B)        This person shall be a full-time employee who is on duty a minimum of 36 hours, four days per week.  At least 50 percent of this person's hours shall be regularly scheduled between 7 a.m. and 7 p.m.

 

C)        A facility may, with written approval from the Department, have two registered nurses share the duties of this position if the facility is unable to obtain a full-time person.  Such an arrangement will be approved only through written documentation that the facility was unable to obtain the full-time services of a qualified individual to fill this position. Such documentation shall include, but not be limited to: an advertisement that has appeared in a newspaper of general circulation in the area for at least three weeks; the names, addresses and phone numbers of all persons who applied for the position and the reasons why they were not acceptable or would not work full time; and information about the numbers and availability of licensed nurses in the area. The Department will approve only when such documentation indicates that there were no qualified applicants who were willing to accept the job on a full-time basis, and the pool of nurses available in the area cannot be expected to produce, in the near future, a qualified person who is willing to work full time.

 

D)        In facilities of fewer than 50 beds, this person may also provide direct patient care, and this person's time may be included in meeting staff/resident ratio requirements.

 

2)         Facilities of 100 or more beds shall have a registered professional nurse designated as the assistant director of nursing service. This person shall perform the duties of the DONS when the DONS is on vacation or extended sick leave. The assistant may provide direct patient care and be included in the staff to resident ratio calculations when not acting as the DONS.

 

A)        The assistant shall be a full-time employee who is on duty a minimum of 36 hours, four days per week. The assistant may be assigned to work hours any time of the day or night.

 

B)        The assistant shall assist the DONS in carrying out the responsibilities of the DONS.

 

3)         The DONS shall oversee the nursing services of the facility. This person's duties shall include:

 

A)        Assigning and directing the activities of nursing service personnel.

 

B)        Assuring that resident care plans are developed and maintained.

 

C)        Recommending to the administrator the number and levels of nursing personnel to be employed, participating in their recruitment and selection and recommending termination of employment when necessary.

 

D)        Participating in planning and budgeting for nursing services including purchasing necessary equipment and supplies.

 

E)        Developing and maintaining nursing service objectives, standards of nursing practice, written policies and procedures, and written job descriptions for each level of nursing personnel.

 

F)         Coordinating health services and nursing services with other resident care services such as medical, pharmaceutical, dietary activities, and any other restorative/rehabilitative services offered.

 

G)        Planning of in-service education, embracing orientation, skill training, and ongoing education for all personnel covering all aspects of resident care and programming. The education program shall include training and practice in activities and restorative/rehabilitative nursing techniques through out-of-facility or in-facility training programs. This person may conduct these programs personally or see that they are carried out.

 

H)        Participating in the development and implementation of resident care policies and bringing resident care problems, requiring changes in policy, to the attention of the facility's policy development group.

 

I)         Participating in the screening of prospective residents and their placement in terms of services they need and nursing competencies available.

 

b)         Nursing Personnel

 

1)         A licensed or registered nurse shall be on duty and designated as being in charge of nursing services on all shifts when neither the director of nursing service nor assistant director of nursing service is on duty.  If registered nurses and licensed practical nurses are on duty on the same shift, this charge nurse shall be the registered nurse.

 

2)         At least one registered nurse shall be on duty seven days per week for eight consecutive hours.  At least one registered nurse or licensed practical nurse shall be on duty on each floor housing residents.

 

3)         The need for licensed nurses on each nursing unit in a nursing facility will be determined on an individual case basis, dependent upon the individual situation. The need for an additional registered or licensed practical nurse to serve as a "house supervisor" will be determined on an individual basis.  If such additional staffing is required, the Department will inform the facility in writing of the kind and amount of additional staff time required, and the reason why it is needed.

 

c)         Nursing Assistants

 

1)         The facility shall ensure that each person employed by the facility as a nursing assistant complies with one of the following conditions:

 

A)        Is approved on the Department's Health Care Worker Registry.  "Approved" means that the nursing assistant has met the training or equivalency requirements of Section 340.1376 of this Part and does not have a disqualifying criminal background check without a waiver.

 

B)        Begins a Department-approved nurse aide training program (see 77 Ill. Adm. Code 395) no later than 45 days after employment.  The nursing assistant shall successfully complete the training program within 120 days after the date of initial employment. A nursing assistant enrolled in a program approved in accordance with 77 Ill. Adm. Code 395 shall not be employed more than 120 days prior to successfully completing the program.

 

C)        Within 120 days after initial employment, submits documentation in accordance with Section 340.1376 of this Part to be registered on the Health Care Worker Registry.

 

2)         The facility shall ensure that each person employed by the facility as a nursing assistant or habilitation aide has met each of the following requirements:

 

A)        Is at least 16 years of age, of temperate habits and good moral character, honest, reliable, and trustworthy.  (Section 3-206(a)(1) of the Act)

 

B)        Is able to speak and understand the English language or a language understood by a substantial percentage of the facility's residents.  (Section 3-206(a)(2) of the Act)

 

C)        Has provided evidence of prior employment or occupation, if any, and residence for two years prior to present employment as a nursing assistant or habilitation aide.  (Section 3-206(a)(3) of the Act)

 

D)        Has completed at least eight years of grade school or provide proof of equivalent knowledge.  (Section 3-206(a)(4) of the Act)

 

E)        Is familiar with and has general skills related to resident care.  (Section 3-206(a)(6) of the Act)

 

F)         Has completed the training or equivalency requirements for nursing assistants, habilitation aides, or has begun a current course of training for nursing assistants, habilitation aides, or child care aides, approved by the Department, within 45 days of initial employment in the capacity of a nursing assistant, habilitation aide, or child care aide at any facility.  Such courses of training shall be successfully completed within 120 days of initial employment in the capacity of nursing assistant, habilitation aide, or child care aide at a facility, except as follows:

 

i)          Nursing assistants, habilitation aides, and child care aides who are enrolled in approved courses in community colleges or other educational institutions on a term, semester, or trimester basis, shall be exempt from the 120-day completion time limit.  During a statewide public health emergency, as defined in the Illinois Emergency Management Agency Act, all nursing assistants, habilitation aides, and child-care aides shall, to the extent feasible, complete the training.

 

ii)         The Department may accept comparable training in lieu of the 120-hour course for student nurses, foreign nurses, military personnel, or employees of the Department of Human Services.  (Section 3-206(a)(5) of the Act)

 

3)         The facility shall maintain in the personnel folder of the employee, proof of compliance by each employee with the requirements set out in Section 3-206(d) of the Act.

 

4)         The facility shall obtain access to the Health Care Worker Registry's web application, maintain the employment and demographic information relating to each employee, and verify by the category and type of employment that each employee meets all the requirements of Section 3-206(e) of the Act.

 

5)         A facility shall not employ an individual as a nursing assistant, habilitation aide, home health aide, psychiatric services rehabilitation aide, or child care aide, or newly hired as an individual who may have access to a resident, a resident's living quarters, or a resident's personal, financial, or medical records, unless the facility has inquired of the Department's Health Care Worker Registry and the individual is listed on the Health Care Worker Registry as eligible to work for a health care employer. (Section 3-206.01 (a) of the Act)

 

6)         Nursing assistants and habilitation aides shall be able to demonstrate competency in the principles, techniques, and procedures covered by the basic nursing assistant training program curriculum described in 77 Ill. Adm. Code 395.

 

d)         There shall be at least one person on duty at all times who has been properly trained to handle the medical emergencies listed in Section 340.1300(g) of this Part. This person may also be counted in fulfilling the requirements of other subsections of this Section.

 

e)         When a facility has only one employee on duty, that employee shall have been certified within the past 12 months in the provision of basic life support by an American Heart Association or American Red Cross certified training program. When there is more than one person on duty in the facility, at least two of the people on duty shall be so certified. A facility employee who is on duty serving in any capacity in the facility may be utilized to meet this requirement.

 

f)         Direct Care Staffing

 

1)         The facility must have adequate staff in numbers, training and supervision to meet all residents' nursing, personal care and psychosocial needs at all times.

 

2)         Staffing shall apply to hours of actual on duty time, not hours scheduled to be provided. The director of nursing services time shall not be included to fulfill required hours except as allowed in subsection (a)(1)(D) of this Section. Direct care staff includes licensed nurses, certified nurse aides, social service staff, qualified mental retardation professionals, and activity personnel.

 

3)         Each resident shall be provided at least 2.5 hours per patient per 24 hours, 7 days per week in accordance with 38 CFR 51.130.

 

4)         In a facility whose residents participate in regularly scheduled therapeutic programs outside the facility, such as school or sheltered workshops, the minimum hours per day of direct care staffing may be reduced proportionately for the hours the residents are not in the facility as long as the facility meets the needs of the residents.

 

g)         The facility shall provide a Resident Services Director who is assigned responsibility for the coordination and monitoring of the resident's comprehensive care plan. The director of nursing services or an individual on the professional staff of the facility may fill this assignment to ensure that residents' comprehensive care plans are individualized, written in terms of short and long-range goals, understandable and utilized; their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible, in the preparation of their plan of care.

 

h)         A facility shall designate a person or persons as Infection Prevention and Control Professionals (IP) to develop and implement policies governing control of infections and communicable diseases. The IPs shall be qualified through education, training, experience, or certification or a combination of these qualifications. The IP's qualifications shall be documented and shall be made available for inspection by the Department.  (Section 2-213(d) of the Act)

 

1)         IPs shall complete, or provide proof of completion of initial infection control and prevention training provided by CDC or equivalent training, covering topics listed in subsection (h)(2)(A) to the facility, within 30 days after accepting an IP position.  Documentation of required initial infection control and prevention training shall be maintained in the employee file.

 

2)         A qualified IP candidate shall:

 

A)        Have completed at least 19 hours of training in infection prevention and control including, but not limited to, training in the following areas:

 

i)          Principles of Standard Precautions

 

ii)         Principles of Transmission-Based Precautions

 

iii)        Prevention of Healthcare-Associated Infections

 

iv)        Hand Hygiene

 

v)         Environmental Cleaning, Sterilization, Disinfection, and Asepsis

 

vi)        Environment of Care and Water Management

 

vii)       Employee/Occupational Health

 

viii)      Surveillance and Epidemiological Investigations

 

ix)        Antimicrobial Stewardship

 

B)        Have clinical work experience related to infection prevention and control in health care settings including, but not limited to, hospitals or long-term care settings.

 

3)         A facility shall have at least one IP on-site for a minimum of 20 hours per week to develop and implement policies governing prevention and control of infectious diseases.

 

4)         Facilities with more than 100 licensed beds or facilities that offer high-acuity services, including but not limited to on-site dialysis, infusion therapy, or ventilator care shall have at least one IP on-site for a minimum of 40 hours per week to develop and implement policies governing control of infectious diseases.  For the purposes of this subsection (h)(4), "infusion therapy" refers to parenteral, infusion, or intravenous therapies that require ongoing monitoring and maintenance of the infusion site (e.g., central, percutaneously inserted central catheter, epidural, and venous access devices).

 

5)         A facility's IP shall coordinate with the facility group listed in Section 340.1335(b) to ensure compliance with Section 340.1335.

 

(Source:  Amended at 49 Ill. Reg. 6539, effective April 22, 2025)