Section 380.400  Employee Personnel Policies and Records

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 the Department for review.

2)         Individual personnel files for each employee, intern, unpaid staff and volunteer regularly scheduled at least weekly to work directly with consumers 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.

3)         Individual personnel files for each employee, intern, unpaid staff and volunteer regularly scheduled at least weekly to work directly with consumers shall contain health records, including the initial health evaluation and the results of the tuberculin skin test, and any other pertinent health records.

4)         Individual personnel records for each employee, intern, unpaid staff and volunteer regularly scheduled at least weekly to work directly with consumers shall contain records of the employee's performance evaluations.

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

d)         For all non-licensed employees, interns, unpaid staff and volunteers regularly scheduled at least weekly to work directly with consumers, the facility shall comply with Section 380.420.

e)         All personnel shall have either training or experience, or both, in the job assigned to them. Written documentation of this training shall be placed in each employee's personnel file and shall be made available to the Department upon request.

f)         The facility shall have a comprehensive set of written personnel policies and procedures that include, but are not limited to:

1)         Job descriptions and qualifications and documentation of current licensure and certification for all staff, including those on contract with the facility or with an entity subcontracting with the facility.  The facility shall also maintain job descriptions for volunteers, interns and other unpaid personnel;

2)         Documentation that staff and interns who provide or supervise services pursuant to this Part meet the staff qualifications defined in this Part and that their individual performance is evaluated at least once every 12 months;

3)         Documentation that volunteers regularly scheduled at least weekly to work directly with consumers and other unpaid personnel who provide services pursuant to this Part meet the requirements in Section 380.130(m) and that their individual performance is evaluated at least once every 12 months; and

4)         Documentation that the facility has written personnel policies concerning hiring, evaluating, disciplining and terminating employees, interns, unpaid staff and volunteers regularly scheduled at least weekly to work directly with consumers.

g)         The facility shall provide to the Department, upon request, written documentation indicating that staff have engaged in professional development and continuing education as prescribed by DHS-DMH.  Acceptable documentation shall demonstrate post-training competency, including copies of post tests or certificates of completion.  Annual in-service training programs approved by DHS-DMH shall include the facility's policies, skill training and ongoing education to enable all personnel to perform their duties effectively.  The facility shall keep written records of program content for each session and of personnel attending each session, and the records shall be available to the Department upon request.

h)         Facilities shall not allow any person to work in any capacity until the facility has inquired of the Department's Health Care Worker Registry concerning the person.  If the Registry has information substantiating a finding of abuse or neglect against the person, the facility shall not employ him or her in any capacity.

i)          Facilities shall not allow volunteers regularly scheduled at least weekly to work directly with consumers until the facility has inquired of the Department's Health Care Worker Registry concerning the person.  If the Registry has information substantiating a finding of abuse or neglect against the person, the facility shall not allow him or her to volunteer in any capacity.

j)          Each facility shall develop, implement and maintain a plan for clinical supervision of QMHPs, MHPs and RSAs who perform services under the Act and this Part.  Group supervision is acceptable, and the size of the group shall be conducive to the provision of clinical supervision.  Supervision shall be documented in writing.  Supervision of staff as noted in this subsection shall be for a minimum of one hour per week through face-to-face, teleconference or videoconference contact.

1)         QMHPs shall be supervised by an LPHA.

2)         MHPs and RSAs shall be supervised by, at a minimum, a QMHP.

3)         LPHAs are not required to have clinical supervision under this Section.