Section 132.70  Personnel and Administrative Recordkeeping

a)         The provider shall have a comprehensive set of 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 provider or with an entity subcontracting with the provider.  The provider shall also maintain job descriptions for volunteers, interns and other unpaid personnel;  

2)         Documentation that staff, volunteers, interns and other unpaid personnel providing or supervising services pursuant to this Part meet the staff qualifications defined in this Part, and that their individual performance is evaluated no less frequently than once every 12 months; and

3)         Documentation that the provider has written personnel policies concerning hiring, evaluating, disciplining and terminating staff.

b)         The provider must show documentation indicating that staff have engaged in professional development and continuing education.  Acceptable documentation may include, but is not limited to, training approval forms, reimbursement/payments for training, training calendars, outlines of training activities, or a list of notifications or training events.

c)         Providers shall not allow any person to work or volunteer in any capacity until the provider has inquired of the Department of Public Health as to information in the Health Care Worker Registry concerning the person.  If the Registry has information substantiating a finding of abuse or neglect against the person, the provider shall not employ him or her in any capacity.

d)         Providers shall perform background checks in compliance with requirements set forth in the Healthcare Worker Background Check Act and in the Illinois Department of Public Health's rules at 77 Ill. Adm. Code 955.

e)         Each provider shall develop, implement and maintain a plan for clinical supervision of QMHPs, MHPs and RSAs who perform Part 132 services.  Group supervision is acceptable and the size of the group should be conducive to the provision of clinical supervision.  Supervision must be documented in a written record.  Supervision of staff as noted in this subsection must be for a minimum of one hour per month through face-to-face, teleconference or videoconference.

1)         QMHPs must be supervised by an LPHA.

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

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

(Source:  Amended at 36 Ill. Reg. 18582, effective December 13, 2012)