Section 245.30  Organization and Administration


a)         Governing Body – All Agencies 

The agency shall have a governing body or a clearly defined body having legal authority and responsibility for the conduct of the agency.  Where the governing body of a large organization is functionally remote from the operation of the agency, the Department may approve the designation of an intermediate level "governing body".  For the purposes of this Section, the governing body shall:


1)         Have bylaws or the equivalent, which shall be reviewed annually and be revised as needed.  They shall be made available to all members of the governing body and, for home health agencies, to the professional advisory group.  The bylaws or the equivalent shall specify the objectives of the agency;


2)         Employ a qualified administrator for home health agencies;


3)         Adopt and revise, as needed, policies and procedures for the operation and administration of the agency;


4)         Meet to review the operation of the agency;


5)         Keep minutes of all meetings; and


6)         Provide and maintain an office facility adequately equipped for efficient work, and confidentiality of patient and/or client records, and that provides a safe working environment in compliance with local ordinances and fire regulations.


b)         Administration − All Agencies


1)         The agency shall have written administrative policies and procedures to ensure that the patient or client is provided safe and adequate care.


2)         The agency shall show evidence of liability insurance in accordance with Section 245.90(a).


3)         The agency shall develop and implement written policies for complaint resolution between the agency and its patients/clients and/or patient/client advocates in regard to services being provided to the patient/client.


c)         Personnel Policies – All Agencies (Placement agencies shall meet the requirements of subsections (c)(1)(B), (2), (3) and (4).)


1)         Personnel policies applicable and available to all full- and part-time employees shall include, but not be limited to, the following:


A)        Wage scales, benefits, hours of work and leave time;


B)        Requirements for an initial health evaluation of each new employee or the placed home services worker/placed nurse who has contact with clients/patients,  as specified by the governing body;


C)        Orientation to the agency and appropriate continuing education;


D)        Job descriptions for all positions used by the agency;


E)        Annual performance evaluation for all employees;


F)         Compliance with all applicable requirements of the Civil Rights Act of 1964;


G)        Confidentiality of personnel records;


H)        Employee health policies that require employees to report health symptoms and exposure to any communicable or infectious disease, and that specify conditions under which employees are to be removed from patient or client contact and conditions under which employees may resume patient/client contact; and


I)         Agency procedures for identifying potential dangers to the health and safety of agency personnel providing services in the home and procedures for protecting agency personnel from identified dangers.


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


3)        The agency shall, prior to hiring, check the status of employee or placement prospects who have direct patient/client care responsibilities with the Department's Health Care Worker Registry concerning findings of abuse, neglect or misappropriation of property.


4)         Personnel records for all employees or placement agency registry files for placement workers shall include the name and address of the employee or placement worker, Social Security number, date of birth, name and address of next of kin, evidence of qualifications (including any current licensure, registration, or certification that is required by State or federal law for the functions performed), and dates of employment or placement and separation from the agency and the reason for separation.


5)         Home health agencies that provide other home health services under arrangement through a contractual purchase of services shall ensure that these services are provided by qualified personnel, who hold any current licensure, registration, or certification that is required by State or federal law for the functions performed, under the supervision of the agency.


6)         Home services and home nursing agencies that use some contractual services shall ensure that these services are provided by qualified personnel who hold any current licensure, registration or certification that is required by State or federal law for the functions performed under the supervision of the agency.


d)         Professional Advisory Group − Home Health Agencies


1)         The professional advisory group shall be appointed by the governing body and shall assist in developing and recommending policies and procedures for administration and home health services provided by the agency.  Policies and procedures shall be in accordance with the scope of services offered by the agency and based on the home health needs of the patient and the area being served.  Policies and procedures shall be reviewed annually or more frequently as needed to determine their adequacy and suitability.  Recommendations for any improvements are made to the governing body.  Policies and procedures shall include, but are not limited to:


A)        Administration and supervision of the home health agency and the home health services it provides;


B)        Criteria for the acceptance, non-acceptance, and discharge of patients;


C)        Home health services;


D)        Medical supervision and plans of treatment;


E)        Patient care plans;


F)         Clinical records;


G)        Personnel data;


H)        Evaluation; and


I)         Coordination of services.


2)         The group shall keep minutes of its meetings and meet as often as necessary to carry out its purposes.


e)         Agency Supervision – Home Health Agencies


1)         The governing body shall appoint a Home Health Administrator with the duties prescribed in Section 245.40. 


2)         The home health agency shall designate an agency supervisor with one of the following sets of qualifications to supervise the provision of home health services:


A)        A registered nurse who:


i)          Has completed a baccalaureate degree program approved by the National League for Nursing; and


ii)         Has at least one year of nursing experience;


B)        A registered nurse who does not have a baccalaureate degree, but who has at least three years of nursing experience that meets the following requirements:


i)          At least two years of the nursing experience must have been in:  a home health agency; a community health program that included care of the sick; or a generalized family-centered nursing program in a community health agency.


ii)         At least two years of the three years of nursing experience must have been obtained within five years prior to current employment with the home health agency.


3)         The agency supervisor shall be a full-time registered nurse who is available at all times during operating hours of the agency and who participates in all activities related to providing home health services.  The agency supervisor shall designate a qualified staff member to act in his or her absence.


4)         Any person employed as an agency supervisor prior to July 1, 1983, who does not meet the qualifications for agency supervisor that were in effect prior to October 1, 1983, may continue to serve in that capacity only at that agency.


5)         No one person may hold the positions of both home health agency administrator and agency supervisor.


6)         If the licensed home health agency also is licensed as a home nursing agency, the agency supervisor may supervise the provision of skilled nursing services in the home nursing agency only if there are equally qualified individuals available in each licensed component of the organization to act in his or her absence.


f)         Agency Supervisor Responsibilities − Home Health Agency


1)         The entire clinical program shall be under the direction of the agency supervisor.  The agency shall organize the personnel and clinical activities of the home health agency so that safe and adequate care will be provided to the patient.


2)         The skilled nursing service of a home health agency shall be under the direction of the agency supervisor.


3)         The agency supervisor shall be responsible for:


A)        Supervising all registered nurses, licensed practical nurses, home health aides, therapists, social workers and other clinical personnel employed by the agency or with whom the agency contracts for services;


B)        Assuring that all staff providing patient care maintain the professional standards of community nursing practice;


C)        Maintaining and adhering to agency procedure and patient care policy manuals;


D)        Participating in establishing service policies and procedures;


E)        Participating in selecting and evaluating nursing personnel and other staff providing patient care;


F)         Coordinating patient care services;


G)        Keeping and maintaining records of case assignments and case management;


H)        Preparing and maintaining the schedule of cases to be brought to the clinical record review committee; and


I)         Conducting selective program evaluations to improve deficient services and developing and implementing plans of correction.


g)         Agency Manager – Home Services and Home Nursing Agencies


1)         A home services agency shall designate a person to supervise the provision of services or to oversee the placement of workers through the licensed home services agency.


2)         If the home nursing agency has appointed an agency manager who is not a registered nurse or an advanced practice nurse, the home nursing agency shall identify a registered nurse or advanced practice nurse to supervise the provision of skilled nursing services as required by Section 2.11 of the Act. The supervisor shall be a registered nurse who is available at all times during the operating hours of the agency and who participates in all activities related to the provision of home nursing services. If the agency has both a home health and a home nursing agency license, one person may fulfill this requirement, but he or she shall be full-time.


(Source:  Amended at 39 Ill. Reg. 16406, effective December 10, 2015)