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 the 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.

 

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 the provision of safe and adequate care of the patient or client.

 

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 must 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, fringe benefits, hours of work and leave time;

 

B)        Requirements for an initial health evaluation of each new employee 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 utilized by the agency;

 

E)         Annual performance evaluation for all employees;

 

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

 

G)        Provision for 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 related to 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 check the status of employee or placement prospects who have direct patient/client care responsibilities with the Health Care Worker Registry prior to hiring.

 

4)         Personnel records for all employees/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.

 

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.  These 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.  These 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 345.40 of this Part. 

 

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

 

A)        A physician;

 

B)        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;

 

C)        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 nursing experience must have been obtained within five years prior to current employment with the home health agency.

 

3)         The agency supervisor shall be available at all times during operating hours of the agency and participate in all activities relevant to the provision of home health services.

 

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)         One person may hold the positions of both home health agency administrator and agency supervisor, if that person meets the requirements of both positions.

 

f)          Supervising Nurse – Home Health Agencies

 

1)         The skilled nursing service of a home health agency shall be under the supervision of a full-time registered nurse.

 

2)         The supervising nurse shall be responsible for:

 

A)        The overall supervision of all registered nurses, licensed practical nurses, and home health aides;

 

B)        Assuring that the professional standards of community nursing practice are maintained by all nurses providing care;

 

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

 

D)        Participation in the establishment of service policies and procedures;

 

E)         Participation in the selection of nursing personnel and the evaluation of nursing personnel;

 

F)         Coordination of patient care services;

 

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

 

H)        Preparation and maintenance of scheduling of cases to be brought to the clinical record review committee; and

 

I)          The conduct of selective program evaluations to improve deficient services and the development and implementation of 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)         A home nursing agency shall designate a person who is qualified under the laws of the State of Illinois to supervise the provision of skilled nursing care to clients or to oversee the placement of workers qualified to provide skilled nursing services to consumers through the licensed home nursing agency.

 

(Source:  Amended at 32 Ill. Reg. 8949, effective June 5, 2008)