Section 250.410  Organization

a)         Personnel department organization

1)         There shall be an organized personnel department or service designed to meet the needs of the personnel.

2)         The chief executive officer shall designate an individual as department or service chief.

3)         The chief executive officer (administrator) shall ensure that personnel policies and practices that adequately support hospital services and quality of patient care are established and maintained.

4)         There shall be sufficient qualified personnel to properly operate the various departments and the adjunct services requiring technical skill, such as laboratory, x-ray, physical therapy, pharmacy, nursing, surgery, respiratory therapy, etc.

5)         There shall be sufficient service personnel to properly operate service departments.

6)         Qualified personnel shall mean those persons who hold necessary licenses for the activities they perform.  If no license is required, qualified personnel shall mean those persons who are registered or certified by the Department, the Illinois Department of Professional Regulation, the Council on Medical Education of the American Medical Association or Agencies or Committees established in collaboration with the Council, other accrediting agencies approved by the Department, or an acceptable experience equivalent to the above.

b)         Personnel policies shall be written and available to all personnel.

c)         Personnel policies shall be reviewed and/or revised periodically, but no less than once every two years.  The date of review or revision shall be indicated on the personnel policies.

d)         The governing body, through its chief executive officer, shall identify functions for the management of personnel and place responsibility for implementation and actions related to established policies and procedures.

e)         Under the direction of administration, the personnel service shall have available organizational charts that identify all departments and/or services.

f)         All positions shall be authorized by the governing authority, either directly or through delegation to the administrator.

g)         There shall be a written job description including minimum qualifications for each position in the hospital.

h)         Prior to employing any individual in a position that requires a State license, the hospital shall contact the Illinois Department of Professional Regulation to verify that the individual's license is active.  A copy of the license shall be placed in the individual's personnel file.

i)          The hospital shall check the status of all applicants with the Nurse Aide Registry prior to hiring.

(Source:  Amended at 27 Ill. Reg. 13467, effective July 25, 2003)