Section 340.1375 Personnel Requirements

Section 340

Section 340.1375  Personnel

Requirements

a)         Supervision of Nursing Services

1)         The facility shall have a director of nursing service (DONS)

who shall be a registered nurse.

A)        This person shall have knowledge and training in nursing

service administration and restorative and rehabilitative nursing. This person

shall also have some knowledge and training in the care of the type of

residents for which the facility cares.

B)        This person shall be a full-time employee who is on duty a

minimum of 36 hours, four days per week.  At least 50 percent of this person's

hours shall be regularly scheduled between 7 a.m. and 7 p.m.

C)        A facility may, with written approval from the Department, have

two registered nurses share the duties of this position if the facility is

unable to obtain a full-time person.  Such an arrangement will be approved only

through written documentation that the facility was unable to obtain the

full-time services of a qualified individual to fill this position. Such

documentation shall include, but not be limited to: an advertisement that has

appeared in a newspaper of general circulation in the area for at least three

weeks; the names, addresses and phone numbers of all persons who applied for

the position and the reasons why they were not acceptable or would not work

full time; and information about the numbers and availability of licensed

nurses in the area. The Department will approve only when such documentation

indicates that there were no qualified applicants who were willing to accept

the job on a full-time basis, and the pool of nurses available in the area cannot

be expected to produce, in the near future, a qualified person who is willing

to work full time.

D)        In facilities of fewer than 50 beds, this person may also

provide direct patient care, and this person's time may be included in meeting

staff/resident ratio requirements

plicants who were willing to accept

the job on a full-time basis, and the pool of nurses available in the area cannot

be expected to produce, in the near future, a qualified person who is willing

to work full time.

D)        In facilities of fewer than 50 beds, this person may also

provide direct patient care, and this person's time may be included in meeting

staff/resident ratio requirements.

2)         Facilities of 100 or more beds shall have a registered

professional nurse designated as the assistant director of nursing service.

This person shall perform the duties of the DONS when the DONS is on vacation

or extended sick leave. The assistant may provide direct patient care and be

included in the staff to resident ratio calculations when not acting as the

DONS.

A)        The assistant shall be a full-time employee who is on duty a

minimum of 36 hours, four days per week. The assistant may be assigned to work

hours any time of the day or night.

B)        The assistant shall assist the DONS in carrying out the

responsibilities of the DONS.

3)         The DONS shall oversee the nursing services of the facility.

This person's duties shall include:

A)        Assigning and directing the activities of nursing service

personnel.

B)        Assuring that resident care plans are developed and maintained.

C)        Recommending to the administrator the number and levels of

nursing personnel to be employed, participating in their recruitment and

selection and recommending termination of employment when necessary.

D)        Participating in planning and budgeting for nursing services including

purchasing necessary equipment and supplies.

E)        Developing and maintaining nursing service objectives,

standards of nursing practice, written policies and procedures, and written job

descriptions for each level of nursing personnel

ent and

selection and recommending termination of employment when necessary.

D)        Participating in planning and budgeting for nursing services including

purchasing necessary equipment and supplies.

E)        Developing and maintaining nursing service objectives,

standards of nursing practice, written policies and procedures, and written job

descriptions for each level of nursing personnel.

F)         Coordinating health services and nursing services with other

resident care services such as medical, pharmaceutical, dietary activities, and

any other restorative/rehabilitative services offered.

G)        Planning of in-service education, embracing orientation, skill

training, and ongoing education for all personnel covering all aspects of

resident care and programming. The education program shall include training and

practice in activities and restorative/rehabilitative nursing techniques

through out-of-facility or in-facility training programs. This person may

conduct these programs personally or see that they are carried out.

H)        Participating in the development and implementation of resident

care policies and bringing resident care problems, requiring changes in policy,

to the attention of the facility's policy development group.

I)         Participating in the screening of prospective residents and

their placement in terms of services they need and nursing competencies

available.

b)         Nursing Personnel

1)         A licensed or registered nurse shall be on duty and designated

as being in charge of nursing services on all shifts when neither the director

of nursing service nor assistant director of nursing service is on duty.  If

registered nurses and licensed practical nurses are on duty on the same shift,

this charge nurse shall be the registered nurse.

2)         At least one registered nurse shall be on duty seven days per

week for eight consecutive hours.  At least one registered nurse or licensed

practical nurse shall be on duty on each floor housing residents

assistant director of nursing service is on duty.  If

registered nurses and licensed practical nurses are on duty on the same shift,

this charge nurse shall be the registered nurse.

2)         At least one registered nurse shall be on duty seven days per

week for eight consecutive hours.  At least one registered nurse or licensed

practical nurse shall be on duty on each floor housing residents.

3)         The need for licensed nurses on each nursing unit in a nursing

facility will be determined on an individual case basis, dependent upon the

individual situation. The need for an additional registered or licensed

practical nurse to serve as a "house supervisor" will be determined

on an individual basis.  If such additional staffing is required, the

Department will inform the facility in writing of the kind and amount of additional

staff time required, and the reason why it is needed.

c)         Nursing

Assistants

1)         The facility shall ensure that each person employed by the

facility as a nursing assistant complies with one of the following conditions:

A)        Is approved on the Department's Health Care Worker Registry.

"Approved" means that the nursing assistant has met the training or

equivalency requirements of Section 340.1376 of this Part and does not have a

disqualifying criminal background check without a waiver.

B)        Begins a Department-approved nurse aide training program (see

77 Ill. Adm. Code 395) no later than 45 days after employment.  The nursing

assistant shall successfully complete the training program within 120 days

after the date of initial employment. A nursing assistant enrolled in a program

approved in accordance with 77 Ill. Adm. Code 395 shall not be employed more

than 120 days prior to successfully completing the program.

C)        Within 120 days after initial employment, submits documentation

in accordance with Section 340.1376 of this Part to be registered on the Health

Care Worker Registry

ays

after the date of initial employment. A nursing assistant enrolled in a program

approved in accordance with 77 Ill. Adm. Code 395 shall not be employed more

than 120 days prior to successfully completing the program.

C)        Within 120 days after initial employment, submits documentation

in accordance with Section 340.1376 of this Part to be registered on the Health

Care Worker Registry.

2)         The facility shall ensure that each person employed by the

facility as a nursing assistant or habilitation aide has met each of the

following requirements:

A)        Is

at least 16 years of age, of temperate habits and good

moral character, honest, reliable, and trustworthy.

(Section 3-206(a)(1)

of the Act)

B)        Is

able to speak and understand the English language or a

language understood by a substantial percentage of the facility's residents.

(Section 3-206(a)(2) of the Act)

C)        Has provided

evidence of

prior

employment or

occupation, if any, and residence for

two

years prior to

present

employment

as a nursing assistant or habilitation aide.  (Section

3-206(a)(3) of the Act)

D)        Has

completed at least

eight

years of grade school or

provide proof of equivalent knowledge.

(Section 3-206(a)(4) of the Act)

E)        Is

familiar with and

has

general skills related to

resident care.

(Section 3-206(a)(6) of the Act)

F)         Has completed the training or equivalency requirements for

nursing

assistants, habilitation aides,

or has begun

a current course of

training for nursing assistants, habilitation aides, or child care aides,

approved by the Department, within 45 days of initial employment in the

capacity of a nursing assistant, habilitation aide, or child care aide at any

facility

6(a)(6) of the Act)

F)         Has completed the training or equivalency requirements for

nursing

assistants, habilitation aides,

or has begun

a current course of

training for nursing assistants, habilitation aides, or child care aides,

approved by the Department, within 45 days of initial employment in the

capacity of a nursing assistant, habilitation aide, or child care aide at any

facility.  Such courses of training shall be successfully completed within 120

days of initial employment in the capacity of nursing assistant, habilitation

aide, or child care aide at a facility,

except as follows:

i)

Nursing assistants, habilitation aides, and child care

aides who are enrolled in approved courses in community colleges or other

educational institutions on a term, semester, or trimester basis, shall be

exempt from the 120-day completion time limit.  During a statewide public

health emergency, as defined in the Illinois Emergency Management Agency Act,

all nursing assistants, habilitation aides, and child-care aides shall, to the

extent feasible, complete the training.

ii)

The Department may accept comparable training in lieu of

the 120-hour course for student nurses, foreign nurses, military personnel, or

employees of the Department of Human Services.

(Section 3-206(a)(5) of the

Act)

3)         The facility shall maintain

in the personnel folder of the

employee,

proof of compliance by each employee with the requirements set

out in

Section 3-206(d) of the Act.

4)         The

facility shall obtain access to the Health Care Worker

Registry's web application, maintain the employment and demographic information

relating to each employee, and verify by the category and type of employment

that each employee meets all the requirements of

Section 3-206(e) of the

Act

compliance by each employee with the requirements set

out in

Section 3-206(d) of the Act.

4)         The

facility shall obtain access to the Health Care Worker

Registry's web application, maintain the employment and demographic information

relating to each employee, and verify by the category and type of employment

that each employee meets all the requirements of

Section 3-206(e) of the

Act

.

5)

A facility shall not employ an individual as a

nursing

assistant

,

habilitation aide, home health aide, psychiatric services

rehabilitation aide, or child care aide, or newly hired as an individual who

may have access to a resident, a resident's living quarters, or a resident's

personal, financial, or medical records, unless the facility has inquired of

the Department's Health Care Worker Registry and the individual is listed on

the Health Care Worker Registry as eligible to work for a health care employer

.

(Section 3-206.01 (a) of the Act)

6)         Nursing assistants and habilitation aides shall be able to

demonstrate competency in the principles, techniques, and procedures covered by

the basic nursing assistant training program curriculum described in 77 Ill.

Adm. Code 395.

d)         There shall be at least one person on duty at all times who

has been properly trained to handle the medical emergencies listed in Section

340.1300(g) of this Part. This person may also be counted in fulfilling the

requirements of other subsections of this Section.

e)         When a facility has only one employee on duty, that employee

shall have been certified within the past 12 months in the provision of basic

life support by an American Heart Association or American Red Cross certified

training program. When there is more than one person on duty in the facility,

at least two of the people on duty shall be so certified. A facility employee

who is on duty serving in any capacity in the facility may be utilized to meet

this requirement

een certified within the past 12 months in the provision of basic

life support by an American Heart Association or American Red Cross certified

training program. When there is more than one person on duty in the facility,

at least two of the people on duty shall be so certified. A facility employee

who is on duty serving in any capacity in the facility may be utilized to meet

this requirement.

f)         Direct Care Staffing

1)         The facility must have adequate staff in numbers, training and

supervision to meet all residents' nursing, personal care and psychosocial

needs at all times.

2)         Staffing shall apply to hours of actual on duty time, not

hours scheduled to be provided. The director of nursing services time shall not

be included to fulfill required hours except as allowed in subsection (a)(1)(D)

of this Section. Direct care staff includes licensed nurses, certified nurse

aides, social service staff, qualified mental retardation professionals, and

activity personnel.

3)         Each resident shall be provided at least 2.5 hours per patient

per 24 hours, 7 days per week in accordance with 38 CFR 51.130.

4)         In a facility whose residents participate in regularly

scheduled therapeutic programs outside the facility, such as school or

sheltered workshops, the minimum hours per day of direct care staffing may be

reduced proportionately for the hours the residents are not in the facility as

long as the facility meets the needs of the residents.

g)         The facility shall provide a Resident Services Director who is

assigned responsibility for the coordination and monitoring of the resident's

comprehensive care plan

hool or

sheltered workshops, the minimum hours per day of direct care staffing may be

reduced proportionately for the hours the residents are not in the facility as

long as the facility meets the needs of the residents.

g)         The facility shall provide a Resident Services Director who is

assigned responsibility for the coordination and monitoring of the resident's

comprehensive care plan. The director of nursing services or an individual on

the professional staff of the facility may fill this assignment to ensure that

residents' comprehensive care plans are individualized, written in terms of

short and long-range goals, understandable and utilized; their needs are met

through appropriate staff interventions and community resources; and residents

are involved, whenever possible, in the preparation of their plan of care.

h)

A

facility shall designate a person or persons as Infection Prevention and

Control Professionals

(IP)

to develop and implement policies governing

control of infections and communicable diseases. The IPs shall be qualified

through education, training, experience, or certification or a combination of

these

qualifications. The IP's qualifications shall be documented and shall be made

available for inspection by the Department

.  (Section 2-213(d) of the Act)

1)         IPs

shall complete, or provide proof of completion of initial infection control and

prevention training provided by CDC or equivalent training, covering topics

listed in subsection (h)(2)(A) to the facility, within 30 days after accepting

an IP position.  Documentation of required initial infection control and

prevention training shall be maintained in the employee file

of the Act)

1)         IPs

shall complete, or provide proof of completion of initial infection control and

prevention training provided by CDC or equivalent training, covering topics

listed in subsection (h)(2)(A) to the facility, within 30 days after accepting

an IP position.  Documentation of required initial infection control and

prevention training shall be maintained in the employee file.

2)         A

qualified IP candidate shall:

A)        Have

completed at least 19 hours of training in infection prevention and control

including, but not limited to, training in the following areas:

i)          Principles of Standard

Precautions

ii)         Principles of

Transmission-Based Precautions

iii)        Prevention of

Healthcare-Associated Infections

iv)        Hand Hygiene

v)         Environmental

Cleaning, Sterilization, Disinfection, and Asepsis

vi)        Environment of Care and

Water Management

vii)       Employee/Occupational

Health

viii)      Surveillance and

Epidemiological Investigations

ix)        Antimicrobial

Stewardship

B)        Have

clinical work experience related to infection prevention and control

in health care settings including, but not limited to,

hospitals or long-term care settings.

3)         A

facility shall have at least one IP on-site for a minimum of 20 hours per week

to develop and implement policies governing prevention and control of

infectious diseases.

4)         Facilities

with more than 100 licensed beds or facilities that offer high-acuity services,

including but not limited to on-site dialysis, infusion therapy, or ventilator

care shall have at least one IP on-site for a minimum of 40 hours per week to

develop and implement policies governing control of infectious diseases

olicies governing prevention and control of

infectious diseases.

4)         Facilities

with more than 100 licensed beds or facilities that offer high-acuity services,

including but not limited to on-site dialysis, infusion therapy, or ventilator

care shall have at least one IP on-site for a minimum of 40 hours per week to

develop and implement policies governing control of infectious diseases.  For

the purposes of this subsection (h)(4), "infusion therapy" refers to

parenteral, infusion, or intravenous therapies that require ongoing monitoring

and maintenance of the infusion site (e.g., central, percutaneously inserted

central catheter, epidural, and venous access devices).

5)         A facility's IP shall coordinate with the facility group

listed in Section 340.1335(b) to ensure compliance with Section 340.1335.