Personnel and Staffing Requirements

Section 132.55  Personnel and Staffing Requirements The CSP shall: a)         Establish and maintain a comprehensive set of personnel policies and procedures, minimally addressing hiring, training, evaluation, disciplining, termination, and other personnel matters related to staffing. Establish and maintain job descriptions detailing the duties and qualifications for all positions, including volunteers, interns and unpaid personnel. Establish and maintain individual personnel records for all personnel, paid and unpaid, minimally including the following components: 1)         Documentation of current education, experience, licensure and certification; 2)         Employment status of the individual (e.g., hire date, employee/contractor, termination date, etc.); 3)         Review of individual employee's performance within the last 12 months; and 4)         Documentation of training and continuing education units, as applicable. b)         Upon hire, perform sufficient background checks for all employees, volunteers, interns, unpaid personnel, or other individuals who are agents of the CSP or CMHC.  At a minimum, the review shall include: 1) Searching the Illinois Department of Public Health's (DPH) 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 them in any capacity. 2)         Performing background checks in compliance with requirements set forth in the Health Care Worker Background Check Act [225 ILCS 46] and in DPH rules at 77 Ill. Adm. Code 955. 3) Reviewing the Provider Sanctions List, provided by the HFS Office of Inspector General (HFS-OIG), to ensure the provider is not on the list of sanctioned providers.  The CSP/CMHC shall not employ or contract with any provider found on the List. c) The provisions of Section 132.55(b), except for subsection (b)(3), do not apply to Peer Support Workers (PSWs) providing services as part of a Violence Prevention Community Support Team (VP-CST) pursuant to 89 Ill. Adm. Code 140.453.  PSWs delivering VP-CST must meet the background check requirements outlined in 89 Ill. Adm. Code 140.TABLE P. d)         Annually, at a minimum, comply with all requirements set forth in the Health Care Worker Background Check Act and in DPH rules. e)         Ensure that all assessment activities and subsequent individual treatment plans are developed with the active involvement of a QMHP and the clinical review of an LPHA. f)         Ensure management and oversight of all treatment staff by a QMHP.  Management and oversight may be face to face or virtual, to include group supervision as well as supervision by teleconference and videoconference.  All treatment staff must have access to a QMHP who is available for immediate consultation and supervision of treatment services. g)         All staff shall receive, at a minimum, one hour of supervision per month delivered face to face, or by teleconference or videoconference. 1)         Group supervision is acceptable and the size of the group shall be conducive to the topic being discussed. 2)         Supervision must be documented in a written record. 3)         LPHAs are not required to have supervision under this Section. 4)         QMHPs must be supervised by an LPHA. MHPs and RSAs must be supervised by, at a minimum, a QMHP.