Personnel Requirements and Procedures

Section 2060.335  Personnel Requirements and Procedures a)         All professional staff as specified in Section 2060.320(a) and (b) or any staff working under supervision as specified in Section 2060.320(f) shall: 1)         Be at least 18 years of age; and 2)         Not have been convicted of any felony under any law of the United States two years prior to the date of employment or anytime during employment unless an exception is granted by DHS/SUPR as specified below in subsection (d). b)         All professional staff as specified in Section 2060.320(a) and (b) who provide DUI evaluation or risk education shall not have a suspension or revocation of driving privileges for an alcohol- or drug-related driving offense for at least two years prior to the date of employment or anytime during employment.  If the suspension or revocation occurs during employment, such person cannot resume the provision of services until two years from the date of the revocation or suspension. c)         Verification of the requirements specified in subsection (a) and the staff qualifications specified in Sections 2060.320 and 2060.415 shall be documented on the DHS/SUPR Schedule L and E, respectively, upon employment and submitted, as applicable, at the time of application for licensure and upon renewal. d)         An exception may be requested from DHS/SUPR for any person who does not meet the requirements specified in subsection (a).  Exception requests will be evaluated on criteria including, but not limited to, time since the offense occurred, evidence of rehabilitation, and the number and type of convictions.  A Schedule L for the person shall accompany the exception request and the organization shall have a policy to ensure that delivery of services is prohibited for such person unless the exception is granted or for any staff who does not meet the requirements specified in subsection (a) any time during employment. e)         Each organization shall establish and maintain a comprehensive set of personnel policies and procedures that are approved by management or, if applicable, the Board of Directors.  These policies and procedures must, at a minimum, address hiring, training, evaluation, promotions, disciplining and termination, and the process for handling employee or client/patient/resident complaints or grievances.  Additionally, the policies and procedures shall include the process for handling instances of suspected or confirmed client/patient/resident abuse/assault and or neglect by staff.  The reporting procedure shall also include when to report to law enforcement and the requirements for notifying DHS/SUPR.  The organization shall ensure that personnel policies and procedures are readily available to all staff, including interns and volunteers, and that any changes are distributed to staff at least once annually. f)         Each organization shall provide documentation that any new or revised personnel policies and procedures are reviewed and approved, at least once annually, by the authorized organization representative or management designee, or as applicable, organization ownership or Board of Directors. g)         Each organization shall have a policy and procedure for addressing, intervening, and reporting to DHS/SUPR or the applicable credentialing body, when there is any staff violation of the code of ethics established by the organization and/or the applicable certifying or licensing body that negatively impacts client/patient/resident care or could impact any staff credential or license. h)         Each organization shall establish and maintain job descriptions detailing the duties and qualifications for all positions, including volunteers, interns, and unpaid personnel. i)          The organization shall determine the criteria for full- and part-time employees, contractual employees, interns, and volunteers and have such criteria in writing. j)          Upon hire, and prior to every license renewal cycle, the organization shall perform background checks for all employees, contractual employees, volunteers, and interns. At a minimum, the review shall include: 1)         Conducting a background check using the free online National Sex Offender Registry at https://www.nsopw.gov/ for all staff; 2)         Conducting an additional background check using the Child Abuse and Neglect Tracking System (CANTS), maintained by the Illinois Department of Children and Family Services (DCFS) and authorized by the Abused and Neglected Child Reporting Act [325 ILCS 11.1(15)] for any staff that have contact with children or adolescents or provide clinical services or any other supportive services for a child or adolescent who is receiving intervention or treatment, or is receiving childcare at a facility or is residing at a facility with a parent receiving intervention or treatment services. 3)         Complying with a procedure that precludes hiring of persons based on the reasons specified in this Section and as set forth in 89 Ill. Adm. Code 385.50(a) and of those convicted of, or with pending charges of, crimes as set forth in 89 Ill. Adm. Code 385.60(a).  The organization shall also have and follow procedures allowing for waiver of these restrictions based on 89 Ill. Adm. Code Sections 385.50(b), 385.60(d) through (e), and 385.70(b); and 4)         Complying with policies and procedures to ensure the protection of other staff or client/patient/residents during the interim between initial submission of the staff background check and obtaining the results.  These policies must identify any staff limitations regarding the delivery of SUD intervention or treatment services during this interim.  The organization is responsible for all such hiring and service delivery decisions and the results thereof and for following recordkeeping procedures consistent with 89 Ill. Adm. Code 385.90. k)         The organization shall, at a minimum with each license renewal cycle, comply with all requirements for background checks specified in this Section for all applicable staff and update all Schedules L and E, as applicable. l)          The organization shall establish and maintain individual personnel records for all employees, volunteers, and interns, paid and unpaid, that minimally include the following components: 1)         Documentation of current education, experience, licensure, and/or certification; 2)         Employment status of the individual (e.g., hire date, full- or part-time status, promotion date, change in job description, termination date); 3)         Documentation of Schedule L or E, as applicable, and all relevant background checks and or exception requests; 4)         Documentation of required training; 5)         Documentation of required supervision with time, date, and duration; 6)         Review of individual employee's performance in accordance with organization policy; and 7)         A copy of the applicable professional code of ethics for the employee's credentials or as specified in Section 2060.320(f)(5). m)        The organization shall maintain the personnel record for a period of five years from the last date of employment.