6.5 Personnel

Part I: Guidelines for Delegate Agency Program Management and Administration


Personnel working in the IDHS delegate agencies should be broadly representative of all significant elements of the population to be served by the project, and should be sensitive to and able to deal effectively with the language and cultural needs of the client population.

Delegate agencies, and/or their organizing bodies, must establish and maintain written personnel policies that comply with Federal and State requirements, including Title VI of the Civil Rights Act, Section 504 of the Rehabilitation Act of 1973, and Title I of the Americans with Disabilities Act. These personnel policies must include the following elements:

  1. Nondiscrimination in hiring employees
  2. Staff recruitment and selection methods
  3. Job descriptions of duties, responsibilities and qualifications for each staff position
  4. Compensation and benefits
  5. Methodology for annual performance evaluation
  6. Staff promotion
  7. Staff termination
  8. Staff orientation that is specific to the Family Planning Program
  9. Grievance procedures
  10. Client confidentiality issues

IDHS further requires that delegate agency personnel policies cover the use of contractual consultants for providing care, the use of volunteers, and a system for replacing key staff in cases of illness, vacation or unexpected absence.

Delegates must ensure that:

  • The family planning project is administered by a qualified project director;
  • Licensure of applicants for positions requiring licensure are verified prior to employment and that there is documentation that licenses are kept current (use of a credentialing service is recommended as a risk management tool);
  • The medical care component of the project operates under the supervision of a medical director who is a licensed and qualified physician with training or experience in family planning;
  • Physical assessment, diagnosis, treatment, and provision of medication and devices must be performed by a physician or licensed and/or certified mid-level (non-physician) clinician. Mid-level clinicians shall include nurse practitioners, certified nurse midwives, and physician assistants. Clinicians other than physicians performing medical functions must do so under protocols and/or standing orders approved by the medical director. All clinicians employed in the family planning program must agree to follow the appropriate clinic procedures and/or standing orders and protocols;
  • All Advance Practice Nurses must maintain current licensure, certification and have a signed collaborative agreement by the standards defined by the 225 ILCS 65/, the Illinois Nursing and Advanced Practice Nursing Act; and that other health professionals and para-professionals may be utilized to perform non-medical responsibilities, or assist in medical functions as approved by the medical director;
  • Organizational charts and personnel policies are available to all personnel;
  • Job descriptions are available for all positions, reviewed annually, and updated as needed;
  • All personnel, students, volunteers, auditors and program consultants and reviewers must sign a written confidentiality agreement. (Refer to Appendix B for a Confidentiality Statement);
  • Written annual performance evaluation is discussed with the employee and is kept in the employee's personnel files;
  • Personnel are knowledgeable about the agency's compliance with OSHA regulations;
  • Family planning personnel must be informed that they may be subject to prosecution under Federal law if they coerce or endeavor to coerce any person to undergo an abortion or sterilization procedure;
  • Personnel records are kept confidential; and,
  • The organizational chart and personnel policies are reviewed annually and updated as needed.

Agencies must submit provider directory information, listing key personnel and means of contact, annually with the grant application and promptly as changes occur. Refer to Appendix A for the Provider Directory Information form.


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