Ensuring that Home Health Agencies (HHAs) in Illinois operate under competent supervision is critical for both patient safety and the integrity of healthcare services. The State of Illinois, through the Illinois Department of Public Health, mandates a comprehensive process to vet the qualifications of individuals aiming to fulfill supervisory roles within these agencies. This process is encapsulated in the 445104 form, officially known as the HHA Agency Supervisor Qualification Review Form. This form serves not only as a tool to assess the educational background and experience of prospective agency supervisors but also as a means to ensure compliance with Section 245.30 of the 77 Illinois Administrative Code. According to this section, a supervisor must be a registered nurse equipped with either a baccalaureate degree and one year of pertinent nursing experience or, alternatively, without such a degree but with at least three years of relevant experience, including two years specifically within a home health, community health, or related setting. Additionally, the form collects detailed information about the applicant's educational history, including high school and college attended, degrees obtained, and professional licenses or certifications held. Moreover, it asks for a comprehensive employment history over the last five years, highlighting administrative roles that qualify the individual to oversee a home health agency effectively. The importance of honesty is underscored in the form's closing declaration, reminding applicants of the legal implications of providing false information.
| Question | Answer |
|---|---|
| Form Name | Form 445104 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | COOS HHA supervisor qualification review form attmnt b home health formcomcomplaints |