Section 385.1010  General Requirements

 

a)         This Part applies to the operators/licensees of facilities that are to be licensed and classified to provide supportive residential services to persons with HIV disease.

 

b)         The license issued to each operator/licensee shall designate the licensee's name, facility name, address, the date the license was issued and the expiration date.  Such licenses shall be issued for a period of not less than six months nor more than 18 months. (Section 25 of the Act)

 

c)         When application for licensure is made in accordance with Section 385.1020 and the facility is in compliance with all other licensure requirements or has an accepted plan of correction for any areas of non-compliance, the license shall be issued.

 

Section 385.1020  Application for License

 

a)         Any person acting individually or jointly with other persons who proposes to build, own, establish, or operate a supportive residence for persons with HIV disease shall submit pre-application information on forms provided by the Department.

 

b)         Application for a license to establish or operate a residential facility for persons with HIV disease shall be made in writing and submitted, with other such information as the Department may require, on forms provided by the Department.

 

c)         The application shall contain the following information:

 

1)         The name and address of the person or business entity who will be the licensee, and if appropriate:

 

A)        The name and address of the corporation, Board of Directors, Officers and Registered Agent;

 

B)        Documentation certifying the corporation as a general not-for-profit corporation in accordance with the General Not-For-Profit Corporation Act of 1986 (Ill. Rev. Stat. 1991, ch. 32, par. 101.01 et seq.) [805 ILCS 105];

 

2)         The names and locations of the facilities for which a license is sought;

 

3)         The name of the person or persons under whose management or supervision the facility will be operated;

 

4)         Ownership disclosure as required in Section 385.1070.

 

Section 385.1030  Ownership Change or Discontinuation

 

a)         The license is not transferable.  It is issued to a specific licensee and for a specific location(s).  A licensee may have one license to service more than one geographic location.  The license shall immediately become void and shall be returned to the Department when the facility is sold or leased; when operation is discontinued; when operation is moved to a new location; or when the corporation which is the licensee dissolves or terminates.

 

b)         A license issued to a corporation shall become null, void and of no further effect upon the dissolution of the corporation.  The license shall not be revised if the corporation is subsequently reinstated.  A new license must be obtained in such cases.

 

Section 385.1040  Inspections, Surveys, Evaluations and Consultation

 

The terms survey, inspection and evaluation are synonymous.  These terms refer to the overall examination of compliance with the Act and this Part.  All facilities to which this Part applies shall be subject to and shall be deemed to have given consent to annual inspections, surveys, and evaluations by properly identified personnel of the Department, or by such other properly identified persons, including local health department staff, as the Department may designate.  The licensee, or person representing the licensee in the facility, shall provide to the representative of the Department access and entry to the premises or facility for obtaining information required to carry out the Act and this Part.  In addition, representatives of the Department shall have access to and may reproduce or photocopy at the Department's cost any books, records, and other documents maintained by the facility, the licensee, or their representatives to the extent necessary at a rate determined by the facility not to exceed the rate in the Department's Freedom of Information rules entitled "Freedom of Information Code" (77 Ill. Adm. Code 1126).

 

Section 385.1050  Filing an Annual Attested Financial Statement

 

Each licensee shall submit an annual attested financial statement to the Department.

 

Section 385.1060  Information to be Made Available to the Public by the Licensee

 

a)         Every facility shall conspicuously post or display in an area of its offices accessible to clients, employees, and visitors the following:

 

1)         Its current license;

 

2)         A copy of any order currently in effect pertaining to the operation of the facility issued by the Department or a court; and

 

3)         A list of information available for public inspection.

 

b)         A facility shall retain the following for public inspection:

 

1)         A complete copy of every inspection report of the facility received from the Department during the past five years;

 

2)         A copy of every order pertaining to the operation of the facility issued by the Department or a court during the past five years;

 

3)         A description of the services provided by the facility and the rates charged for those services and items for which a resident may be separately charged;

 

4)         A list of the corporation's Officers and Board of Directors; and

 

5)         A list of personnel employed or retained by the facility who are licensed, certified or registered by the Department of Professional Regulation.

 

Section 385.1070  Ownership Disclosure

 

a)         As a condition of the issuance or renewal of a license, the applicant or licensee shall file a statement of ownership.  The applicant shall notify the Department of any change in the information required in the statement of ownership within ten days of the change.  (Section 25 of the Act)

 

b)         The statement of ownership shall include:

 

1)         The name, address, Social Security Number, telephone number, occupation or business activity, business address, and business telephone number, of the corporation Officers and Board of Directors for the legal entity designated as the operator/licensee of the facility that is the subject of the application or license;

 

2)         The name, address, Social Security Number, telephone number, occupation or business activity, business address, business telephone number, and the percent of direct or indirect financial interest of those persons who have a direct or indirect financial interest of five percent or more in the legal entity that owns the building in which the operator/licensee is operating the facility that is the subject of the application or license; and

 

3)         The name and address of any facility, wherever located, any financial interest of which is owned by the applicant or licensee if the facility were required to be licensed if it were located in this State. (Section 25 of the Act)

 

Section 385.1080  Definitions

 

Abuse – Any physical or mental injury or sexual assault inflicted on a client in a facility other than by accidental means.

 

Act – The Supportive Residences Licensing Act (Ill. Rev. Stat. 1991, ch. 111½, par. 9001 et seq.) [210 ILCS 65].

 

Activities of Daily Living – Eating, toileting, bathing, dressing, ambulation, and transfer.

 

Adequate – Enough in either quantity or quality, as determined by a reasonable person familiar with the professional standards of the subject under review, to meet the needs of the clients of a facility under the particular set of circumstances in existence at the time of review.

 

            Advance Directive – A written instruction, such as a living will, power of attorney for healthcare, or Do Not Resuscitate Order, relating to the provision of care to the individual.

 

Aide or Orderly – Any person providing direct personal care, training or habilitation services to clients.

 

Applicant – Any Not-For-Profit Corporation making application for a license.  (Section 10 of the Act)

 

Appropriate – A term used to indicate that a requirement is to be applied according to the needs of a particular client, individual or situation.

 

Assessment – The use of an objective system with which to evaluate the physical, social, developmental, behavioral, and psychosocial aspects of a client.

 

Board of Directors – Same as Governing Body.

 

Case Management System – A standardized and systematic process of assessment, planning, service coordination, referral, advocacy, and follow-up through which the multiple service needs of clients are identified and met.

 

Client – A person residing in a Supportive Residence.

 

Client's representative – An individual who is authorized to act on behalf of a client who is unable to reach and communicate an informed decision as determined by the attending physician.  The following order of priority shall apply:

agent authorized by durable power of attorney for health care;

 

legal representative or other court appointed personal representative;

 

an individual who is designated in writing as such by a client.

 

Confinement – To involuntarily limit a client to a room or other small enclosed area.

 

Contract – A binding agreement between a client or the client's guardian (or, if the client is a minor, the client's parent) and the facility or its agent.

 

Department – The Illinois Department of Public Health.  (Section 10 of the Act)

 

Direct Care Aide – Any person who provides nursing care, personal care or psychosocial support to clients of Supportive Residences, regardless of title, and who is not a Qualified Professional, as defined in this Part.  Direct Care Aides must function under the supervision of a licensed nurse when performing nursing or personal care duties.

 

Direct Care Volunteer – Any person who provides non-nursing services to clients of the facility, and who does not receive fiduciary compensation for these services.

 

Director – The Director of the Illinois Department of Public Health or his/her designee.  (Section 10 of the Act)

 

Discharge – The full release of any client from a facility.

 

Emergency – A situation, physical condition, or one or more practices, methods or operations that present imminent danger of death or serious physical or mental harm to clients of a facility.

 

Facility – A private home, institution, building, residence, or any other place that provides a home-like atmosphere as well as a continuum of care which takes into account the special needs of persons with HIV disease.  (Section 10 of the Act)

 

Facility Management – The individual, or structure, identified responsible for the overall facility operation by the governing body.

 

Full-time – On duty a minimum of 36 hours, four days per week.

 

Goal – An expected result or condition that involves a relatively long period of time to achieve, that is specified in behavioral terms in a statement of relatively broad scope, and that provides guidance in establishing specific short-term objectives directed toward its attainment.

 

Governing Body – The policy-making authority, whether an individual or a group, that exercises general direction over the affairs of a facility and establishes policies concerning its operation and the welfare of the individual it serves.

 

HIV Disease – Infected with the human immunodeficiency virus or any other causative agent of acquired immunodeficiency syndrome (AIDS).

 

Hospitalization – The care and treatment of a person in a hospital as an inpatient.

 

Integrated Care Plan – The overall document that assesses and interprets the needs identified in the case management system into specific actions for a client to maintain or attain his/her maximum potential for as long as possible. This shall include consideration of medical, nutritional, social and psychosocial issues.  If needed, the medical plan of care is one part of this plan.

 

Immediately – To take action without hesitation.

 

License – Any of the following types of licenses issued to an applicant or licensee by the Department:

 

"Probationary License" means a license issued to an applicant or licensee which has not held a license contiguous to its application.

 

"Regular License" means a license issued to an applicant or licensee that is in substantial compliance with the Act and this Part.  (Section 10 of the Act)

 

Medical Plan of Care – Those aspects of a client's integrated care plan which center on treatments, pharmaceuticals or modalities provided directly by or under the direct supervision of a physician or nurse.

 

Misappropriation of Property – Using a client's cash, clothing, or other possessions without authorization by the client or the client's authorized representative; failure to return valuables within seven days after a client's discharge; or failure to refund money within seven days after death or discharge.

 

Neglect – A failure in a facility to provide adequate medical or personal care or maintenance, which failure results in physical or mental injury to a client or in the deterioration of a client's physical or mental condition.

 

Nurse – A registered nurse or a licensed practical nurse as defined in the Illinois Nursing Act of 1987 (Ill. Rev. Stat. 1991, ch. 111, par. 3501 et seq.) [225 ILCS 65].

 

Nursing Care – A complex of activities which carries out the diagnostic, therapeutic, and rehabilitative plan as prescribed by the physician; care for the client's environment; observing symptoms and reactions and taking necessary measures to carry out nursing procedures involving understanding of cause and effect in order to safeguard life and health.

 

Operator – The person responsible for the control, maintenance and governance of the facility, its personnel and physical plant.

 

            Owner – The not-for-profit corporation that owns a supportive residence. If a supportative residence is operated by a person or entity who leases the physical plant that is owned by another person or entity,  "owner" means the person who operates the supportive residence; except that if the person or entity who owns the physical plant is an affiliate of the person who operates the supportive residence and has significant control over the day-to-day operations of the supportive residence, the person or entity who owns the physical plant shall incur, jointly and severally with the owner, all liabilities imposed on an owner under the Act.  (Section 10 of the Act)

 

Pharmacist, Registered – A person who holds a certificate of registration as a registered pharmacist, a local registered pharmacist or a registered assistant pharmacist under the Pharmacy Practice Act of 1987 (Ill. Rev. Stat. 1991, ch. 111, par. 4121 et seq.) [225 ILCS 85].

 

Physician – Any person licensed by the State of Illinois to practice medicine in all its branches as provided in the Medical Practice Act of 1987 (Ill. Rev. Stat. 1991, ch. 111, par. 4400-1 et seq.) [225 ILCS 60].

 

Plan of Correction – A written plan submitted to the Department for correction of a violation of the Act or this Part that is cited by the Department.  The plan shall describe the steps that will be taken in order to bring the supportive residence into compliance and the time frame for completion of each step.  (Section 10 of the Act)

 

Potentially Hazardous Food – Any food that consists in whole or in part of milk or milk products, eggs, meat, poultry, fish, shellfish, edible crustacea, or other ingredients, including synthetic ingredients, in a form capable of supporting rapid and progressive growth of infectious or toxigenic microorganisms.  The term does not include foods which have a pH level of 4.6 or below or a water activity (aw) value of 0.85 or less.

 

Qualified Professional – A person who meets the educational, technical and ethical criteria of a health care profession, as evidenced by eligibility for membership in an organization established by the profession for the purpose of recognizing those persons who meet such criteria; and who is licensed, registered, or certified by the State of Illinois, if required.

 

Registered Nurse – A person with a valid Illinois license from the Illinois Department of Professional Regulation to practice as a registered professional nurse under the Illinois Nursing Act of 1987.

 

Restraint of a Client – The application of a device or administration of a drug to limit movements.

 

Room – A part of the inside of a facility that is partitioned continuously from floor to ceiling with openings closed with glass or hinged doors.

 

Satisfactory – Same as Adequate.

 

Sufficient – Same as Adequate.

 

Supportive Residence – A supportive residence for persons with HIV disease. (Section 10 of the Act)

 

Transfer – A change in status of client's living arrangements from one facility to another facility.

 

Universal Precautions or Universal Blood and Body Fluid Precautions – Measures utilized by health care providers to protect both patients and health care providers from contact with blood and body fluids to prevent transmission of the human immunodeficiency virus (HIV) during health care procedures.  In this context, body fluids means semen, vaginal secretions, cerebrospinal fluid (CSF), synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid.  In this context, body fluids does not mean feces, nasal secretions, saliva, sputum, sweat, tears, urine or vomitus unless they contain visible blood.

 

Volunteer – Both direct care volunteers and other individuals working without fiduciary compensation indirectly assisting facility management and clients.  Examples include housekeeping, building or yard maintenance, writing letters for clients, visiting with clients, reading with clients, or sharing other recreational activities with clients.

 

Section 385.1200  Facility Manager

 

A full-time employee shall be designated as the facility manager and shall be responsible for overall management of the facility.  The manager must, at a minimum, have a Bachelor's Degree from an accredited college or adequate equivalent experience.

 

Section 385.1250  Disaster Preparedness

 

The facility shall develop and implement plans for disaster preparedness and fire safety, including a plan for evaluation of the facility.  Employees shall receive instruction on implementation of the plans including instruction in the use of fire extinguishers.  These plans shall be practiced in accordance with facility policies at least twice annually.

 

Section 385.1300  Infection Control

 

The facility shall develop and implement infection control policies and procedures, and adhere to universal precautions.  The manager shall establish programs to assure compliance with the infection control policies and procedures.  The facility shall develop and implement internal reporting requirements in the event that an employee or volunteer is exposed to blood or body fluids, or in the case of a needle stick.  The internal reporting requirements shall include written records of exposures.

 

Section 385.1350  Case Management System

 

The facility must develop and maintain a case management system as part of its services.  Individuals identified as having case management responsibility shall create and monitor an integrated care plan for each client, which shall be regularly accessible to those responsible for implementing the plan.

 

Section 385.1400  Facility Admission

 

a)         Before a person is admitted to a facility, or at the expiration of the period of a previous contract, a written contract shall be executed between a licensee and client or client's representative.

 

b)         An adult person shall be presumed to have the capacity to contract for admission to a residential facility for persons with HIV disease unless adjudicated a "disabled person" within the meaning of Section 11a-2 of the Probate Act of 1975 (Ill. Rev. Stat. 1991, ch. 110½, par. 1-2 et seq.) [755 ILCS 5], or unless a petition for such an adjudication is pending in a circuit court of Illinois.

 

c)         If there is no guardian, agent or member of the person's immediate family available, able, or willing to execute the contract and a physician determines that a person is so disabled as to be unable to consent to placement in a facility, or if a person has already been found to be a "disabled person," but no order has been entered allowing residential placement of the person, that person may be admitted to a facility before the execution of a contract required by this Section; provided that a petition for guardianship or for modification of guardianship is filed within 15 days after the person's admission to a facility, and provided further that such a contract is executed within ten days after the disposition of the petition.

 

d)         Facilities shall ensure that all forms, agreements, and signage which carry information significant to the clients shall be available, and worded so as not to be confusing to the reader.

 

Section 385.1450  Contract

 

At the time of the client's admission to the facility, a copy of the written contract shall be given to the client and his/her client representative.  The contract shall specify the services that will or will not be provided. The contract shall specify the rights, duties and financial obligations of the client and the facility.

 

Section 385.1500  Policies and Procedures

 

a)         The facility shall develop and implement written policies and procedures that provide for the following: admission and discharge practices; information concerning an individual's rights under State law to make decisions regarding treatment and to make advance directives; the rights of clients to file a grievance in response to facility actions; and the rights of the client in accordance with Sections 385.1550, 385.1600, 385.1650, 385.1700, 385.1750, and 385.1800.  These policies and procedures shall be shared with the client before or at the time of admission.

 

b)         The execution of any advance directives must be documented in the client's record.  The facility cannot condition provision of care or otherwise discriminate on the basis of the execution of any advance directive.

 

c)         The facility shall develop and implement policies and procedures relating to services which can or cannot be provided to dependent minors of clients.

 

d)         The facility shall develop policies and procedures that specify discharge and transfer practices due to improvement or decline in the client's medical condition.

 

Section 385.1550  Clients' Rights

 

a)         A client shall not be deprived of any rights, benefits, or privileges guaranteed by law based solely on his/her status as a resident of the facility.

 

b)         A client shall be permitted to retain and use or wear his/her personal property in his/her immediate living quarters unless deemed medically inappropriate or socially disruptive by a physician and so documented in the client's record.

 

c)         The facility shall provide a means of safeguarding small items of value for the clients in their rooms or in any other part of the facility, so long as the client has daily access to such valuables.

 

d)         The facility shall make reasonable efforts to prevent loss and theft of clients' property.  The facility shall develop procedures for investigating complaints concerning theft of clients' property and shall promptly investigate all such complaints.

 

e)         There shall be no traffic through a client's room to reach any other area of the building.

 

f)         Children under 16 years of age who are related to employees or volunteers of a facility, and who are not themselves employees/volunteers of the facility, shall be restricted to quarters reserved for family or employee use except during times when such children are part of a group visiting the facility as part of a planned program, or similar activity.

 

g)         A client may refuse to perform labor for a facility unless specified in the admission contract, and the client's integrated care plan.

 

h)         A client shall be permitted the free exercise of religion.  Upon a client's request, and if necessary at his/her expense, the facility management shall make arrangements for a client's attendance at religious services of the client's choice.  However, no religious beliefs or practices or attendance at religious services may be imposed upon any client.

 

i)          The facility shall encourage and not prohibit a client's right to vote in person or by absentee ballot in all elections.

 

j)          Upon entering the facility, clients shall be provided with a form on which they may list those persons to be notified in the event of their death, or at such time as their death appears imminent.  A client may decline to have any person notified of his/her death.  In all cases, the client's physician shall be notified by the facility.

 

k)         The facility shall notify the client's representative whenever the client suffers from a sudden illness or accident, or if and when unexplained absences occur, in accordance with the terms of the contract.

 

l)          A client may not be transferred, discharged, evicted, harassed, dismissed, or retaliated against for filing a complaint or providing information concerning a complaint against the facility.

 

Section 385.1600  Rights in Medical Services

 

a)         A client shall be permitted to retain the services of his/her own personal physician at his/her own expense under an individual or group plan of health insurance, or under any public or private assistance program providing such coverage.

 

b)         The Department shall not prescribe the course of medical treatment provided to an individual client by the client's physician in a facility.

 

c)         All clients shall be permitted to obtain from their own physician or the physician retained by the facility complete and current information concerning his/her medical diagnosis, treatment and prognosis in terms and language the client can reasonably be expected to understand.

 

d)         All clients shall be permitted to participate in the planning of their total care and medical treatment to the extent that their condition permits. Any person a client chooses may also participate in the planning of the client's care.

 

e)         No client shall be subjected to experimental research or treatment without first obtaining his/her informed, written consent and advising facility management.  The experimental research/treatment shall be part of the client's integrated care plan.

 

f)         Every client shall be permitted to refuse medical treatment and to know the consequences of such action.

 

g)         Every client or client's representative shall be permitted to inspect and copy all of the client's clinical and other records concerning the client's care and maintenance kept by the facility or by the client's physician.

 

h)         All clients shall be permitted respect and privacy in their medical and personal care program.  Every client's case discussion, consultation, examination and treatment shall be confidential and shall be conducted discreetly.  Those persons not directly involved in the client's care must have the client's permission to be present.

 

Section 385.1650  Restraints

 

a)         Restraints shall not be used except as a temporary measure to administer treatment or medications or in an emergency.

 

1)         In the case of administering treatment or medication, restraints shall be used only with the written order of the physician.  The order shall specify the reasons for use, duration and type of restraint.

 

2)         In the case of an emergency, the restraint shall only be used to protect a client from harming himself/herself or others.  The physician shall be notified, immediately after the restraint is applied and the client's needs are met.  The physician may order continued use of restraints while steps are taken to mitigate the need for restraints or to locate a more appropriate health care setting for the client.  In no case may restraints be used for more than 48 hours.

 

3)         In either case, when restraints are used, a trained, licensed healthcare professional who is knowledgeable in restraint application and use shall be available at the facility at all times the restraint is in use.  Further, a client wearing a restraint shall have it released for a few minutes at least once every two hours, or more often if necessary.  The client's position shall be changed at these times.

 

b)         No chemical, medication, or tranquilizer shall be employed by a facility as a restraint or confinement in lieu of or in addition to any physical restraint.  Such chemicals, medications or tranquilizers may only be employed as part of a duly prescribed therapeutic medical treatment program authorized by the client's physician and documented in the client's integrated care plan and medical record.

 

Section 385.1700  Communication and Visitation

 

a)         Every client shall be permitted unimpeded, private and uncensored communication of his/her choice by mail and public telephone. The facility management shall ensure that correspondence is promptly received and mailed, and that telephones are reasonably accessible.

 

b)         The facility management shall ensure that clients may have private visits at any reasonable hour unless such visits are not medically advisable for the client as documented in the client's record by the client's physician.  The facility shall allow daily visiting.  Visiting hours shall be posted in plain view of visitors.  The facility management shall ensure that space for visits is available and that facility personnel knock, except in an emergency, before entering any client's room.

 

c)         Unimpeded, private and uncensored communication by mail, public telephone, and visitation may be reasonably restricted by a physician or facility management only in order to protect the client or others from harm, harassment or intimidation, provided that the reason for such restriction is placed in the client's integrated care plan and medical plan of care by the physician or facility management.  Upon admission, all clients shall be advised of the potential causes of such restrictions.

 

d)         Any employee or agent of a public agency, any representative of a community legal services program or any member of a community organization shall be permitted access at reasonable hours to any individual client or any facility, if the purpose of such agency, program or organization includes rendering assistance to clients without charge, but only if there is neither a commercial purpose nor effect to such access and if the purpose is to do any of the following:

 

1)         Visit, talk with, and make personal, social, and legal services available to all clients:

 

2)         Inform clients of their rights and entitlements and their corresponding obligations, under federal and State laws, by means of educational materials and discussions in groups and with individual clients;

 

3)         Assist clients in asserting their legal rights regarding claims for public assistance, medical assistance and social security benefits, as well as in all other matters in which clients are aggrieved.  Assistance may include counseling and litigation; or

 

4)         Engage in other methods of asserting, advising and representing clients so as to extend to them full enjoyment or their rights;

 

e)         No visitor shall enter the immediate living area of any client without first identifying himself/herself and then receiving permission from the client to enter.  The rights of other clients present in the room shall be respected. A client may terminate at any time a visit by a person having access to the client's living area.  Facility staff may terminate visits or provide other accommodations for the visits if they are so requested by the client, or the visitor is involved in behavior violating other clients' rights.  The visitor may be removed from the facility by facility staff if the visitor is participating in illegal activity or has been removed for engaging in such activity on the premises in the past.

 

Section 385.1750  Client's Funds

 

A client shall be permitted to manage his/her own financial affairs. A facility shall not manage client funds.

 

Section 385.1800  Transfer or Discharge

 

a)         A client shall be voluntarily discharged from the facility after he/she gives facility management, a physician, or a nurse of the facility written notice of the desire to be discharged.  A client shall be discharged upon written consent of his/her representative unless there is a court order to the contrary.  In such cases, upon the client's discharge, the facility is relieved of any responsibility for the client's care, safety, or well-being.

 

b)         The facility shall establish involuntary discharge procedures that shall include at least the following:

 

1)         Client behavior that may result in involuntary discharge:

 

A)        the client's decline or improvement in medical condition that may result in involuntary discharge;

 

B)        the client's physical safety;

 

C)        the client's action, or inaction, which directly impinges on the physical safety of other clients, the facility staff or facility visitors;

 

2)         Client counseling that will be provided to avoid involuntary discharge;

 

3)         Client notification and due process concerning involuntary discharge;

 

4)         Timeframes between counseling, notice, and involuntary discharge consistent with the reason for the involuntary discharge;

 

5)         Discharge planning that will be done.

 

Section 385.1850  Clients Advising the Facility

 

a)         There shall be a mechanism for regular client input in the decision-making processes of the facility.  Provisions shall be made for evaluation and review of conditions and policies by the governing body.

 

b)         There shall be regular meetings with clients for the purpose of advising the facility management on procedures and policies.  These meetings may be a vehicle for participation by direct care volunteers and community representatives who reflect the facility's clients' racial and ethnic makeup. These meetings shall be convened by facility management or clients of the facility, and shall be conducted in accordance with confidentiality rules of the facility.

 

Section 385.1900  Abuse and Neglect

 

a)         A licensee, facility manager, employee, volunteer or agent of a facility shall not abuse or neglect a client.

 

b)         A facility employee, agent, or volunteer who becomes aware of abuse or neglect of a client shall immediately report the matter to the facility management.

 

c)         Upon becoming aware of abuse or neglect, facility management shall immediately report the matter by telephone and in writing to the client's representative and the Department.

 

Section 385.1950  Employee and Volunteer Policies and Procedures

 

a)         The facility shall develop job descriptions for each position including specifying minimum qualifications.  Employees and volunteers shall meet or exceed the minimum qualifications for the position for which they are employed.

 

b)         All employees shall receive orientation including general information relating to facility goals, client safety, disaster preparedness, fire safety, universal precautions and infection control, and job tasks.

 

c)         Employees and volunteers shall be provided training to assure staff can effectively perform their jobs and be familiar with the requirements of the AIDS Confidentiality Act [210 ILCS 115] and its regulations (77 Ill. Adm. Code 697).

 

d)         At least annual evaluations of employee work performance shall be made by the management of the facility.

 

e)         Each facility must have policies and procedures related to volunteer services.  Direct care volunteers shall receive the same general orientation as employees; and orientation to their specific work assignment.

 

f)         Each facility shall have an employee handbook that defines employee rights and responsibilities, client rights, confidentiality requirements and appropriate client/employee interaction.

 

g)         Each employee or direct care volunteer shall have an initial health evaluation.  The initial health evaluation shall be conducted no more than 30 days prior to or 30 days after the employee or direct care volunteer begins work. The initial health evaluation shall include tuberculin testing in accordance with the Control of Tuberculosis Code (77 Ill. Adm. Code 696).  Testing shall be completed no more than 90 days prior to or 10 days after the first day of work.  The facility shall maintain records of the initial health evaluation and the tuberculosis screening.  Individuals who are  significant reactors shall have documentation in their records of follow-up and consideration for therapy.

 

h)         The facility shall identify a responsible person to be available on the premises 24 hours a day to respond to emergency needs of the clients. This person may be an employee, volunteer, or client.  The facility shall ensure that clients are informed of the identity of the responsible person.

 

i)          Prior to employing any individual in a position that requires a State license, the facility shall contact the Illinois Department of Professional Regulation to verify that the individual's license is active.  A copy of the license shall be placed in the individual's personnel file.

 

j)          The facility shall check the status of all applicants with the Nurse Aide Registry prior to hiring.

 

(Source:  Amended at 26 Ill. Reg. 11990, effective July 31, 2002)

 

Section 385.2000  Medical and Supportive Services

 

a)         Each client admitted shall be under the care of a physician.  Clients shall be referred to a physician if they do not have one identified at the time of admission.

 

b)         Each client admitted shall have had a physical examination within three days after admission, unless the client has had a physical examination no more than 30 days prior to admission; or has been admitted directly from an acute care hospital where the client had been admitted as a patient.

 

c)         Each client admitted shall have  tuberculin testing in accordance with the Control of Tuberculosis Code (77 Ill. Adm. Code 696) within 10 days after admission or be able to produce the results of a tuberculin test administered within the last 90 days or be under the care of a physician for tuberculosis.  All individuals who are significant reactors shall have documentation in their record of follow-up and consideration for therapy.

 

d)         The names and telephone numbers of persons to contact in medical and other emergencies shall be available.  This information shall be reviewed with staff, contractual employees and direct care volunteers.

 

e)         There shall be one or more agreements with area hospitals for emergency admissions and needed hospital-based services, for use in instances where a client is incapable of deciding his/her own hospital admission.

 

f)         Each client shall have an assessment of physical, mental, and psychosocial needs.  These needs shall be addressed in an integrated care plan that will allow the client to maintain his/her maximum potential for as long as possible.

 

g)         The facility shall either contract, or provide directly, the staff and services needed to meet each client's integrated care plan.  The integrated care plan shall be updated as needed, or at least every 3 months.

 

(Source:  Amended at 26 Ill. Reg. 11990, effective July 31, 2002)

 

Section 385.2050  General Requirements for Nursing and Assistance with Activities of Daily Living

 

a)         Adequate and properly supervised nursing care and assistance with activities of daily living shall be provided to each client to meet the total care needs of the client as determined by the integrated care plan.  Provision of staff may be made directly or through a licensed home health agency or hospice program.

 

b)         All treatments and procedures shall be administered as ordered by the physician.

 

c)         Objective observations of changes in a client's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further evaluation and treatment, shall be made by staff and recorded in the client's medical plan of care.

 

d)         Assistance with activities of daily living shall be provided, as needed. This shall include, but not be limited to, the following:

 

1)         Each client shall have proper daily personal attention, including skin, nails, hair, or oral hygiene, in addition to treatment ordered by the physician.

 

2)         Each client shall have at least one complete bath and hair wash weekly and as many additional baths and hair washes as necessary for satisfactory personal hygiene and comfort.

 

3)         Each client shall have clean, suitable clothing in order to be comfortable, sanitary, free of odors, and decent in appearance.

 

4)         Each client shall have clean bed linens at least once weekly and more often if necessary.

 

Section 385.2100  Medication Policies and Procedures

 

a)         Development of Medication Policies

 

1)         Every facility shall adopt written policies and procedures which shall be followed in the operation of the facility for properly and promptly obtaining, dispensing, administering, and disposing of drugs and medications.  These policies and procedures shall be in compliance with all applicable federal, State and local laws.

 

2)         These policies and procedures shall be developed with the advice of a pharmaceutical advisory committee that includes at least one pharmacist, one physician, the facility manager, and a registered nurse.

 

b)         Physician's Orders and Telephone Orders

 

1)         All medications, including cathartics, headache remedies, or vitamins, shall be given only upon the written order of a physician.  All such orders shall have the handwritten signature of the physician. Rubber stamp signatures are not acceptable.  These medications shall be given as prescribed by the physician and at the designated time.

 

2)         Telephone orders may be taken by a registered nurse or licensed practical nurse.  All such orders shall be immediately written in the client's medical plan of care record or a "telephone order form" and signed by the nurse taking the order.  These orders shall be countersigned by the physician within five working days.

 

c)         All medications to be released to the client, or person responsible for the client's care, at the time of discharge or when the client is going to be temporarily out of the facility at medication time shall be approved by the physician.  A notation concerning their disposition shall be made in the client's medical plan care.

 

Section 385.2150  Control of Medications

 

a)         The facility shall comply with all federal and State laws and regulations relating to the procurement, storage, dispensing, administration, and disposal of medications.

 

b)         All Schedule II controlled substances shall be stored in such a manner that two separate locks, using two different keys, must be unlocked to obtain these substances.  This may be accomplished by several methods such as locked cabinets within locked medicine rooms, separately locked, securely fastened boxes (or drawers) within a  locked medicine cabinet, locked portable medication carts, which are stored in a locked medicine room when not in use, or portable medication carts containing a separate locked area within the locked medication cart, when such cart is made immobile.

 

c)         All discontinued medications, medications having expiration dates that have passed, and medications of clients who have been discharged or who have expired shall be disposed of in accordance with the written policies and procedures.  This rule shall not apply to clients who have been temporarily transferred to a hospital or who are on a temporary home visit.  Medications for such persons shall be kept in the facility until such time as the client expires or is discharged from the facility.

 

d)         For all Schedule II substances, a controlled substances record shall be maintained that lists on separate sheets, for each type and strength of Schedule II substance, the following information:  date, time administered, name of client, dose, physician's name, signature of person administering dose, and number of doses remaining.

 

Section 385.2200  Labeling, Storage and Administration of Medications

 

a)         Clients shall be encouraged to independently administer their own medications.  If a client cannot administer his/her own medications, administration shall be by licensed medical or licensed nursing personnel in accordance with their respective licensing requirements.

 

b)         Medications for all clients shall be properly labeled and stored in accordance with the facility's policy and procedures.

 

c)         The medications of each client shall be kept and stored in the containers in which they were originally received.  Medications shall not be transferred between containers, except that a licensed nurse may remove medication from original containers and place it in other containers to be sent with a client when the client will be out of the facility at the time of scheduled administration of medication.

 

d)         Medications prescribed for one client shall not be administered to another client.

 

e)         If for any reason a physician's medication order cannot be followed, the physician shall be notified as soon as is reasonable, depending upon the situation, and a notation made in the client's medical plan of care.

 

f)         Medication errors and drug reactions shall be immediately reported to the client's physician.  An entry thereof shall be made in the client's medical plan of care, and the error or reaction shall also be described in an incident report.

 

Section 385.2250  Nutritional Issues

 

If the integrated care plan identifies that client intake of adequate nutrition or hydration is a problem, a plan shall be developed to meet those needs.

 

Section 385.2300  Meal Service

 

Meals shall be scheduled in accordance with times customary in the community. Care shall be taken to ensure a variety of menus that recognize client preferences.

 

Section 385.2350  Food Service Sanitation

 

a)         Food shall be free from spoilage, filth, and other contamination, and shall be safe for human consumption.  Food must be prepared in an inspected food service establishment.

 

b)         Food must be protected from potential contamination while being stored, prepared, served, or transported.  Potentially hazardous foods shall be maintained at 45Ί F. or below or 140Ί F. or above.  (Refer to Section 750.10 of the Food Service Sanitation Code (77 Ill. Adm. Code 750) for a definition of potentially hazardous foods.)

 

c)         Adequate refrigeration facilities and hot food storage facilities shall be provided to assure the maintenance of food at the required temperature during storage.

 

d)         No person shall work in food service while infected with a disease in a communicable form that can be transmitted by foods, or who is a carrier of organisms that cause such a disease, or while afflicted with a boil or infected wound, or an acute respiratory infection.

 

e)         Staff shall thoroughly wash their hands with soap and warm water before starting work, during work  as often as necessary to keep them clean, and after smoking, eating, drinking, or using the toilet.  Staff shall not use tobacco in any form while engaged in food preparation or service nor while in any equipment or utensil washing or food preparation area.

 

f)         Food contact surfaces shall be easily cleanable, smooth, free of breaks, open seams, cracks, chips, pits, and similar imperfections, and free of difficult to clean internal corners and crevices.  Non-food contact surfaces of equipment shall be designed and fabricated to be smooth, washable, free of unnecessary ledges, projections, or crevices, and shall be of such material and in such repair as to be easily maintained in a clean, sanitary condition.  Food contact and non-food contact surfaces shall be maintained in a clean condition.

 

g)         Equipment and utensils shall be washed, rinsed, and sanitized after each use.  For manual cleaning and sanitizing, items will be washed in a hot detergent solution, rinsed with clear water, and sanitized by one of the following methods:

 

1)         immersion for at least one-half minute in clean, hot water of at least 170Ί F.;

 

2)         immersion for at least one minute in a clean solution of at least 50 parts per million of available chlorine as a hypochlorite and having a temperature of at least 75Ί F.;

 

3)         immersion for at least one minute in a clean solution containing at least 12.5 parts per million of available iodine and having a ph not higher than 5.0 and a temperature of at least 75Ί F.; or

 

4)         immersion in a clean solution containing any other chemical sanitizing agent allowed under 21 CFR 178.1010  (1990, no further editions or amendments included) that will provide the equivalent bactericidal effect of a solution containing at least 50 parts per million of available chlorine as a hypochlorite and having a temperature of at least 75Ί F. for one minute.

 

h)         Mechanical cleaning and sanitizing may be done by spray-type or immersion dishwashing machines, or by any other type of machine or device if it is demonstrated that it thoroughly cleans and sanitizes equipment and utensils. Machines shall be installed and maintained in good repair, and shall be operated in accordance with the manufacturer's instructions.  The final sanitizing rinse shall be at least 180Ί F. or equivalent.  Refer to the Food Service Sanitation Code, Section 750.830(h), for specifics on mechanical sanitizing.

 

i)          Utensils shall be air dried before being stored or stored in a self-draining position.

 

j)          Garbage and refuse shall be kept in durable, easily cleanable, insect and rodent-proof containers that do not leak or absorb liquids.

 

k)         The facility shall be kept in such a condition as to prevent the harborage or feeding of insects and rodents.  Screen doors shall be self-closing, and screening material shall not be less than 16 mesh to the inch.

 

l)          Floors, floor coverings, walls, and ceilings shall be easily cleanable and maintained in good repair.

 

m)        Poisonous or toxic materials shall be properly labeled.  Insecticides and rodenticides and detergents, sanitizers, and other cleaning agents shall be stored physically separate from each other and not stored above or intermingled with food, food equipment and utensils.

 

Section 385.2400  Physical Plant

 

a)         Not more than two people shall share a bedroom.  No room commonly used for other purposes, including, but not limited to, a hall, stairway, attic, garage, storage area, shed or similar detached building, shall be used as a sleeping room for any client.

 

b)         Toilets and bathrooms shall be conveniently located.  At least one toilet, washbasin, and bathtub or shower shall be provided per six clients.  If the bathing area or toilet room contains more than one of each fixture, a means of allowing individual privacy shall be provided.

 

c)         Sufficient room shall be available throughout the facility to accommodate and serve all clients in comfort, safety and privacy.  The premises shall be maintained in good repair and shall provide a safe, clean, and healthful environment, free of pests.  Exits shall not be blocked.

 

d)         Each facility shall be in full compliance with local building codes and fire safety/protection requirements.

 

e)         Garbage shall be disposed of in accordance with State and local requirements.  Potentially infectious medical wastes shall be disposed of in accordance with State and local requirements.  All solid waste shall be handled in the facility to prevent transmission of disease.  Sharps must be stored and disposed of in rigid, puncture-resistant containers.

 

f)         Water supply, sewage disposal and plumbing systems shall comply with all applicable State and local codes and ordinances.

 

Section 385.2500  Violations

 

a)         If the Department determines that a supportive residence is not in compliance with the Act or this Part, the Department shall promptly serve a notice of violation upon the licensee.  The notice shall be served on the licensee personally or by certified mail.  (Section 30 of the Act)

 

b)         Each notice of violation shall be in writing and shall include:

 

1)         A description of the nature of the violation.

 

2)         Citation of the statutory provision or rule alleged to have been violated.

 

3)         A statement that the licensee must submit a plan of correction as provided under subsection (c) of this Section.

 

4)         A description of any other action the Department may take under this Act, including adverse licensure action under Section 50 of the Act and Section 385.2550 of this Part.

 

5)         A statement that the licensee has a right to a hearing to contest the violation as provided in Section 55 of the Act and Section 385.2600 of this Part and a description of the procedure for requesting a hearing. (Section 30 of the Act)

 

c)         In response to the receipt of a notice of violation, the licensee shall submit a written plan of correction to the Department (Section 30 of the Act).  Each plan of correction is subject to the approval of the Department and shall comply with the following requirements:

 

1)         Be filed with the Department within 10 working days after the licensee's receipt of the notice of violation.

 

2)         State with particularity the method by which the licensee intends to correct each violation specified in the notice of violation.

 

3)         Contain a stated date by which each violation will be corrected.

 

Section 385.2550  Adverse Licensure Action

 

a)         Adverse licensure actions include the denial of an initial license application, denial of an application for license renewal, revocation of a license, and suspension of a license.

 

b)         Adverse licensure action shall be considered by the Department under the following conditions:

 

1)         If the applicant or licensee has been convicted of a felony or two or more misdemeanors involving moral turpitude, as shown by a certified copy of the court's conviction, and

 

A)        The Department determines after investigation that the person has not been sufficiently rehabilitated to warrant the public trust; or

 

B)        Upon other satisfactory evidence that the moral character of the applicant or licensee is not reportable.

 

2)         If the licensee submits false information on Department licensure forms.

 

3)         If the licensee submits false information during an inspection.

 

4)         If the licensee refuses to allow an inspection to occur.

 

5)         If the licensee violates the Act or this Part.

 

6)         If the licensee violates the rights of its clients.

 

7)         If the licensee fails to submit or implement a plan of correction within the specified time period. (Section 50 of the Act)

 

8)         If the Department finds licensee conduct or practice to be detrimental to the health, safety, or welfare of a client.

 

c)         In determining whether to take adverse licensure action, the Department shall consider the following factors:

 

1)         The gravity of the violation, including the probability that death or serious physical or mental harm to a client will result or has resulted and the severity of the actual or potential harm.

 

2)         The extent to which the provisions of the Act or this Part were violated.

 

3)         The reasonable diligence exercised  by the licensee and any efforts by the licensee to correct the violations.

 

4)         Any previous violations committed by the licensee.

 

5)         The financial benefit to the licensee of committing or continuing the violation.

 

d)         The Director will order an emergency suspension of a license when the Director finds that continued operation of the facility poses an immediate and serious danger to the public health, safety, or welfare.  The suspension shall take effect upon the issuance of an order of emergency suspension by the Director and shall remain in effect during any administrative proceeding contesting the action.  Promptly following any emergency suspension of a license, the Department shall take action to revoke the license.

 

e)         Notice of Adverse Licensure Action

 

1)         The Department shall notify the applicant or licensee in writing prior to denying an application, refusing to renew a license, or revoking a license.

 

2)         The notice shall be served on the applicant or licensee either by personal service or by registered mail.  The notice shall contain the following information:

 

A)        A description of the particular reasons for the proposed action, including citations of the specific provisions of the Act and this Part under which the proposed action is being taken.

 

B)        The date, not less than 15 days from the date of the mailing or service of the notice, on which the action will take effect, unless appealed by the applicant or licensee.

 

C)        A description of the manner in which the applicant or licensee may appeal the proposed action and the right of the applicant or licensee to a hearing under Section 10 of the Act and Section 385.2600 of this Part.

 

Section 385.2600  Hearings

 

Hearings conducted pursuant to the Act and this Part shall be conducted in accordance with the following:

 

a)         Section 55 of the Act;

 

b)         The Illinois Administrative Procedure Act (Ill. Rev. Stat. 1991, ch. 127, par. 1001-1 et seq.) [5 ILCS 100];

 

c)         The rules of the Department entitled "Rules of Practice and Procedure in Administrative Hearings" (77 Ill. Adm. Code 100).