ADMINISTRATIVE CODE

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: HOSPITALS AND OUTPATIENT SERVICES CARE FACILITIES
PART 270 SUBACUTE CARE HOSPITAL DEMONSTRATION PROGRAM CODE

Section 270.1000 Definitions

Section 270.1050 Statutes and Rules Referenced

Section 270.1100 Demonstration Program Elements

Section 270.1200 Application for and Issuance of a License to Operate a Subacute Care Hospital Model

Section 270.1300 Obligations and Privileges of Subacute Care Hospital Models

Section 270.1400 Inspections and Investigations

Section 270.1500 Notice of Violation and Plan of Correction

Section 270.1600 Adverse Licensure Action

Section 270.1700 Admission Practices

Section 270.1800 Patient Assessment

Section 270.1900 Comprehensive Care Plan

Section 270.2000 Patient's Rights

Section 270.2100 Patient Care Services

Section 270.2200 Personnel

Section 270.2250 Health Care Worker Background Check

Section 270.2300 Quality Assessment and Improvement

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES
PART 270 SUBACUTE CARE HOSPITAL DEMONSTRATION PROGRAM CODE
SECTION 270.1000 DEFINITIONS

Section 270.1000 Definitions

The following terms shall have the meanings ascribed to them here whenever the term is used in this Part.

Act – the Alternative Health Care Delivery Act [210 ILCS 3].

Board – the State Board of Health. (Section 10 of the Act)

Charitable Care – the intentional provision of free or discounted subacute care hospital services to persons who cannot afford to pay.

Comparable Health Care Providers – other facilities holding the comparable Illinois Department of Public Health license.

Comprehensive Care Plan – a document, developed by the Interdisciplinary Team, that includes measurable objectives and timetables to meet a patient's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Intermediate steps must be included for each objective if identification of those steps will enhance the patient's ability to meet the objectives.

Demonstration Program or Program – a program to license and study alternative health care models authorized under the Act. (Section 10 of the Act)

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

Designated Site – a location in the city of Chicago not currently licensed as a hospital or nursing home, which was licensed as a hospital under the Illinois Hospital Licensing Act (Ill. Rev. Stat. 1991, ch. 111½, pars. 142 et seq.) [210 ILCS 85] within the 10 years immediately before application for a license as a Subacute Care Hospital Model. (Section 35 of the Act; see P.A. 88-490)

Dietician – a person who:

is eligible for registration by the American Dietetic Association; or

has a baccalaureate degree with major studies in food and nutrition, dietetics, and food service management, has one year of supervisory experience in the dietetic service of a health care institution, and participates annually in continuing dietetic education.

Director – the Director of Public Health or his designee. (Section 10 of the Act)

Hospital – a facility licensed pursuant to the Hospital Licensing Act.

Inspection – any survey, evaluation or investigation of the subacute care hospital model's compliance with the Act and this Part by the Department or designee.

Interdisciplinary Team – a group primarily responsible for preparing the comprehensive care plan, which includes the patient, the patient's representative, the attending physician, a registered nurse with responsibility for caring for the patient and other appropriate staff in disciplines determined by the patient's needs and facility policy.

Licensee – the person or entity licensed to operate the subacute care hospital model.

Nursing Home – a facility licensed pursuant to the Nursing Home Care Act (Ill. Rev. Stat. 1991, ch. 111½, pars. 4151-101 et seq.) [210 ILCS 45] to provide skilled nursing care.

Patient's Program Manager – a facility staff person responsible for organizing the patient's care. This person will be qualified by training and experience but may be any of several disciplines, such as, nurse, social worker, etc. This person may have other primary job responsibilities. A facility may have a specific program manager or may have many program managers who have responsibility for a few patients.

Patient's Representative – a person authorized by the patient or by law to act on behalf of the patient.

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

Physiological Monitoring on a Continual Basis – monitoring of a physiological function such as breathing, cardiovascular functioning or biochemical functioning on a continual basis by electronic, mechanical, or other medically appropriate method.

Registered Nurse – a person who is licensed as a registered professional nurse under the Illinois Nursing Act of 1987 (Ill. Rev. Stat. 1991, ch. 111, pars. 3501 et seq.) [225 ILCS 65].

Social Worker – a person who is a licensed social worker or licensed clinical social worker under the Clinical Social Work and Social Work Practice Act (Ill. Rev. Stat. 1991, ch. 111, par. 351 et seq.) [225 ILCS 20].

Subacute Care – the provision of inpatient services in a subacute care hospital model for patients who need a greater intensity or complexity of care than generally provided in a skilled nursing facility but who no longer require the stabilization or treatment provided in acute hospital care. Subacute care includes physician supervision, registered nursing and physiological monitoring on a continual basis. (Section 35 of the Act)

Subacute Care Hospital Model – a freestanding building or a distinct physical and operational entity within a hospital or nursing home building that is licensed to participate in the Demonstration Program. A subacute care hospital model shall only consist of beds existing in licensed hospitals or skilled nursing facilities. (Section 35 of the Act)

Substantial Compliance – meeting requirements except for variance from the strict and literal performance, which results in unimportant omissions or defects given the particular circumstances involved. This definition is limited to the phrase as used in Section 270.1200.

(Source: Amended at 19 Ill. Reg. 6315, effective May 1, 1995)

Section 270.1050 Statutes and Rules Referenced

The following Illinois statutes and administrative rules of the Department of Public Health are referenced in this Part.

a) Hospital Licensing Act and Hospital Licensing Requirements (77 Ill. Adm. Code 250)

b) Nursing Home Care Act and Skilled Nursing and Intermediate Care Facilities Code (77 Ill. Adm. Code 300)

c) Long-Term Care for Under Age 22 Facilities Code (77 Ill. Adm. Code 390)

d) Rules of Practice and Procedure in Administrative Hearings (77 Ill. Adm. Code 100)

Section 270.1100 Demonstration Program Elements

a) The Subacute Care Hospital Demonstration Program shall be reviewed annually by the Board to determine if it should continue operation for a period of up to five years, commencing with the effective date of this Part.

b) A Subacute Care Hospital Model shall be licensed pursuant to this Part to be considered a participant in the Program.

c) Applications for participation in the Program shall be considered only when a vacancy exists in one of the allocated Program slots for the relevant geographic area.

d) At the midpoint and end of the program, the Board shall evaluate and make recommendations to the Governor and the General Assembly, through the Department, regarding the program, in accordance with Section 20(b) of the Act.

e) The Department shall deposit all application fees, renewal fees and fines collected under the Act and this Part into the Regulatory Evaluation and Basic Enforcement Fund in the State Treasury. (Section 25(d) of the Act)

Section 270.1200 Application for and Issuance of a License to Operate a Subacute Care Hospital Model

a) The applicant shall be licensed as a skilled nursing home or a pediatric skilled nursing home pursuant to the Nursing Home Care Act or as a hospital pursuant to the Hospital Licensing Act or be a Designated Site.

b) Applications for a license to operate a subacute care hospital model shall be in writing on forms provided by the Department. The application shall be made under oath and shall contain the following:

1) Proof of a Certificate of Need to establish and operate a subacute care hospital model issued by the Health Facilities Planning Board under the Illinois Health Facilities Planning Act [20 ILCS 3960] or proof of compliance with Section 36.5 of the Act;

2) The name and address of the hospital, skilled nursing home or Designated Site's licensee, which shall be the name of the Model licensee;

3) The name of the proposed Model;

4) The address of the proposed Model, if it is a freestanding building;

5) A precise description of the site of the proposed Model, and if it is located within the hospital or skilled nursing home, the room numbers of those rooms which will be used as subacute care beds;

6) The number of subacute care beds;

7) The name and address of the registered agent or other individual authorized to receive Service of Process for the Model license; and

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

c) An application for initial licensure shall be accompanied by an application fee of $500 plus $100 for each subacute care hospital model bed.

d) Upon receipt and review of a complete application for licensure, the Department shall conduct an inspection to determine compliance with the Act and this Part.

e) If the proposed Model is found to be in substantial compliance with the Act and this Part, the Department shall issue a license for a period of one year.

1) The license shall not be transferable; it is issued to the licensee and for the specific location and number of beds identified in the application;

2) The license shall become automatically void and shall be returned to the Department if the facility's hospital or skilled nursing home license is revoked, nonrenewed or relinquished, denied, forfeited or suspended.

f) An application for license renewal shall be filed with the Department 90-120 days prior to the expiration of the license, on forms provided by the Department.

1) The renewal application shall comply with the requirements of subsections (a), (b) and (c) of this Section; and

2) Upon receipt and review of a complete application for license renewal, the Department may conduct a survey. The Department shall renew the license in accordance with subsection (e) of this Section.

g) The Department may issue a provisional license to any subacute care hospital model that does not substantially comply with the provisions of the Act and this Part:

1) A provisional license may be issued only if the Department finds that:

A) The model has undertaken changes and corrections which upon completion will render the model in substantial compliance with the Act; and

B) The health and safety of the patients in the model will be protected during the period for which the provisional license is issued. (Section 30 (c) of the Act)

2) The Department shall advise the applicant or licensee of the conditions under which the provisional license is issued, including:

A) The manner in which the model fails to comply with the provisions of the Act;

B) The changes and corrections that shall be completed;

C) The time within which the necessary changes and corrections shall be completed (Section 30 (c) of the Act); and

D) The interim actions that are necessary to protect the health and safety of the patients.

h) The Subacute Care Hospital Model license or provisional license shall be prominently displayed in an area accessible to the public.

i) Except for the Designated Site, a Subacute Care Hospital Model licensed under this Part shall operate in conformance with the Hospital Licensing Act or Nursing Home Care Act, and the rules promulgated thereunder, corresponding to its primary facility license, for all matters and requirements not specifically addressed in this Part.

j) The Designated Site shall comply with the operational requirements of the Nursing Home Care Act and the rules promulgated thereunder unless the Designated Site obtains a license to operate as a different type of health care facility, in which case the Designated Site must comply with the licensing requirements for that type of facility. The Designated Site need not be licensed as a nursing home.

(Source: Amended at 22 Ill. Reg. 2207, effective January 15, 1998)

Section 270.1300 Obligations and Privileges of Subacute Care Hospital Models

a) Subacute care hospital models shall, within 30 days of licensure, seek certification under Titles XVIII and XIX of the Federal Social Security Act. (Section 30(d) of the Act)

b) Subacute care hospital models shall provide charitable care consistent with that provided by comparable health care providers in the geographic area. For the purpose of this Part, comparable health care providers shall include hospitals, rehabilitation hospitals and skilled nursing facilities. (Section 30(d) of the Act)

c) A licensed subacute care hospital model that continues to be in substantial compliance after the conclusion of the demonstration program shall be eligible for annual license renewals unless and until a different licensure program for that type of health care model is established by legislation. (Section 30(c) of the Act)

d) A subacute care hospital model shall never use the word "hospital" in its advertising or marketing activities or represent or hold itself out to the public as a general acute care hospital. A subacute care hospital model may not accept or purport to treat patients in an emergency condition, and may not operate an emergency department open to the general public. (Section 35 of the Act)

e) The average length of stay for patients treated in a subacute care hospital model shall not be less than 20 days, and for individual patients, the expected stay at the time of admission shall not be less than 10 days. Variations from minimum lengths of stay shall be reported to the Department semi-annually, in writing. (Section 35 of the Act)

Section 270.1400 Inspections and Investigations

a) The Department shall perform licensure inspections of subacute care hospital models, as deemed necessary, to ensure compliance with the Act and this Part. (Section 25(c) of the Act)

b) All facilities to which this Part applies shall be subject to and shall be deemed to have given consent to all inspections by properly identified personnel of the Department, or by other such properly identified persons as the Department might designate. In addition, representatives of the Department shall have access to and may reproduce or photocopy any books, records and other documents maintained by the facility or the licensee to the extent necessary to carry out the Act and this Part.

c) The Department shall investigate an applicant or licensee whenever it receives a verified complaint in writing of any person setting forth facts which, if proven, would constitute grounds for the denial of an application for a license, refusal to renew a license, or suspension or revocation of a license. (Section 50 of the Act)

d) The Department may also investigate an applicant or licensee on its own motion or based upon complaints received by mail, telephone or in person. (Section 50 of the Act)

Section 270.1500 Notice of Violation and Plan of Correction

a) Upon determination that the licensee or applicant is in violation of the Act or this Part, the Department shall issue a written Notice of Violation and request a plan of correction. The notice shall specify the violations, and shall instruct the licensee or applicant to submit a plan of correction to the Department within 10 days after receipt of the Notice.

b) Within the ten-day period, a licensee or applicant may request additional time for submission of the plan of correction. The Department may extend the period for submission of the plan of correction for an additional 30 days, when the Department finds that corrective action by a facility to abate or eliminate the violation will require substantial capital improvement. The Department will consider the extent and complexity of necessary physical plant repairs and improvements and any impact on the health, safety, or welfare of the patients of the facility in determining whether to grant a requested extension.

c) Each plan of correction shall be based on an assessment by the facility of the conditions or occurrences that are the basis of the violation and an evaluation of the practices, policies, and procedures which have caused or contributed to the conditions or occurrences. Evidence of such assessment and evaluation shall be maintained by the facility. Each plan of correction shall include:

1) A description of the specific corrective action the facility is taking, or plans to take, to abate, eliminate, or correct the violation cited in the Notice.

2) A description of the steps that will be taken to avoid future occurrences of the same and similar violations.

3) A specific date by which the corrective action will be completed.

d) Submission of a plan of correction shall not be considered an admission by the facility that the violation has occurred.

e) The Department shall review each plan of correction to ensure that it provides for the abatement, elimination, or correction of the violation. The Department shall reject a submitted plan only if it finds any of the following deficiencies:

1) The plan does not appear to address the conditions or occurrences that are the basis of the violation and an evaluation of the practices, policies, and procedures that have caused or contributed to the conditions or occurrences.

2) The plan is not specific enough to indicate the actual actions the facility will be taking to abate, eliminate, or correct the violation.

3) The plan does not provide for measures that will abate or eliminate, or correct the violation.

4) The plan does not provide steps that will avoid future occurrences of the same and similar violations.

5) The plan does not provide for timely completion of the corrective action, considering the seriousness of the violation, any possible harm to the patients, and the extent and complexity of the correction action.

f) The Department shall notify the licensee or applicant in writing of the acceptance or rejection of the plan of correction, including specific reasons for the rejection of the plan. The facility shall have 10 days after receipt of notice of rejection in which to submit a modified plan that addresses the requirements of subsection (c) of this Section.

g) If a licensee or applicant fails to make a timely submission of a modified plan of correction, or such modified plan is not acceptable to the Department, a plan of correction shall be specified and imposed by the Department.

h) The Department shall verify the completion of the corrective action required by the plan of correction within the specified time period during subsequent investigations, surveys and evaluations of the facility.

Section 270.1600 Adverse Licensure Action

a) Before denying a license application, refusing to renew a license, suspending a license, revoking a license, or assessing an administrative fine, the Department shall notify the applicant or the licensee in writing. The notice shall specify the charges or reasons for the Department's contemplated action, and shall provide an opportunity to file a request for a hearing within 10 days after receiving the notice. (Section 50 of the Act)

1) A failure to request a hearing within 10 days shall constitute a waiver of the applicant's or licensee's right to a hearing. (Section 50 of the Act)

2) The hearing shall be conducted by the Director or an individual designated in writing by the Director as an Administrative Law Judge, and shall be conducted in conformance with the Department's Rules of Practice and Procedure in Administrative Hearings and Section 65 of the Act. (Section 55 of the Act)

b) A license may be denied, suspended, or revoked, or the renewal of a license may be denied or administrative fine assessed, for any of the following reasons:

1) Violation of any provision of the Act or this Part;

2) Conviction of the owner or operator of the subacute care hospital model of a felony or of any other crime under the laws of any state or of the United States arising out of, or in connection with, the operation of a health care facility. The record of conviction or a certified copy of it shall be conclusive evidence of conviction;

3) An encumbrance on a health care license issued in Illinois or any other state to the owner or operator of the subacute care hospital model;

4) Revocation of any facility license issued by the Department during the previous five years or surrender or expiration of the license during the pendency of action by the Department to revoke or suspend the license during the previous five years if:

A) the prior license was issued to the individual applicant, or a controlling owner or controlling combination of owners of the applicant, or

B) any affiliate of the individual applicant, or controlling owner of the applicant or affiliate of the applicant was a controlling owner of the prior license. (Section 45 of the Act)

c) An action to assess an administrative fine may be initiated in conjunction with or in lieu of other adverse licensure action.

d) The amount of an administrative fine shall be determined based on consideration of the following:

1) The nature and severity of the violation(s);

2) The facility's diligence in correcting the violation(s);

3) Whether the facility had been previously cited for similar violation(s);

4) The number of violations;

5) The duration of uncorrected violation(s); and

6) The impact or potential impact of the violation(s) on patient health and safety.

e) The administrative fine shall be calculated in relation to the number of days the violation existed, or continues to exist if it has not been corrected. The total amount of the fine assessed shall fall within the following parameters:

1) For a violation that occurred as a single event or incident – between $100 and $5,000 per violation;

2) For a violation that was or is continuing beyond a single event or incident – between $100 and $500 per day per violation.

Section 270.1700 Admission Practices

a) The facility shall establish admission criteria that provide for:

1) The admission of patients with an expected stay of at least 10 days;

2) The admission of patients who can be served by the facility; and

3) The nondiscrimination of patients based on disability, race, religion, sex, source of payment, and any other basis recognized by applicable State and federal laws.

b) The facility shall have a preadmission screening process to assure that the admission criteria are met. Discharge planning shall be included in the preadmission screening.

c) At the time each patient is admitted, the licensee must assure that the facility has conducted a nursing assessment and has appropriate physician orders for the patient's immediate care needs, which shall include at a minimum dietary, drugs (if necessary), and routine care to maintain or improve the patient's functional abilities until staff can conduct a comprehensive patient assessment and develop a comprehensive care plan.

Section 270.1800 Patient Assessment

a) The licensee shall establish a comprehensive, accurate, standardized, reproducible assessment of each patient's functional ability, strengths and weaknesses. The Minimum Data Set/Patient Assessment Instrument defined by Title XVIII and XIX of the Social Security Act (43 CFR 483.20) meets this Part.

b) This assessment shall coordinate with any preadmission screenings to the maximum extent practicable to avoid duplicative testing.

c) The licensee shall establish which health care professionals are to participate in the assessment. This shall include at least the following:

1) Registered Nurse,

2) Physician,

3) Dietician, and

4) Social Worker.

d) The assessment of each patient shall be completed, in accordance with facility policy, within seven days of admission and promptly after a significant change in the patient's physical or mental condition.

Section 270.1900 Comprehensive Care Plan

a) The results of the assessment shall be used to develop a comprehensive care plan within three days of completing the patient assessment for each patient, which includes measurable objectives and timetables to meet a patient's medical, nursing, mental and psychosocial needs that were identified in the assessment. The comprehensive care plan shall include a discharge plan.

b) The licensee shall establish a policy that defines the members of the interdisciplinary team who will develop and periodically review the comprehensive care plan at a team conference. Team members shall include at least the following:

1) Patient;

2) Patient's representative, if he/she chooses to participate;

3) Patient's Program Manager;

4) Registered nurse; and

5) Physician.

c) The comprehensive care plan shall be implemented.

d) The facility shall develop a comprehensive care plan evaluation component to measure a patient's progress and the need for revised objectives.

e) The comprehensive care plan shall be reviewed and revised by the interdisciplinary team as frequently as needed by the patient. A full care plan conference shall be held by the interdisciplinary team at least every 21 days.

Section 270.2000 Patient's Rights

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

b) A patient 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 patient's record.

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

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

e) 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.

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

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

h) The facility shall notify the patient's representative whenever the patient suffers from a sudden illness or accident, or if and when unexplained absences occur.

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

j) A patient 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.

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

l) No patient shall be subjected to experimental research or treatment without first obtaining his/her informed, written consent. The experimental research/treatment shall be part of the patient's comprehensive care plan.

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

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

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

p) Neither physical restraints nor confinements shall be employed for the purpose of punishment or for the convenience of any facility personnel or volunteer. No physical restraints or confinements shall be employed except as ordered by a physician who documents the need for such restraints or confinements in the patient's comprehensive care plan and medical plan of care.

q) Restraints shall be used only upon written order of the attending physician and for the safety and security of the patients.

r) The reasons for ordering and using restraints shall be recorded in the patient's comprehensive care plan and medical plan of care. The recordings shall contain ongoing evaluations of the need for the restraints and the measures being taken to reduce or eliminate the need for the use of restraints.

s) No patient shall be restrained, confined, or subjected to adverse stimuli for the purpose of behavior modification unless and until the informed consent of the patient or patient representative has been obtained.

t) Restraints and confinements may be employed only when necessary to prevent a patient from injuring himself/herself or others. The physician's written authorization shall specify the precise time periods and conditions in which any restraints or confinements shall be employed.

u) 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 or confinement. Such chemicals, medications or tranquilizers may only be employed as part of a duly prescribed therapeutic medical treatment program authorized by the patient's physician and documented in the patient's comprehensive care plan and medical plan of care.

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

w) The facility management shall ensure that patients may have private visits at any reasonable hour unless such visits are not medically advisable for the patient as documented in the patient's comprehensive care plan by the patient'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 patient's room.

x) 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 patient or any facility if the purpose of such agency, program or organization includes rendering assistance to patients 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 patients;

2) Inform patients 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 patients;

3) Assist patients 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 patients are aggrieved. Assistance may include counseling and litigation; or

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

y) No visitor shall enter the immediate living area of any patient without first identifying himself/herself and then receiving permission from the patient to enter. The rights of other patients present in the room shall be respected. A patient may terminate at any time a visit by a person having access to the patient's living area. Facility staff may terminate visits or provide other accommodations for the visit if they are so requested by the patient, or the visitor is involved in behavior violating other patients' rights.

z) A patient shall be permitted to manage his/her own financial affairs. A facility shall not manage patient funds unless the facility is in compliance with Section 300.3260 of the Skilled Nursing and Intermediate Care Facilities Code.

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

bb) The facility shall establish involuntary discharge procedures in accordance with subsection (cc) of this Section, which shall include at least the following:

1) Patient behavior that may result in involuntary discharge;

2) Patient decline or improvement in medical condition that may result in involuntary discharge;

3) Patient counseling that may be provided to avoid involuntary discharge;

4) Patient notification and due process concerning involuntary discharge;

5) Timeframes between counseling, notice, and involuntary discharge.

cc) A facility may involuntarily transfer or discharge a patient only for one or more of the following reasons:

1) The patient's medical condition;

2) The patient's physical safety;

3) The patient's action, or inaction, which directly impinges on the physical safety of other patients, the facility staff or facility visitors;

4) The patient's late payment or nonpayment for his or her stay. For the purposes of this Part, late payment means non-receipt of payment after submission of a bill. A facility may send a notice to the patient and responsible party requesting payment within 30 days. If payment is not received in 30 days, the facility may institute transfer or discharge proceedings by sending a notice of transfer or discharge to the patient and responsible party by registered or certified mail. Payment in full shall terminate transfer or discharge proceedings. This subsection does not apply to residents whose care is provided under the Illinois Department of Public Aid.

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

ee) A facility employee, agent or volunteer who becomes aware of abuse or neglect of a patient shall immediately report the matter to the facility administrator or designee.

ff) Upon becoming aware of abuse or neglect, the facility administrator or designee shall immediately report the matter by telephone and in writing to the patient's representative and the Department.

Section 270.2100 Patient Care Services

a) The licensee shall provide physician supervision consistent with the needs of the patients, on a continual basis. (Section 35 of the Act)

1) There shall be frequent, consistent contact between physicians and the patient and between physicians and other facility personnel, to provide medical direction for the comprehensive care plan.

2) There shall be one or more direct physician to patient contacts per week.

3) Other contacts may be made through a combination of visits and status reports by other personnel caring for the patient.

b) The licensee shall provide registered nursing on a continual basis through the onsite availability of registered nurses for hands-on care 24 hours per day. (Section 35 of the Act)

c) The licensee shall provide physiological monitoring on a continual Basis, as necessary to meet the needs of each patient, such as continual electronic monitoring of breathing, cardiovascular functioning or biochemical functioning. (Section 35 of the Act)

d) The licensee shall provide 24-hour-per-day access to diagnostic support services consistent with the patient's comprehensive care plan.

e) The licensee shall provide adequate auxiliary and support services to meet each patient's comprehensive care plan.

f) A program manager shall be designated for each patient. A program manager may serve one or more patients. The provision of services to each patient shall be organized through the patient's manager who shall:

1) Assume responsibility for implementation of the comprehensive care plan;

2) Assist the patient in becoming oriented to his/her program;

3) Enable the patient's program to proceed in an orderly, purposeful, and goal-oriented manner;

4) Promote the program's responsiveness to the needs and preferences of the patient;

5) Promote the participation of the patient on an ongoing basis in discussions of plans, goals, status, etc;

6) Participate consistently in team conferences concerning the patient; and

7) Facilitate the discharge process and arrangements for follow-up and supportive services.

g) The licensee shall provide other services as necessary to implement and support the patient's comprehensive care plan and overall needs, including provisions for:

1) Case management;

2) Fostering maximum patient independence;

3) Protection of patient rights, privacy and dignity;

4) Assisting the patient and patient's representative in understanding and adjusting to the patient's current condition, prognosis and future needs; and

5) Discharge planning.

h) A Subacute Care Hospital Model licensee that is not licensed under the Hospital Licensing Act as a general acute care hospital shall have a transfer agreement with at least one general acute care hospital in order to handle cases of complications, emergencies or exigent circumstances. (Section 35 of the Act)

i) A licensee shall develop a written policy to the extent possible, to link and integrate its services with nearby health care facilities to meet the needs of the patients. (Section 30(e) of the Act)

j) If the facility is licensed under the Hospital Licensing Act, the Hospital Licensing Requirements shall apply to blood transfusions. If the facility is licensed under the Nursing Home Care Act or is a Designated Site, blood transfusions may be given to patients receiving subacute care only if the facility has a transfusion protocol that is approved by the medical director, director of nursing services and the administrator. The protocol must be followed and must address, at least, the following to assure the safety of the patient:

1) Acquisition, transportation and storage of the blood or blood products;

2) Supervision by a physician;

3) The supplies necessary for the transfusion and response to emergencies;

4) Administration of the blood or blood products;

5) Monitoring of the patient during and after the transfusion;

6) The qualifications of the staff responsible for implementing subsections (j)(1), (3), (4) and (5) above; and

7) Arrangements with a licensed hospital to have all blood transfusions and transfusion reactions reviewed in accordance with Section 250.520(i) and (j) of the Hospital Licensing Requirements.

(Source: Amended at 19 Ill. Reg. 6315, effective May 1, 1995)

Section 270.2200 Personnel

a) The licensee shall provide adequate, properly trained and supervised staff to meet each patient's comprehensive care plan. Services shall be provided by a coordinated interdisciplinary team.

b) The licensee shall define, through job descriptions, minimum education and experience requirements for all staff, consultants and contract staff providing services to the subacute care hospital model.

c) The licensee shall provide routine, pertinent training to all staff. This training may include return demonstration, one-on-one training, small group exercises or lecture. All training shall be documented with:

1) Date;

2) Starting and ending time;

3) Instructors;

4) Short description of content; and

5) Participants' written and printed signatures.

d) Prior to employing any individual in a position that requires a State license, the licensee 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.

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

(Source: Amended at 26 Ill. Reg. 11978, effective July 31, 2002)

Section 270.2250 Health Care Worker Background Check

a) The facility shall not knowingly hire any individual in a position with duties involving direct care for residents if that person has been convicted of committing or attempting to commit one or more of the following offenses (Section 25(a) of the Health Care Worker Background Check Act [225 ILCS 46/25]):

1) Solicitation of murder, solicitation of murder for hire (Sections 8-1.1 and 8-1.2 of the Criminal Code of 1961 [720 ILCS 5/8-1.1 and 8-1.2] (formerly Ill. Rev. Stat. 1991, ch. 38, pars. 8-1.1 and 8-1.2));

2) Murder, homicide, manslaughter or concealment of a homicidal death (Sections 9-1, 9-1.2, 9-2, 9-2.1, 9-3, 9-3.1, 9-3.2, and 9-3.3 of the Criminal Code of 1961 [720 ILCS 5/9-1, 9-1.2, 9-2, 9-2.1, 9-3, 9-3.1, 9-3.2 and 9-3.3] (formerly Ill. Rev. Stat. 1991, ch. 38, pars. 9-1, 9-1.2, 9-2, 9-2.1, 9-3, 9-3.1, 9-3.2, and 9-3.3; Ill. Rev. Stat. 1985, ch. 38, par. 9-1.1; Ill. Rev. Stat. 1961, ch. 38, pars. 3, 236, 358, 360, 361, 362, 363, 364, 364a, 365, 370, 373, 373a, 417, and 474));

3) Kidnaping or child abduction (Sections 10-1, 10-2, 10-5 and 10-7 of the Criminal Code of 1961 [720 ILCS 5/10-1, 10-2, 10-5, and 10-7] (formerly Ill. Rev. Stat. 1991, ch. 38, pars. 10-1, 10-2, 10-5, and 10-7; Ill. Rev. Stat. 1985, ch. 38, par. 10-6; Ill. Rev. Stat. 1961, ch. 38, pars. 384 to 386));

4) Unlawful restraint or forcible detention (Sections 10-3, 10-3.1, and 10-4 of the Criminal Code of 1961 [720 ILCS 5/10-3, 10-3.1, and 10-4] (formerly Ill. Rev. Stat. 1991, ch. 38, pars. 10-3, 10-3.1, and 10-4; Ill. Rev. Stat. 1961, ch. 38, pars. 252, 252.1, and 252.4));

5) Indecent solicitation of a child, sexual exploitation of a child, exploitation of a child, child pornography (Sections 11-6, 11-9.1, 11-19.2, and 11-20.1 of the Criminal Code of 1961 [720 ILCS 5/11-6, 11-9.1, 11-19.2, and 11-20.1] (formerly Ill. Rev. Stat. 1991, ch. 38, pars. 11-6, 11-19.2, and 11-20.1; Ill. Rev. Stat. 1983, ch. 38, par. 11-20a; Ill. Rev. Stat. 1961, ch. 38, pars. 103 and 104));

6) Assault, battery, heinous battery, tampering with food, drugs or cosmetics, or infliction of great bodily harm (Sections 12-1, 12-2, 12-3, 12-3.1, 12-3.2, 12-4, 12-4.1, 12-4.2, 12-4.3, 12-4.4, 12-4.5, 12-4.6, and 12-4.7 of the Criminal Code of 1961 [720 ILCS 5/12-1, 12-2, 12-3, 12-3.1, 12-3.2, 12-4, 12-4.1, 12-4.2, 12-4.3, 12-4.4, 12-4.5, 12-4.6, and 12-4.7] (formerly Ill. Rev. Stat. 1991, ch. 38, pars. 12-1, 12-2, 12-3, 12-3.1, 12-3.2, 12-4, 12-4.1, 12-4.2, 12-4.3, 12-4.4, 12-4.5, 12-4.6, and 12-4.7; Ill. Rev. Stat. 1985, ch. 38, par. 9-1.1; Ill. Rev. Stat. 1961, ch. 38, pars. 55, 56, and 56a to 60b));

7) Aggravated stalking (Section 12-7.4 of the Criminal Code of 1961 [720 ILCS 5/12-7.4] (formerly Ill. Rev. Stat. 1991, ch. 38, par. 12-7.4));

8) Home invasion (Section 12-11 of the Criminal Code of 1961 [720 ILCS 5/12-11] (formerly Ill. Rev. Stat. 1991, ch. 38, par. 12-11));

9) Sexual assault or sexual abuse (Sections 12-13, 12-14, 12-14.1, 12-15, and 12-16 of the Criminal Code of 1961 [720 ILCS 5/12-13, 12-14, 12-14.1, 12-15, and 12-16] (formerly Ill. Rev. Stat. 1991, ch. 38, pars. 11-1, 11-2, 11-3, 11-4, 11-5, 12-13, 12-14, 12-15, and 12-16; Ill. Rev. Stat. 1985, ch. 38, pars. 11-1, 11-4, and 11-4.1; Ill. Rev. Stat. 1961, ch. 38, pars. 109, 141, 142, 490, and 491));

10) Abuse or gross neglect of a long-term care facility resident (Section 12-19 of the Criminal Code of 1961 [720 ILCS 5/12-19] (formerly Ill. Rev. Stat. 1991, ch. 38, par. 12-19));

11) Criminal neglect of an elderly or disabled person (Section 12-21 of the Criminal Code of 1961 [720 ILCS 5/12-21] (formerly Ill. Rev. Stat. 1991, ch. 38, par. 12-21));

12) Endangering the life or health of a child (Section 12-21.6 of the Criminal Code of 1961 [720 ILCS 5/12-21.6] (formerly Ill. Rev. Stat. 1991, ch. 23, par. 2354; Ill. Rev. Stat. 1961, ch. 38, par. 95));

13) Ritual mutilation, ritualized abuse of a child (Sections 12-32 and 12-33 of the Criminal Code of 1961 [720 ILCS 5/12-32 and 12-33] (formerly Ill. Rev. Stat. 1991, ch. 38, pars. 12-32 and 12-33));

14) Theft, retail theft (Sections 16-1 and 16A-3 of the Criminal Code of 1961 [720 ILCS 5/16-1 and 16A-3] (formerly Ill. Rev. Stat. 1991, ch. 38, pars. 16-1 and 16A-3; Ill. Rev. Stat. 1961, ch. 38, pars. 62, 207 to 218, 240 to 244, 246, 253, 254.1, 258, 262, 262a, 273, 290, 291, 301a, 354, 387 to 388b, 389, 393 to 400, 404a to 404c, 438, 492 to 496));

15) Financial exploitation of an elderly or disabled person (Section 16-1.3 of the Criminal Code of 1961 [720 ILCS 5/16-1.3] (formerly Ill. Rev. Stat. 1991, ch. 38, par. 16-1.3));

16) Forgery (Section 17-3 of the Criminal Code of 1961 [720 ILCS 5/17-3] (formerly Ill. Rev. Stat. 1991, ch. 38, par. 17-3; Ill. Rev. Stat. 1961, ch. 38, pars. 151 and 277 to 286));

17) Robbery, armed robbery (Sections 18-1 and 18-2 of the Criminal Code of 1961 [720 ILCS 5/18-1 and 18-2] (formerly Ill. Rev. Stat. 1991, ch. 38, pars. 18-1 and 18-2));

18) Vehicular hijacking, aggravated vehicular hijacking, aggravated robbery (Sections 18-3, 18-4, and 18-5 of the Criminal Code of 1961 [720 ILCS 5/18-3, 18-4, and 18-5]);

19) Burglary, residential burglary (Sections 19-1 and 19-3 of the Criminal Code of 1961 [720 ILCS 5/19-1 and 19-3] (formerly Ill. Rev. Stat. 1991, ch. 38, pars. 19-1 and 19-3; Ill. Rev. Stat. 1961, ch. 38, pars. 84 to 86, 88, and 501));

20) Criminal trespass to a residence (Section 19-4 of the Criminal Code of 1961 [720 ILCS 5/19-4] (formerly Ill. Rev. Stat. 1991, ch. 38, par. 19-4));

21) Arson (Sections 20-1 and 20-1.1 of the Criminal Code of 1961 [720 ILCS 5/20-1 and 20-1.1] (formerly Ill. Rev. Stat. 1991, ch. 38, pars. 20-1 and 20-1.1; Ill. Rev. Stat. 1961, ch. 38, pars. 48 to 53 and 236 to 238));

22) Unlawful use of weapons, aggravated discharge of a firearm, or reckless discharge of a firearm (Sections 24-1, 24-1.2, and 24-1.5 of the Criminal Code of 1961 [720 ILCS 5/24-1, 24-1.2, and 24-1.5] (formerly Ill. Rev. Stat. 1991, ch. 38, pars. 24-1 and 24-1.2; Ill. Rev. Stat. 1961, ch. 38, pars. 152, 152a, 155, 155a to 158b, 414a to 414c, 414e, and 414g));

23) Armed violence – elements of the offense (Section 33A-2 of the Criminal Code of 1961 [720 ILCS 5/33A-2] (formerly Ill. Rev. Stat. 1991, ch. 38, par. 33A-2));

24) Those provided in Section 4 of the Wrongs to Children Act (Section 4 of the Wrongs to Children Act [720 ILCS 150/4] (formerly Ill. Rev. Stat. 1991, ch. 23, par. 2354));

25) Cruelty to children (Section 53 of the Criminal Jurisprudence Act [720 ILCS 115/53] (formerly Ill. Rev. Stat. 1991, ch. 23, par. 2368));

26) Manufacture, delivery or trafficking of cannabis, delivery of cannabis on school grounds, or delivery to person under 18; violation by person under 18 (Sections 5, 5.1, 5.2, 7, and 9 of the Cannabis Control Act [720 ILCS 550/5, 5.1, 5.2, 7, and 9] (formerly Ill. Rev. Stat. 1991, ch. 56½, pars. 705, 705.1, 705.2, 707, and 709)); or

27) Manufacture, delivery or trafficking of controlled substances (Sections 401, 401.1, 404, 405, 405.1, 407 and 407.1 of the Illinois Controlled Substance Act [720 ILCS 570/401, 401.1, 404, 405, 405.1, 407, 407.1] (formerly Ill. Rev. Stat. 1991, ch. 56½, pars. 1401, 1401.1, 1404, 1405, 1405.1, 1407, and 1407.1)).

b) The facility shall not knowingly employ or retain any individual in a position with duties involving direct care for residents if that person has been convicted of committing or attempting to commit one or more of the offenses listed in subsections (a)(1) to (27) of this Section unless the applicant, employee or employer obtains a waiver pursuant to subsections (m) and (o) of this Section. (Section 25(a) of the Health Care Worker Background Check Act)

c) A facility shall not hire, employ, or retain any individual in a position with duties involving direct care of residents if the facility becomes aware that the individual has been convicted in another state of committing or attempting to commit an offense that has the same or similar elements as an offense listed in subsections (a)(1) to (27) of this Section, as verified by court records, records from a State agency, or an FBI criminal history record check. This shall not be construed to mean that a facility has an obligation to conduct a criminal history records check in other states in which an employee has resided. (Section 25(b) of the Act)

d) For the purpose of this Section:

1) "Applicant" means an individual seeking employment with a facility who has received a bona fide conditional offer of employment.

2) "Conditional offer of employment" means a bona fide offer of employment by a facility to an applicant, which is contingent upon the receipt of a report from the Department of State Police indicating that the applicant does not have a record of conviction of any of the criminal offenses listed in subsections (a)(1) to (27) of this Section.

3) "Direct care" means the provision of nursing care or assistance with feeding, dressing, movement, bathing, or other personal needs.

4) "Initiate" means the obtaining of the authorization for a record check from a student, applicant, or employee. (Section 15 of the Health Care Worker Background Check Act)

e) For purposes of the Health Care Worker Background Check Act, the facility shall establish a policy defining which employees provide direct care. In making this determination the facility shall consider the following:

1) The employee's assigned job responsibilities as set forth in the employee's job description;

2) Whether the employee is required to or has the opportunity to be alone with residents, with the exception of infrequent or unusual occasions; and

3) Whether the employee's regular responsibilities include physical contact with residents, for example to provide therapy or to draw blood.

f) When the facility makes a conditional offer of employment to an applicant who is not exempt under subsection (s) of this Section, for a position with duties that involve direct care for residents, the employer shall inquire of the Nurse Aide Registry as to the status of the applicant's Uniform Conviction Information Act (UCIA) criminal history record check. If a UCIA criminal history record check has not been conducted within the last 12 months, the facility must initiate or have initiated on its behalf a UCIA criminal history record check for that applicant. (Section 30(c) of the Health Care Worker Background Check Act)

g) The facility shall transmit all necessary information and fees to the Illinois State Police within 10 working days after receipt of the authorization. (Section 15 of the Health Care Worker Background Check Act)

h) The facility may accept an authentic UCIA criminal history record check that has been conducted within the last 12 months rather than initiating a check as required in subsection (f) of this Section.

i) The request for a UCIA criminal history record check shall be made as prescribed by the Department of State Police. The applicant or employee must be notified of the following whenever a non-fingerprint-based UCIA criminal history record check is made:

1) That the facility shall request or have requested on its behalf a non-fingerprint-based UCIA criminal history record check pursuant to the Health Care Worker Background Check Act.

2) That the applicant or employee has a right to obtain a copy of the criminal records report from the facility, challenge the accuracy and completeness of the report, and request a waiver in accordance with subsection (m) of this Section.

3) That the applicant, if hired conditionally, may be terminated if the non-fingerprint-based criminal records report indicates that the applicant has a record of conviction of any of the criminal offenses enumerated in subsections (a)(1) to (27) of this Section unless the applicant's identity is validated and it is determined that the applicant or employee does not have a disqualifying criminal history record based on a fingerprint-based records check pursuant to subsection (k) of this Section.

4) That the applicant, if not hired conditionally, shall not be hired if the non-fingerprint-based criminal records report indicates that the applicant has a record of conviction of any of the criminal offenses enumerated in subsections (a)(1) to (27) of this Section unless the applicant's record is cleared based on a fingerprint-based records check pursuant to subsection (k) of this Section.

5) That the employee may be terminated if the criminal records report indicates that the employee has a record of conviction of any of the criminal offenses enumerated in subsections (a)(1) to (27) of this Section unless the employee's record is cleared based on a fingerprint-based records check pursuant to subsection (k) of this Section. (Section 30(e) and (f) of the Health Care Worker Background Check Act)

j) A facility may conditionally employ an applicant to provide direct care for up to three months pending the results of a UCIA criminal history record check. (Section 30(g) of the Health Care Worker Background Check Act)

k) An applicant or employee whose non-fingerprint-based UCIA criminal history record check indicates a conviction for committing or attempting to commit one or more of the offenses listed in subsections (a)(1) to (27) of this Section may request that the facility or its designee commence a fingerprint-based UCIA criminal records check by submitting any necessary fees and information in a form and manner prescribed by the Department of State Police. (Section 35 of the Health Care Worker Background Check Act)

l) A facility having actual knowledge from a source other than a non-fingerprint check that an employee has been convicted of committing or attempting to commit one of the offenses enumerated in Section 25 of the Act must initiate a fingerprint-based background check within 10 working days after acquiring that knowledge. The facility may continue to employ that individual in a direct care position, may reassign that individual to a non-direct care position, or may suspend the individual until the results of the fingerprint-based background check are received. (Section 30(d) of the Health Care Worker Background Check Act)

m) An applicant, employee or employer may request a waiver to subsection (a), (b) or (c) of this Section by submitting the following to the Department within five working days after the receipt of the criminal records report:

1) A completed fingerprint-based UCIA criminal records check form (Section 40(a) of the Health Care Worker Background Check Act) (which the Department will forward to the Department of State Police); and

2) A certified check, money order or facility check made payable to the Department of State Police for the amount of money necessary to initiate a fingerprint-based UCIA criminal records check.

n) The Department may accept the results of the fingerprint-based UCIA criminal records check instead of the items required by subsections (m)(1) and (2) above. (Section 40(a-5) of the Health Care Worker Background Check Act)

o) The Department may grant a waiver based on mitigating circumstances, which may include:

1) The age of the individual at which the crime was committed;

2) The circumstances surrounding the crime;

3) The length of time since the conviction;

4) The applicant's or employee's criminal history since the conviction;

5) The applicant's or employee's work history;

6) The applicant's or employee's current employment references;

7) The applicant's or employee's character references;

8) Nurse Aide Registry records; and

9) Other evidence demonstrating the ability of the applicant or employee to perform the employment responsibilities competently and evidence that the applicant or employee does not pose a threat to the health or safety of residents. (Section 40(b) of the Health Care Worker Background Check Act)

p) An individual shall not be employed in a direct care position from the time that the employer receives the results of a non-fingerprint check containing disqualifying conditions until the time that the individual receives a waiver from the Department. If the individual challenges the results of the non-fingerprint check, the employer may continue to employ the individual in a direct care position if the individual presents convincing evidence to the employer that the non-fingerprint check is invalid. If the individual challenges the results of the non-fingerprint check, his or her identity shall be validated by a fingerprint-based records check in accordance with subsection (k) of this Section. (Section 40(d) of the Health Care Worker Background Check Act)

q) A facility is not obligated to employ or offer permanent employment to an applicant, or to retain an employee who is granted a waiver. (Section 40(f) of the Health Care Worker Background Check Act)

r) A facility may retain the individual in a direct care position if the individual presents clear and convincing evidence to the facility that the non-fingerprint-based criminal records report is invalid and if there is a good faith belief on the part of the employer that the individual did not commit an offense listed in subsections (a)(1) to (27) of this Section, pending positive verification through a fingerprint-based criminal records check. Such evidence may include, but not be limited to:

1) certified court records;

2) written verification from the State's Attorney's office that prosecuted the conviction at issue;

3) written verification of employment during the time period during which the crime was committed or during the incarceration period stated in the report;

4) a signed affidavit from the individual concerning the validity of the report; or

5) documentation from a local law enforcement agency that the individual was not convicted of a disqualifying crime.

s) This Section shall not apply to:

1) An individual who is licensed by the Department of Professional Regulation or the Department of Public Health under another law of this State;

2) An individual employed or retained by a health care employer for whom a criminal background check is required by another law of this State; or

3) A student in a licensed health care field including, but not limited to, a student nurse, a physical therapy student, or a respiratory care student unless he or she is employed by a health care employer in a position with duties involving direct care for residents. (Section 20 of the Health Care Worker Background Check Act)

t) The facility must send a copy of the results of the UCIA criminal history record check to the State Nurse Aide Registry for those individuals who are on the Registry. (Section 30(b) of the Health Care Worker Background Check Act) The facility shall include the individual's Social Security number on the criminal history record check results.

u) The facility shall retain on file for a period of 5 years records of criminal records requests for all employees. The facility shall retain the results of the UCIA criminal history records check and waiver, if appropriate, for the duration of the individual's employment. The files shall be subject to inspection by the Department. A fine of $500 shall be imposed for failure to maintain these records. (Section 50 of the Health Care Worker Background Check Act)

v) The facility shall maintain a copy of the employee's criminal history record check results and waiver, if applicable, in the personnel file or other secure location accessible to the Department.

(Source: Added at 24 Ill. Reg. 14055, effective August 31, 2000)

Section 270.2300 Quality Assessment and Improvement

a) The licensee shall develop and implement a quality assessment and improvement program designed to meet at least the following goals:

1) Ongoing monitoring and evaluation of the quality and accessibility of care and services provided at the facility or under contract, including but not limited to:

A) Admission of patients appropriate to the capabilities of the facility;

B) Patient assessment;

C) Development and implementation of appropriate comprehensive care plans;

D) Patient satisfaction;

E) Costs for delivery of services; and

F) Infection control.

2) Identification and analysis of problems.

3) Identification and implementation of corrective action or changes in response to problems.

b) The program shall operate pursuant to a written plan, which shall include, but not be limited to:

1) A detailed statement of its goals;

2) The methodology and criteria that will be used to meet each stated goal;

3) The action plans for addressing problems;

4) Procedures for evaluating the effectiveness of action plans and revising action plans to prevent reoccurrence of problems;

5) Procedures for documenting the activities of the program; and

6) Identifying the persons responsible for administering the program.

c) The licensee shall afford the Department and the Board access to any materials or documents generated pursuant to the facility's quality assessment and improvement program or that otherwise relate to patient demand, utilization and satisfaction; healthcare costs; healthcare cost effectiveness; financial viability of the facility; and access to healthcare services. Such information shall be used by the Department and the Board to evaluate and assess the facility in relation to the Demonstration Program, and shall be afforded the same confidential status as is provided information concerning medical studies in Article VIII, Part 21 of the Code of Civil Procedure (Ill. Rev. Stat. 1991, ch. 110, pars 1-101 et seq.) [735 ILCS 5/1-101 - 1-109].