TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.100 DEFINITIONS
Section 380.100 Definitions
Act – the Specialized Mental
Health Rehabilitation Act of 2013.
Activities of daily living or ADL
– a consumer's abilities to bathe, dress and groom; transfer and ambulate; use
the toilet; eat; and use speech, language or other functional communication
systems.
Abuse – any physical or mental
injury or sexual assault inflicted on a consumer other than by accidental means
in a facility. (Section 1-102 of the Act)
Physical abuse means the
infliction of injury or threat of injury by a consumer upon himself or herself,
or by another consumer, a staff or a visitor on a consumer, that occurs other
than by accidental means.
Verbal abuse means the use of
demeaning, intimidating or threatening words, written or oral, or gestures, by
another consumer, a staff or a visitor about, or toward, a consumer and in the
presence of another person.
Accreditation – recognition
by any of the following that a program meets their nationally-recognized
standards of behavioral health care:
the Joint
Commission;
the Commission on Accreditation
of Rehabilitation Facilities;
the Healthcare Facilities
Accreditation Program; or
any other national standards of
care as approved by the Department. (Section 1-102 of the Act)
Active treatment – treatment that
addresses an acute crisis in a consumer and that facilitates a return to a
community setting. Active treatment includes, but is not limited to, therapy, family
meetings, group sessions and assessment.
Agent – a representative of a
facility who is an owner, licensee, executive director or employee.
Ambulatory – the ability to move
from place to place independent of staff assistance. A consumer may use assistive
devices, such as a cane, walker or wheelchair, and still be considered
ambulatory, provided that the consumer is able to move and transfer
independently on a regular basis. A consumer who needs temporary time-limited
assistance, such as after surgery or a medical illness, is also still
considered ambulatory.
Applicant – any person making
application for a license or a provisional license under the Act and
this Part. (Section 1-102 of the Act)
Assessment – a comprehensive
clinical evaluation to determine the strengths, preferences, clinical status,
including the level of functioning, and the clinical needs of a consumer. The
assessment may also fulfill the requirements of federal law or State consent
decrees for assessment or mental health preadmission screening and resident
review prior to admission, or resident reviews during treatment. The assessment
shall be conducted by a Licensed Practitioner of the Healing Arts and shall:
Determine the individualized
intervention strategies that will assist the consumer in advancing in his or
her recovery;
Determine what supports are needed
for the individual to live in community-based settings; and
Determine the appropriate level of
care for service delivery.
Authorization – a determination of
the level of treatment services that best suits the clinical needs of the
consumer.
Authorized representative – a
person other than an owner, agent or employee of a facility designated in
writing by a consumer to be his or her representative. A consumer may designate
his or her guardian as an authorized representative.
Biopsychosocial approach – a model
for the treatment of persons with mental illness that acknowledges the
biological, psychological and social influences on a person's psyche, relying
on multiple disciplines for the treatment and rehabilitation of persons with
mental illness.
Certified Recovery Support
Specialist or CRSS – an individual who is certified and in good standing as a
Recovery Support Specialist by the Illinois Alcohol and Other Drug Abuse
Professional Certification Association. A CRSS, at a minimum, shall function as
a mental health professional.
Community-based behavioral health
services – services provided to a consumer, e.g., by a community-based
behavioral health provider, while living in his or her own home or in a group
living situation of 16 or fewer beds. The services are designed to assist
consumers in achieving rehabilitative, resiliency and recovery goals in the
least restrictive natural settings possible. The services consist of
interventions that facilitate illness self-management, identification and use
of adaptive and compensatory strategies, skills-building, and the
identification and use of natural supports and community resources.
Consumer – a person, 18 years
of age or older, admitted to a specialized mental health rehabilitation
facility for evaluation, observation, diagnosis, treatment, stabilization,
recovery, and rehabilitation. "Consumer" does not mean any of the
following:
an
individual requiring a locked setting;
an
individual requiring psychiatric hospitalization because of an acute
psychiatric crisis;
an
individual under 18 years of age;
an
individual who is actively suicidal or violent toward others;
an
individual who has been found unfit to stand trial;
an
individual who has been found not guilty by reason of insanity based on
committing a violent act, such as sexual assault, assault with a deadly weapon,
arson, or murder;
an
individual subject to temporary detention and examination under Section 3-607
of the Mental Health and Developmental Disabilities Code;
an
individual deemed clinically appropriate for inpatient admission in a State psychiatric hospital; and
an
individual transferred by the Department of Corrections pursuant to Section
3-8-5 of the Unified Code of Corrections. (Section
1-102 of the Act)
Consumer record – a record that
organizes all information on the care, treatment, and rehabilitation services
rendered to a consumer in a specialized mental health rehabilitation facility.
(Section 1-102 of the Act)
Controlled drugs – those drugs
covered under the federal Comprehensive Drug Abuse Prevention Control Act of
1970, as amended, or the Illinois Controlled Substances Act. (Section
1-102 of the Act)
Crisis stabilization – a secure
and separate unit that provides short-term behavioral, emotional, or
psychiatric crisis stabilization as an alternative to hospitalization or
re-hospitalization for consumers from residential or community placement. (Section 1-102 of the Act)
Debrief – a meeting with a
consumer and facility staff following a period of restraint, holding or
therapeutic separation in which the impact of the intervention is assessed from
a perspective of emotional impact, outcome and possible alternatives to the use
of restraint.
Department – the Department of
Public Health. (Section 1-102 of the Act)
DHS − the Illinois
Department of Human Services
DHS-DMH − the Illinois
Department of Human Services-Division of Mental Health
Dietetic Service Supervisor
− a person who:
is a dietitian; or
is a graduate of a dietetic
technician or dietetic assistant training program, corresponding or classroom,
approved by the American Dietetic Association; or
is a graduate, prior to July 1,
1990, of a Department-approved course that provided 90 or more hours of
classroom instruction in food service supervision and has had experience as a
supervisor in a health care institution that included consultation from a
dietitian; or
has successfully completed a
Dietary Manager's Association approved dietary manager course; or
is certified as a dietary manager
by the Dietary Manager's Association; or
has training and experience in
food service supervision and management in a military service equivalent in
content to the programs in the second, third or fourth paragraph of this
definition.
Dietitian – a person licensed as a
dietitian under the Dietitian Nutritionist Practice Act.
Director – the Director of the
Department of Public Health or his or her designee.
Discharge – the full release of
any consumer from a facility. (Section 1-102 of the Act)
Drug administration – the act
in which a single dose of a prescribed drug or biological is given to a
consumer. The complete act of administration entails removing an individual
dose from a container, verifying the dose with the prescriber's orders, giving
the individual dose to the consumer, and promptly recording the time and dose
given. (Section 1-102 of the Act)
Drug dispensing – the act
entailing the following of a prescription order for a drug or biological and
proper selection, measuring, packaging, labeling, and issuance of the drug or
biological to a consumer. (Section 1-102 of the Act)
DSP – the Department of State
Police.
Dual diagnosis – the condition of
experiencing a mental illness and a comorbid substance abuse problem.
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 consumers of a facility. (Section 1-102 of
the Act)
Evidence-based practice – the
conscientious use of current evidence in making decisions about the care of the
individual consumer, integrating individual clinical expertise with available
external clinical evidence from systematic research.
Executive director – a person
who is charged with the general administration and supervision of a facility
licensed under the Act and this Part. (Section 1-102 of the Act)
Face check – visual confirmation
by a staff person to ensure the consumer's safety and well-being, to be
performed at intervals as determined by the individualized treatment plan of
the consumer.
Facility – a specialized mental health rehabilitation facility
(SMHRF) that provides at least one of the following services: triage
center; crisis stabilization; recovery and rehabilitation supports; or transitional
living units for 3 or more persons. The facility shall provide a 24-hour
program that provides intensive support and recovery services designed to
assist persons, 18 years or older, with mental disorders to develop the skills
to become self-sufficient and capable of increasing levels of independent
functioning. It includes facilities that meet the following criteria:
100%
of the consumer population of the facility has a diagnosis of serious mental illness;
no
more than 15% of the consumer population of the facility is 65 years of age or
older;
none
of the consumers are non-ambulatory;
none
of the consumers have a primary diagnosis of moderate, severe, or profound
intellectual disability; and
the
facility must have been licensed under the Specialized Mental Health
Rehabilitation Act or the Nursing Home Care Act immediately preceding the
effective date of the Act and
qualifies as an institute for mental disease under the federal definition of
the term.
"Facility" does not include the following:
a
home, institution, or place operated by the federal government or agency of the federal government, or by the State of Illinois;
a hospital, sanitarium, or
other institution whose principal activity or business is the diagnosis, care,
and treatment of human illness through the
maintenance and operation as organized
facilities for the treatment of mental illness that is required to be
licensed under the Hospital Licensing Act;
a facility for child care as
defined in the Child Care Act of 1969;
a community living facility as
defined in the Community Living Facilities Licensing Act;
a nursing home or sanatorium
operated solely by and for persons who rely exclusively upon treatment by
spiritual means through prayer, in accordance with the creed or tenets of any
well-recognized church or religious denomination; however, the nursing
home or sanatorium shall comply with all local laws and rules relating to
sanitation and safety;
a facility licensed by the
Department of Human Services as a community-integrated living arrangement as
defined in the Community-Integrated Living Arrangements Licensure and
Certification Act;
a supportive residence licensed
under the Supportive Residences Licensing Act;
a supportive living facility in
good standing with the program established under Section 5-5.01a of the
Illinois Public Aid Code, except only for purposes of the employment of persons
in accordance with Section 3-206.01 of the Nursing Home Care Act;
an assisted living or shared
housing establishment licensed under the Assisted Living and Shared Housing
Act, except only for purposes of the employment of persons in accordance with
Section 3-206.01 of the Nursing Home Care Act;
an Alzheimer's disease
management center alternative health care model licensed under the Alternative
Health Care Delivery Act;
a home, institution, or other
place operated by or under the authority of the Illinois Department of Veterans'
Affairs;
a facility licensed under the
ID/DD Community Care Act; or
a facility licensed under the
Nursing Home Care Act after July 22, 2013 (Section 1-102 of the Act)
Findings of root cause analysis –
the conclusions of a facility's root cause analysis that summarize how the
incident, accident or violation happened and reasons for the incident, accident
or violation. Reportable findings do not include investigatory notes, data,
staff interviews and other unrelated documentation that led to the conclusions
of the root cause analysis.
Governing body – the persons
responsible for the overall leadership, oversight and administration of a
specialized mental health rehabilitation facility
Guardian – a person appointed
as a guardian of the person or guardian of the estate, or both, of a consumer
under the Probate Act of 1975. (Section 1-102 of the Act)
Identified Offender – a person
who:
Has been convicted of, found
guilty of, adjudicated delinquent for, found not guilty by reason of insanity
for, or found unfit to stand trial for, any felony offense listed in Section 25
of the Health Care Worker Background Check Act, except for the following: a felony
offense described in Section 10-5 of the Nurse Practice Act; a felony offense
described in Section 5, 5.1, 5.2, 7, or 9 of the Cannabis Control Act; a felony
offense described in Section 401, 401.1, 404, 405, 405.1, 407, or 407.1 of the
Illinois Controlled Substances Act; and a felony offense described in the
Methamphetamine Control and Community Protection Act; or
Has been convicted of,
adjudicated delinquent for, found not guilty by reason of insanity for, or
found unfit to stand trial for, any sex offense as defined in Section 10(c) of
the Sex Offender Management Board Act. (Section 1-102 of the Act)
Illness Management and Recovery or
IMR – an evidence-based practice aimed at assisting individuals with mental
illnesses in learning to manage the symptoms of the illness to reduce
interference with pursuit of personal goals.
Individualized Treatment Plan or
Treatment Plan or ITP – a written compilation of the consumer's goals; the
anticipated outcomes of services; the intermediate objectives to achieve the
goals; the specific SMHRF services to be provided to the consumer; the amount,
frequency and duration of the services; and the staff responsible for providing
the services.
Institute for Mental Disease or
IMD – facilities that are federally designated as institutes for mental
diseases and that will be licensed as specialized mental health rehabilitation
facilities under the Act and this Part, subject to the provisions in Section
1-101.5 of the Act.
Instrumental activities of daily
living or IADL – activities to support daily life within the home and community
that require more complex interactions than the self-care in ADLs, including,
but not limited to, communication, community mobility, health management, home
management, meal preparation and clean up, safety and emergency management,
shopping and money management.
Interdisciplinary Team or IDT
− a group of persons, representing those professions, disciplines or
service areas that are relevant to identifying a consumer's strengths,
preferences and needs, that designs a program to meet those needs.
Lead Defendant Agency – State of
Illinois Agency named in each fiscal year's Implementation Plan as the lead
agency for the Williams and Colbert Consent Decrees on behalf of the
Defendants. For the purposes of this definition, "Implementation
Plan" refers to the plan set forth in the Consent Decree, created and
implemented by the Defendants, with the input of the Monitor and Plaintiffs, to
accomplish the obligations and objectives set forth in the Decree.
Licensed Practitioner of the
Healing Arts or LPHA – shall have the meaning ascribed to it in the DHS-DMH
rule Medicaid Community Mental Health Services Program.
Licensed Practical Nurse − a
person with a valid Illinois license to practice as a practical nurse under the
Nurse Practice Act.
Licensee
– the person, persons, firm, partnership, association, organization, company,
corporation, or business trust to which a license has been issued. (Section
1-102 of the Act)
Linkage – A partnership between a
facility and a community-based behavioral health provider that includes the
community-based behavioral health provider from the time of a consumer's
admission into a facility (in crisis stabilization, transitional living units,
and recovery and rehabilitation supports), or as soon as possible following
admission, in developing and implementing the consumer's individualized
treatment plan for effective care coordination and transitioning the consumer
to independent living in the community, or to the least restrictive setting of
the consumer's choice. Linkage includes a face-to-face meeting between the
consumer and the community-based behavioral health provider with which he or
she is linked prior to discharge, except for consumers in the 23-hour triage
center.
Mental Health Preadmission
Screening and Resident Review or MH PASRR – a comprehensive review conducted
under the auspices of DHS-DMH prior to the admission of a consumer with serious
mental illness, at the end of 90 days following admission, at the end of six
months, and then annually.
Mental Health Professional or MHP
– shall have the meaning ascribed to it in the DHS-DMH rule the Medicaid
Community Mental Health Services Program.
Misappropriation
of a consumer's property – the deliberate misplacement, exploitation, or
wrongful temporary or permanent use of a consumer's belongings or money without
the consent of a consumer or his or her guardian. (Section 1-102 of
the Act)
Neglect
– a facility's failure to provide, or willful withholding of, adequate medical
care, mental health treatment, psychiatric rehabilitation, personal care, or
assistance that is necessary to avoid physical harm and mental anguish of a
consumer. (Section 1-102 of the Act)
On
site – in a facility and in a particular level of service within a facility.
Performance
Improvement Project or PIP – an effort by a facility to address a specific
violation or problem, either in one service area of a facility, or
facility-wide. PIPs require a systematic gathering of information to clarify
issues and problems to improve the delivery of care to consumers.
Person-centered
care – an approach to mental health treatment that involves collaboration
between the consumer, treatment providers, and other supporters of the
individual, including the consumer's guardian and substitute decision maker,
and is focused on the goals the consumer has identified for recovery in his or
her treatment plan. Person centered care focuses on building upon the
strengths and resources of the consumer to achieve recovery goals. Roles are
defined for the consumer, the treatment providers, and other supporters to
assist in reaching these goals.
Personal
care or Activities of daily living or
ADL – assistance with meals, dressing, movement, bathing, or other personal
needs, maintenance, or general supervision and oversight of the physical and
mental well-being of an individual who is incapable of maintaining a private,
independent residence or who is incapable of managing his or her person,
whether or not a guardian has been appointed for the individual.
"Personal care" shall not be construed to confine or otherwise constrain
a facility's pursuit to develop the skills and abilities of a consumer to
become self-sufficient and capable of increasing levels of independent
functioning. (Section 1-102 of the Act)
Psychiatric Medical Director – a
physician who is licensed under the Medical Practice Act of 1987 and who is
board eligible or board certified in psychiatry by the American Board of
Psychiatry and Neurology.
Psychotropic medication –
medications used for antipsychotic, antidepressant, anti-manic, anti-anxiety,
or behavior modification, for behavioral management purposes as listed in the
American Medical Association Drug Evaluation and the Physicians' Desk
Reference.
Qualified Mental Health
Professional or QMHP – shall have the meaning ascribed to it in the DHS-DMH
rule Medicaid Community Mental Health Services Program.
Recovery
and rehabilitation supports or RRS –
a unit with a program that facilitates a consumer's longer-term symptom management
and stabilization while preparing the consumer for transitional
living units or transition to the community by improving living skills
and community socialization. (Section
1-102 of the Act)
Recovery – the process in which
persons are able to live, work, learn and participate fully in their communities.
For some persons, recovery is the ability to live a fulfilling and productive
life despite a disability. For others, recovery implies the reduction or
complete remission of symptoms.
Registered Nurse − a person
with a license to practice as a registered professional nurse under the Nurse
Practice Act.
Rehabilitation Services Associate
(RSA) – shall have the meaning ascribed to it in the DHS-DMH rule Medicaid
Community Mental Health Services Program.
Restorative care – care that is
designed to facilitate the consumer's recovery and re-entry into the community.
Restraint −
a physical restraint that is
any manual method or physical or mechanical device, material, or equipment
attached or adjacent to a consumer's body that the consumer cannot remove
easily and restricts freedom of movement or normal access to one's body;
devices used for positioning, including, but not limited to, bed rails, gait
belts, and cushions, shall not be considered to be restraints for purposes of
this Part. For the purposes of the Act and this Part,
restraint shall be administered only after utilizing a coercive-free
environment and culture; or
a chemical restraint that is
any drug used for discipline or convenience and not required to treat medical
symptoms. (Section 1-102 of the Act)
Root cause – a fundamental reason
or reasons for an incident, accident or violation, without which the incident,
accident or violation would not have occurred.
Root cause analysis – the process
for determining how an incident, accident or violation occurred.
Self-administration of
medication – means that consumers shall be responsible for the control,
management, and use of their own medication. (Section 1-102 of the
Act)
Serious mental illness – as used
in this Part, any of the following diagnoses:
DSM-5 diagnosis of a psychotic
disorder, excluding those caused by a general medical condition or substance
use when of moderate or severe intensity and associated with moderate or severe
functional impairment of a greater than 90-day duration.
DSM-5 diagnosis of bipolar or
related disorder, excluding those caused by a general medical condition or
substance use, when of moderate or severe intensity and associated with
moderate to severe functional impairment of a greater than 90-day duration.
DSM-5 diagnosis of a depressive
disorder, excluding those caused by a general medical condition or substance
use, when of moderate or severe intensity and associated with severe functional
impairment of a greater than 90-day duration.
DSM-5 diagnosis of borderline
personality disorder associated with moderate to severe functional impairment
of a greater than 90-day duration.
DSM-5 diagnosis of post-traumatic
stress disorder associated with moderate to severe functional impairment of a
greater than 90-day duration.
DSM-5 diagnosis of obsessive
compulsive disorder associated with moderate to severe functional impairment of
a greater than 90-day duration.
State Authorized Personnel –
individuals who have a legal duty to provide specified services to residents of
long-term care facilities, including, but not limited to, representatives of
the Office of the State Long-Term Care Ombudsman Program, the Office of State
Guardian, and the Legal Advocacy Service; and community-service providers or third
parties serving as agents of the State for purposes of providing telemedicine,
transitional services to community-based living, and any other supports related
to existing consent decrees and court-mandated actions.
Substitute decision maker – a
person who possesses the authority to make mental health decisions on behalf of
the consumer under the Powers of Attorney for Health Care Law, under the Mental
Health Treatment Preference Declaration Act, or the Probate Act of 1975.
Transitional living units –
residential units within a facility that have the purpose of assisting the
consumer in developing and reinforcing the
necessary skills to live independently
outside of the facility. The duration of stay in this setting shall not exceed 120 days for each
consumer. Nothing in this definition shall be construed to be a prerequisite
for transitioning out of a facility. (Section 1-102 of the Act)
Therapeutic separation – the
removal of a consumer from the milieu to a room or area that is designed
to aid in the emotional or psychiatric stabilization of that consumer. (Section
1-102 of the Act)
Triage center – a
non-residential, 23-hour center that serves as an alternative to emergency room
care, hospitalization, or re-hospitalization for consumers in need of
short-term crisis stabilization. (Section 1-102 of the Act)
Unit – a crisis stabilization,
recovery and rehabilitation supports, or transitional living level of service
within a facility.
Wellness Recovery Action Plan
(WRAP) – an evidence-based system developed by the Copeland Center for use by
people dealing with mental health and other challenges who want to attain the
highest possible level of wellness.
Williams Consent Decree – Williams
et al. v. Pritzker et al., Case No. 05 C 4673, N.D. Illinois, Eastern Division.
Williams Consent Decree Class
Members or Williams Class Members – all Illinois residents who are eighteen
(18) years old or older and who have a Mental Illness; are institutionalized in
a privately owned Institution for Mental Diseases; and, with appropriate
supports and services, may be able to live in an integrated community setting.
Williams Consent Decree Defendant
Agencies – the Illinois Department of Human Services, the Division of Mental
Health of the Illinois Department of Human Services, the Illinois Department of
Public Health, and the Illinois Department of Healthcare and Family Services,
including any successor to these departments.
(Source: Amended at 46 Ill. Reg. 16870,
effective September 26, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.110 INCORPORATED AND REFERENCED MATERIALS
Section 380.110 Incorporated and Referenced Materials
a) The following
regulations and standards are incorporated in this Part:
1) National
Fire Protection Association (NFPA) Standard No. 101: Life Safety Code, Chapter
33, Existing Board and Care Occupancies (2012) or Chapter 32, New Board and
Care Occupancies (2012), and the following additional standards, which may be
obtained from the National Fire Protection Association, 1 Batterymarch Park,
Quincy MA 02169.
A) No. 10 (2010): Standard
for Portable Fire Extinguishers
B) No. 13 (2010): Standard
for the Installation of Sprinkler Systems
C) No. 25
(2011): Standard for the Inspection, Testing and Maintenance of Water-Based
Fire Protection Systems
D) No. 54 (2012): National
Fuel Gas Code
E) No. 70 (2011): National
Electrical Code
F) No. 72 (2010): National
Fire Alarm and Signaling Code
G) No. 80
(2010): Standard for Fire Doors and Other Opening Protectives
H) No.
90A (2012): Standard for Installation of Air Conditioning and Ventilating
Systems
I) No.
96 (2011): Standard for Ventilation Control and Fire Protection of Commercial
Cooking Operations
J) No. 99 (2012): Health Care
Facilities Code
K) No.
101A (2013), Guide on Alternative Approaches to Life Safety, Chapter 6 and
Chapter 7
L) No.
110 (2010): Standard for Emergency and Standby Power Systems
M) No. 220 (2012): Standard
on Types of Building Construction
N) No. 241
(2009): Standard for Safeguarding Construction, Alteration and Demolition Operations
2) American
Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE),
Handbook of Fundamentals (2009), and Handbook of Applications (2007), which may
be obtained from the American Society of Heating, Refrigerating, and Air
Conditioning Engineers, Inc., 1791 Tullie Circle, N.E., Atlanta GA 30329.
3) American
Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5) (2022) (American Psychiatric Association), available at:
http:appi.org/Products/dsm or from the American Psychiatric Association, 800
Maine Avenue, SW, Suite 900, Washington, DC 20024.
4) American
College of Obstetricians and Gynecologists, Guidelines for Women's Healthcare, Fourth
Edition (2014), which may be obtained from the American College of
Obstetricians and Gynecologists Distribution Center, P.O. Box 933104, Atlanta
GA 31193-3104 (800-762-2264).
5) Drug
Burden Index to Define the Functional Burden of Medications in Older People
(April, 2007), which may be obtained from the American Medical Association, AMA
Plaza, 330 N. Wabash Ave., Suite 38300, Chicago IL 60611-5885, or accessed at:
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/412262
6) Accreditation:
A) Joint
Commission Resources 2022 Comprehensive Accreditation Manual for Behavioral
Health Care and Human Services, available at: https://store.jcrinc.com/2022-comprehensive-accreditation-manuals/2022-comprehensive-accreditation-manual-for-behavioral-health-care-and-human-services-cambhc-hard-copy-/
or from Joint Commission Resources, 1515 West 22nd Street, Suite
1300W; Oak Brook, IL 60523.
B) Commission
on Accreditation of Rehabilitation Facilities (CARF) 2022 Behavioral Health
Standards Manual, available at: http://bookstore.carf.org/category/INT-2022_BH.html
or
C) ACHC
Accreditation Standards, available at: https://cc.achc.org/Registration/Register
or from the Accreditation Commission for Health Care, 139 Weston Oaks Ct.,
Cary, NC 27513.
7) Federal
Guidelines:
A) General
Best Practice Guidelines for Immunization, Best Practices Guidance of the
Advisory Committee on Immunization Practices (ACIP) (March 15, 2022), available
at: https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html or
from the Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta
GA 30329-4027 (800-232-4636).
B) Sexually
Transmitted Infections Treatment Guidelines (July 23, 2021), available at: https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf
or from the Centers for Disease Control and Prevention, 1600 Clifton Rd.,
Atlanta GA 30333 (800-232-4636).
C) "Recommended
Dietary Allowances", 10th Edition (1989), adopted by the Food
and Nutrition Board of the National Research Council of the National Academy of
Science, available at: https://www.ncbi.nlm.nih.gov/books/NBK234932/ or the
National Academy of Science, Keck Center 500 Fifth St. NW, Washington DC 20001
(202-334-2000).
8) Evidence-based
and evidence-informed treatment practices, including but not limited to:
A) The
Illness Management and Recovery: Practitioner Guides and Handouts (2009), HHS
Pub. No. SMA-09-4462, available at:
https://tinyurl.com/6vwh6n4c or
from the Center for Mental Health Services, Substance Abuse and Mental Health
Services Administration, U.S. Department of Health and Human Services, 5600
Fishers Lane; Rockville, MD, 20857.
B) Wellness
Recovery Action Plan (WRAP), by Copeland, Mary Ellen, Ph.D., Peach Press (2011),
P.O. Box 301, West Dummerston VT 05357.
C) Motivational
Interviewing: Helping People Change, Third Edition (2013), Miller, W. R., &
Rollnick, S, available at: https://www.guilford.com/ or from Guilford Press,
370 Seventh Avenue, Suite 1200, New York, NY 10001-1020 (800-365-7006).
9) ADA
Standards for Accessible Design (2010), available at: https://www.ada.gov/regs2010/2010ADAStandards/2010ADAStandards_prt.pdf
or from the U.S., Department of Justice ADA website (www.ada.gov) or by writing
U.S. Department of Justice, 950 Pennsylvania Avenue, NW, Civil Rights Division,
950 Pennsylvania Avenue, NW, 4CON, 9th Floor, Washington, DC 20530.
10) Federal
Rules:
A) 21 CFR 1306.11,
Requirement of Prescription (April 1, 2022)
B) 21 CFR 1306.21,
Requirement of Prescription (April 1, 2022)
C) 24 CFR 578.3, Definitions
(April 1, 2022)
D) 45 CFR 46, Protection of
Human Subjects (October 1, 2021)
b) All
incorporations by reference of federal regulations and guidelines and the
standards of nationally recognized organizations refer to the regulations,
guidelines and standards on the date specified and do not include any editions
or amendments subsequent to the date specified.
c) The following statutes
and State regulations are referenced in this Part:
1) Federal
Statutes:
A) Americans
With Disabilities Act of 1990 (42 U.S.C. 12101)
B) Health
Insurance Portability and Accountability Act (110 U.S.C. 1936)
C) Comprehensive
Drug Abuse Prevention Control Act of 1970 (21 U.S.C. 13)
2) State
of Illinois Statutes:
A) Specialized
Mental Health Rehabilitation Act of 2013 [210 ILCS 49]
B) Mental
Health and Developmental Disabilities Code [405 ILCS 5]
C) Unified
Code of Corrections [730 ILCS 5]
D) Nurse
Practice Act [225 ILCS 65]
E) Medical
Practice Act of 1987 [225 ILCS 60]
F) Clinical
Psychologist Licensing Act [225 ILCS 15]
G) Clinical
Social Work and Social Work Practice Act [225 ILCS 20]
H) Illinois
Occupational Therapy Practice Act [225 ILCS 75]
I) Professional
Counselor and Clinical Professional Counselor Licensing and Practice Act [225
ILCS 107]
J) Marriage
and Family Therapy Licensing Act [225 ILCS 55]
K) Health
Care Worker Background Check Act [225 ILCS 46]
L) Nursing
Home Administrators Licensing and Disciplinary Act [225 ILCS 70]
M) Illinois
Controlled Substances Act [720 ILCS 570]
N) AIDS
Confidentiality Act [410 ILCS 305]
O) Dietitian
Nutritionist Practice Act [225 ILCS 30]
P) Smoke
Detector Act [425 ILCS 60]
Q) Illinois
Power of Attorney Act [755 ILCS 45/Art. IV]
R) Mental
Health Treatment Preference Declaration Act [755 ILCS 43]
S) Whistleblower
Act [740 ILCS 174]
T) Criminal
Code of 2012 [720 ILCS 5]
U) Smoke
Free Illinois Act [410 ILCS 82]
V) Mental
Health and Development Disabilities Confidentiality Act [740 ILCS 110]
W) Probate
Act of 1975 [755 ILCS 5]
X) Language
Assistance Services Act [210 ILCS 87]
Y) Safety
Glazing Materials Act [430 ILCS 60]
Z) Child
Care Act of 1969 [225 ILCS 10]
AA) Community
Living Facilities Licensing Act [210 ILCS 35]
BB) Community-Integrated
Living Arrangements Licensure and Certification Act [210 ILCS 135]
CC) Supportive
Residences Licensing Act [210 ILCS 65]
DD) Illinois
Public Aid Code [305 ILCS 5]
EE) Assisted
Living and Shared Housing Act [210 ILCS 9]
FF) Alternative
Health Care Delivery Act [210 ILCS 3]
GG) Cannabis
Control Act [720 ILCS 550]
HH) Methamphetamine
Control and Community Protection Act [720 ILCS 646]
II) Sex
Offender Management Board Act [20 ILCS 4026]
JJ) Illinois Human Rights
Act [775 ILCS 5]
KK) Illinois Uniform
Conviction Information Act [20 ILCS 2635]
LL) Hospital Licensing Act
[210 ILCS 85]
MM) Nursing Home Care Act [210
ILCS 45]
NN) Sex Offender Registration
Act [730 ILCS 150]
OO) ID/DD
Community Care Act [210 ILCS 47]
PP) MC/DD
Act [210 ILCS 46]
3) State
of Illinois Administrative Rules:
A) Department
of Public Health, Practice and Procedure in Administrative Hearings (77 Ill.
Adm. Code 100)
B) Department
of Public Health, Illinois Plumbing Code (77 Ill. Adm. Code 890)
C) Department
of Public Health, Control of Tuberculosis Code (77 Ill. Adm. Code 696)
D) Department
of Public Health, Health Care Worker Background Check Code (77 Ill. Adm. Code
955)
E) Department
of Public Health, Control of Communicable Diseases Code (77 Ill. Adm. Code 690)
F) Department
of Public Health, Control of Sexually Transmissible Infections Code (77 Ill.
Adm. Code 693)
G) Department
of Public Health, Food Code (77 Ill. Adm. Code 750)
H) Department
of Public Health, Drinking Water Systems Code (77 Ill. Adm. Code 900)
I) Department
of Public Health, Water Well Construction Code (77 Ill. Adm. Code 920)
J) Department
of Public Health, Illinois Water Well Pump Installation Code (77 Ill. Adm. Code
925)
K) Department
of Public Health, Sexual Assault Survivors Emergency Treatment Code (77 Ill.
Adm. Code 545)
L) Department
of Public Health, Language Assistance Services Code (77 Ill. Adm. Code 940)
M) Department
of Public Health, Skilled Nursing and Intermediate Care Facilities Code (77
Ill. Adm. Code 300)
N) Department
of Public Health, Long-Term Care Assistants and Aides Training Programs Code
(77 Ill. Adm. Code 395)
O) Department
of Public Health, Emergency Medical Services, Trauma Center, Comprehensive
Stroke Center, Primary Stroke Center and Acute Stroke Ready Hospital Code (77
Ill. Adm. Code 515)
P) Department
of Human Services, Medicaid Community Mental Health Services Program (59 Ill.
Adm. Code 132)
Q) Healthcare
and Family Services, Mental Health Services in Nursing Facilities (89 Ill. Adm.
Code 145)
R) Office
of the State Fire Marshal, Fire Prevention and Safety (41 Ill. Adm. Code 100)
S) Office
of the State Fire Marshal, Boiler and Pressure Vessel Safety (41 Ill. Adm. Code
2120)
T) Capital
Development Board, Illinois Accessibility Code (71 Ill. Adm. Code 400)
(Source:
Amended at 47 Ill. Reg. 7777, effective May 17, 2023)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.120 APPLICABILITY AND GENERAL REQUIREMENTS
Section 380.120 Applicability and General Requirements
a) The Act
and this Part provide for licensure of long term care facilities that are
federally designated as institutions for mental disease on July 22, 2013 and
specialize in providing services to individuals with serious mental illness.
On and after July 22, 2013, these facilities shall be governed by the
Act instead of the Nursing Home Care Act. (Section 1-101.5(a) of the Act)
b) All
consent decrees that apply to facilities federally designated as institutions
for mental disease shall continue to apply to facilities licensed under the
Act and this Part. (Section 1-101.5(b) of the Act)
c) A
facility licensed under the Act and this Part may voluntarily
close, and the facility may reopen in an underserved region of the State, if
the facility receives a certificate of need from the Health Facilities and
Services Review Board. At no time shall the total number of licensed beds under
the Act and this Part exceed the total number of licensed beds
existing on July 22, 2013 (the effective date of Public Act 98-104)
(Section 1-105(c) of the Act).
d) Subject
to the Act and this Part, the facility shall develop and implement a
psychiatric rehabilitation program providing individual and group therapeutic
interventions, services and supports to address the goals, preferences, needs,
strengths and risks of persons with a diagnosis of mental illnesses and who
meet clinical criteria as specified in each level of service.
e) Triage
centers, crisis stabilization units, transitional living units, and recovery
and rehabilitation supports units shall be designed to improve the adaptive
functioning of persons with mental illness, facilitate the recovery of those
persons, and enable those persons to achieve a higher level of independence
while preventing regression to a lower level of functioning.
f) As
defined in the Act and this Part, the facility may develop specialized units
and programs to serve different consumers in different stages of illness,
including:
1) Non-residential
triage centers, with a length of stay no more than 23 hours, for short-term
crisis assessment and disposition;
2) Crisis
stabilization units that serve consumers for no more than 21 days;
3) Recovery
and rehabilitation supports units that address longer-term consumer mental
health rehabilitation needs and training; and
4) Transitional
living units that prepare consumers for community transition within 120 days
following admission.
g) Each
of these programs shall have its own separate program and staffing
requirements, based on the crisis intervention and recovery treatment needs of
the consumers, and as required by the Act and this Part.
h) A
facility is not required to implement all of the programs in subsection (e)(1)
through (4).
i) All
levels of service shall incorporate evidence-based practices, biopsychosocial
approaches, and programs regarding the treatment and rehabilitation of persons
who have mental illnesses.
j) The
mental health rehabilitation and recovery services shall be designed to assist
consumers in developing skills to effectively manage their symptoms and
effectively become capable of increasing levels of independent functioning in
the community.
k) All
services shall reflect varying individual goals, diverse needs, concerns,
strengths, motivations and abilities of each consumer, which shall be
documented in writing within the medical chart. The programs shall emphasize
the participation of consumers in all aspects of treatment, including, but not
limited to, individual treatment, services planning, program design and
evaluation.
l) The
facility shall have an interdisciplinary team at all levels of service. The IDT
shall include a physician and a licensed clinical social worker or a licensed
clinical professional counselor, as well as the consumer, the consumer's
guardian, and other professionals, including the consumer's primary service
providers, particularly the staff most familiar with the consumer, and other
appropriate professionals and caregivers as determined by the consumer's needs.
The consumer or his or her guardian may also invite other people to meet with
the IDT and participate in the process of identifying the consumer's strengths
and needs.
m) For
all levels of service except triage centers, a facility shall provide linkage,
including coordinating the consumer's care with other health care providers,
including, but not limited to, primary care physicians, psychiatrists,
hospitals and other medical professionals, to ensure that the mental and
physical health care needs of the consumer are met. The facility shall share
all relevant treatment information for a consumer with the community-based
behavioral health provider or other health care provider to facilitate a
consumer's recovery and rehabilitation. Linkage may occur through direct
partnerships with providers, as well as through managed care entities.
n) For
triage centers, linkage means connecting the consumer to a community-based
behavioral health provider if the triage staff determines that community
behavioral health services are needed.
o) A
crisis stabilization center, recovery and rehabilitation supports center, or a
transitional living unit shall not accept for treatment anyone with medical
issues requiring active intervention or treatment, or who requires a higher
level of medical care, e.g., issues beyond medical maintenance, including, but
not limited to, persons:
1) Who
require skilled nursing care, who have limited feeding capacity, or who need
assistance ambulating;
2) With
a swallowing problem with recurring aspiration;
3) Who
require a catheter, such as a foley catheter, feeding tubes or nasogastric
tubes, or central lines;
4) Who
are at risk of medically significant complications due to recent major medical
trauma, according to the requirements for trauma in the Emergency Medical
Services, Trauma Center, Primary Stroke Center and Emergent Stroke Ready
Hospital Code;
5) With
acute neurological symptoms, including unstable seizure disorders;
6) Who
require ongoing nebulizer treatments that are not self-administered;
7) Who
require electrocardiogram monitoring/telemetry;
8) For
transitional living and rehabilitation and recovery only, with a condition that
potentially requires urgent surgery;
9) Who
are at risk of medically significant complications due to drug withdrawal;
10) With
medically significant bleeding;
11) With
communicable diseases requiring isolation, except for brief contact isolation;
12) With
delirium;
13) With
primary dementia;
14) With
moderate, severe or profound developmental disability;
15) With
methadone dependency, unless he or she is in an accredited methadone program;
or
16) With
toxic levels of medication or who are at risk to become toxic (i.e.,
acetaminophen).
p) A
triage center shall screen all consumers for the medical issues in subsection
(n).
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.130 STAFF QUALIFICATIONS AND TRAINING REQUIREMENTS
Section 380.130 Staff Qualifications and Training
Requirements
a) Training
for all new employees specific to the various levels of care offered by a
facility shall be provided to employees during their orientation period and then
annually. Training shall be independent of the Department and overseen by
DHS-DMH to determine the content of all facility employee training and to
provide training for all trainers of facility employees. (Section 2-103 of
the Act) DHS-DMH will determine if the outlined employee training plan
submitted to it by the facility meets the DHS-DMH requirements prior to the
acceptance of the facility's plan of operation by the Department.
b) Training
of employees shall be consistent with nationally recognized national
accreditation standards as defined in the Act and this Part. Training
shall be required for all existing staff at a facility prior to the
implementation of any new services authorized under the Act and this
Part. (Section 2-103 of the Act)
c) The facility shall have a written policy for
regular staff training at all levels of service that the facility provides.
Training referenced in this Section may be provided via any of the usual
methods of adult education, including, but not limited to, in-service training,
webinar, comport programs, on-line education, and on-the-job training.
d) The curriculum for staff training will be
developed or approved by DHS-DMH and will include, but not be limited to,
understanding symptoms of mental illnesses; principles of evidence-based
practices and emerging best practices, including trauma informed care, illness
management and recovery, wellness recovery action plans, crisis prevention
intervention training, consumer rights, and recognizing, preventing, and
mandatory reporting of abuse and neglect. Training shall also include relevant
health and safety matters. Training shall use didactic as well as practical
and on-the-job experiences.
e) Executive
Director
1) The
executive director shall meet the requirements in Section 380.430.
2) The
executive director shall complete at least 15 hours of training as prescribed
by DHS-DMH on mental illness, mental health services, psychiatric
rehabilitation, State mental health administrative rules, and the mental health
service system prior to assuming duties in a facility.
3) Individuals
who have successfully completed training on the specific topics and training
hours prescribed in subsection (e)(2) within the past five years may use this
training to meet the requirements of this subsection (e). The facility shall
document this training in the employee's personnel file.
4) The
executive director also shall complete additional training annually as
prescribed by DHS-DMH.
f) Psychiatric
Medical Director
1) The
psychiatric medical director shall be a board eligible or board certified
psychiatrist.
2) The psychiatric
medical director shall complete training as prescribed by DHS-DMH on mental
illness, mental health services, psychiatric rehabilitation, State mental
health administrative rules, and the mental health service system prior to
assuming the duties of this position.
3) Individuals
who have successfully completed training on the specific topics and training
hours prescribed in subsection (f)(2) within the past five years may use this
training to meet the requirements of this subsection (f). The facility shall
document this training in the employee's personnel file.
4) The
psychiatric medical director shall not have a revoked or currently suspended
license, and shall not be on probation.
g) Program
Director
Each program operated by the
licensee shall have a program director who is a licensed practitioner of the
healing arts.
h) Licensed
Practitioner of the Healing Arts (LPHA)
1) The
LPHA shall meet the definition of this job title in 59 Ill. Adm. Code 132.
2) The
LPHA shall complete training as prescribed by DHS-DMH on mental illness, mental
health services, psychiatric rehabilitation, State mental health administrative
rules, and the mental health service system prior to assuming the duties of
this position.
3) Individuals
who have successfully completed training on the specific topics and training
hours prescribed in subsection (h)(2) within the past five years may use this
training to meet the requirements of this subsection (h). The facility shall
document this training in the employee's personnel file.
4) The
LPHA also shall complete additional training annually as prescribed by DHS-DMH.
i) Qualified
Mental Health Professional (QMHP)
1) The
QMHP shall meet the definition of this job title.
2) The
QMHP shall complete training as prescribed by DHS-DMH on mental illness, mental
health services, psychiatric rehabilitation, State mental health administrative
rules, and the mental health service system prior to assuming the duties of
this position.
3) Individuals
who have successfully completed training on the specific topics and training
hours prescribed in subsection (i)(2) within the past five years may use this
training to meet the training requirements of this subsection (i). The facility
shall document this training in the employee's personnel file.
4) The
QMHP also shall complete additional training annually as prescribed by DHS-DMH.
j) Mental
Health Professional (MHP)
1) The
MHP shall meet the definition of this job title in 59 Ill. Adm. Code 132.
2) The
MHP shall complete training as prescribed by DHS-DMH on mental illness, mental
health services, psychiatric rehabilitation, State mental health administrative
rules, and the mental health service system prior to assuming the duties of
this position.
3) Individuals
who have successfully completed training on the specific topics and training
hours prescribed in subsection (j)(2) within the past five years may use this
training to meet the requirements of this subsection (j). The facility shall document
this training in the employee's personnel file.
4) The
MHP also shall complete additional training annually as prescribed by DHS-DMH.
k) Certified
Recovery Support Specialist (CRSS)
1) The
CRSS shall meet the definition of this job title in Section 380.100.
2) The
CRSS shall complete at least 60 hours of training as prescribed by DHS-DMH on
mental illness, mental health services, psychiatric rehabilitation, State
mental health administrative rules, and the mental health service system prior
to assuming the duties of this position.
3) Individuals
who have successfully completed training on the specific topics and training
hours prescribed in subsection (k)(2) within the past five years may use this
training to meet the requirements of this subsection (k). The facility shall
document this training in the employee's personnel file.
4) The
CRSS also shall complete additional training annually as prescribed by DHS-DMH.
5) A
facility shall make its best efforts to hire the required CRSS staffing. If a
facility is unable to meet the minimum staffing requirements of Sections
380.300(g)(4), 380.310(j)(5), 380.320(g)(3) and 380.330(i)(3), the facility may
hire a person who is eligible to obtain the CRSS certification within 12 months
after the date of hire. The facility shall support the individual toward
obtaining the necessary training hours, work hours and completion of the exam.
A) The
individual shall have a high school diploma or GED. The individual shall
receive 100 hours of training and education, including 40 hours in the CRSS
domains of recovery support, mentoring, advocacy and professional
responsibility; 6 hours in professional ethics for a CRSS; and 54 hours in
areas related to the work of the CRSS but not necessarily specific to the four
domains.
B) The
facility shall continue to make documented efforts to recruit and hire
employees who are already certified as a CRSS.
l) Rehabilitation
Services Associate (RSA)
1) The
RSA shall meet the definition of this job title in 59 Ill. Adm. Code 132.
2) The
RSA shall complete training as prescribed by DHS-DMH on mental illness, mental
health services, psychiatric rehabilitation, State mental health administrative
rules, and the mental health service system prior to assuming the duties of
this position.
3) Individuals
who have successfully completed training on the specific topics and training
hours prescribed in subsection (l)(2) within the past five years may use this
training to meet the requirements of this subsection (l). The facility shall
document this training in the employee's personnel file.
4) The
RSA also shall complete additional training annually as prescribed by DHS-DMH.
m) Volunteers
Volunteers who are regularly
scheduled to work at least weekly with consumers at the facility shall complete
at least 12 hours of supervised training as prescribed by DHS-DMH prior to
beginning their volunteer services. Volunteers shall be subject to all the
hiring requirements in Subpart C. Volunteers are prohibited from working in
triage centers or crisis stabilization units. In recovery and rehabilitation
supports units and transitional living units, their services shall be limited
to assisting consumers with ADLs, IADLs and recreational activities.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.140 CONSUMER RIGHTS AND CHOICES
Section 380.140 Consumer Rights and Choices
a) Consumers
served by a facility under the Act and this Part shall have all
the rights guaranteed pursuant to Chapter II, Article I of the Mental Health
and Developmental Disabilities Code, a list of which shall be prominently
posted in English and any other language representing at least 5% of the county
population in which the specialized mental health rehabilitation facility is
located. (Section 3-101 of the Act)
1) Each
consumer and consumer's guardian or other person acting on behalf of the
consumer shall be given a written explanation of all of his or her rights. The
explanation shall be given at the time of admission to a facility or as soon
thereafter as the condition of the consumer permits, but in no event later than
48 hours after admission and again at least annually thereafter, except for
triage. If a consumer is unable to read the written explanation, it
shall be read to the consumer in a language the consumer understands.
(Section 3-209 of the Act)
2) The
facility shall ensure that its staff is familiar with and observes the rights
and responsibilities enumerated in Article 3 of the Act. (Section 3-210 of
the Act)
b) A
consumer shall be permitted to manage his or her own financial affairs unless
he or she or his or her guardian authorizes the executive director of the
facility in writing to manage the consumer's financial affairs. (Section
3-102 of the Act)
c) To
the extent possible, each consumer shall be responsible for his or her own
moneys and personal property or possessions in his or her own immediate living
quarters unless deemed inappropriate by a physician or other facility LPHA clinician
and so documented in the consumer's record. In the event the moneys or
possessions of a consumer come under the supervision of the facility, either
voluntarily on the part of the consumer or so ordered by a facility physician
or other LPHA clinician, each facility to whom a consumer's moneys or
possessions have been entrusted shall comply with the following:
1) No
facility shall commingle consumers' moneys or possessions with those of the
facility; consumers' moneys and possessions shall be maintained separately,
intact, and free from any liability that the facility incurs in the use of the
facility's funds;
2) The
facility shall provide reasonably adequate space for the possessions of the
consumer; the facility shall provide a means of safeguarding small items of
value for its consumers in their rooms or in any other part of the facility so
long as the consumers have reasonable and adequate access to their
possessions; and
3) The
facility shall make reasonable efforts to prevent loss and theft of consumers'
possessions; those efforts shall be appropriate to the particular facility and
particular living setting within each facility and may include staff training
and monitoring, labeling possessions, and frequent possession inventories; the
facility shall develop procedures for investigating complaints concerning theft
of consumers' possessions and shall promptly investigate all complaints.
(Section 3-103 of the Act)
d) Every
consumer, except those in triage centers, shall be permitted unimpeded,
private, and uncensored communication of his or her choice by mail, telephone,
Internet, or visitation.
1) The
executive director shall ensure that correspondence is conveniently received
and reasonably accessible.
2) The
executive director shall ensure that consumers may have private visits at any
reasonable hour unless visits are restricted due to the treatment plan of the
consumer.
3) The
executive director shall ensure that space for visits is available and that
facility personnel reasonably announce their intent to enter, except in an
emergency, before entering any consumer's room during visits.
4) Consumers
shall be free to leave at any time. If a consumer in a triage center expresses
a desire to contact a third party for any purpose, the facility staff shall
contact that third party on behalf of the consumer. (Section 3-108 of the
Act)
e) A
consumer shall be permitted the free exercise of religion. Upon a consumer's
request, and if necessary, at the consumer's expense, the executive director
may make arrangements for a consumer's attendance at religious services of the
consumer's choice. However, no religious beliefs or practices or attendance at
religious services may be imposed upon any consumer. (Section 3-109 of the
Act)
f) Access
to Consumers
1) Any
employee or agent of a public agency, any representative of a community legal
services program, or any other member of the general public shall be permitted
access at reasonable hours to any individual consumer of any facility, unless
the consumer is receiving care and treatment in triage centers. This
subsection (f)(1) shall not be construed to limit the Department's ability to
conduct off-hour surveys or inspections.
2) All
persons entering a facility under the Act and this subsection (f) shall
promptly notify appropriate facility personnel of their presence. They shall,
upon request, produce identification to establish their identity. No person
shall enter the immediate living area of any consumer without first identifying
himself or herself and then receiving permission from the consumer to enter.
The rights of other consumers present in the room shall be respected. A
consumer may terminate at any time a visit by a person having access to the
consumer's living area under the Act and this subsection.
3) This
subsection (f) shall not limit the power of the Department or other
public agency otherwise permitted or required by law to enter and inspect a
facility.
4) Notwithstanding
subsection (f)(1), the executive director of a facility may refuse
access to the facility to any person if the presence of that person in the
facility would be injurious to the health and safety of a consumer or would
threaten the security of the property of a consumer or the facility, or if the
person seeks access to the facility for commercial purposes.
5) Nothing
in this subsection (f) shall be construed to conflict with, or infringe
upon, any court orders or consent decrees regarding access. (Section 3-110
of the Act)
g) A
consumer shall be permitted to present grievances on behalf of himself or
herself or others to the executive director, the consumers' advisory council
(see subsection (j)), State governmental agencies, or other persons without
threat of discharge or reprisal in any form or manner whatsoever. The executive
director shall provide all consumers or their representatives with the name,
address, and telephone number of the appropriate State governmental office
where complaints may be lodged. (Section 3-112 of the Act) All facilities
shall display contact information and make it accessible and visible to
consumers and visitors with a minimum of interaction with staff.
h) A
consumer may refuse to perform labor for a facility. (Section 3-113 of the
Act)
i) No
consumer shall be subjected to unlawful discrimination as defined in Section
1-103 of the Illinois Human Rights Act by any owner, licensee, executive
director, employee, or agent of a facility. Unlawful discrimination does not
include an action by any licensee, executive director, employee, or agent of a
facility that is required by the Act or by this Part. (Section 3-114
of the Act)
j) Except
for triage centers and crisis stabilization units, each facility shall
establish a consumers' advisory council consisting of at least five
consumers chosen by consumers. If there are not five consumers capable of
functioning on the consumers' advisory council, as determined by the
interdisciplinary team, consumers' substitute decision makers shall take the
place of the required number of consumers. The executive director shall
designate a member of the facility staff other than the executive director
to coordinate the establishment of, and render assistance to, the council.
1) No
employee or affiliate of a facility shall be a member of the council.
2) The
council shall meet at least once each month with the staff coordinator, who
shall provide assistance to the council in preparing and disseminating a report
of each meeting to all consumers, the executive director, and the staff.
3) Records
of council meetings shall be maintained in the office of the executive director,
subject to compliance with the Health Insurance Portability and Accountability
Act and Mental Health and Developmental Disabilities Confidentiality Act.
4) The
consumers' advisory council may communicate to the executive director the
opinions and concerns of the consumers. The council shall review procedures for
implementing consumer rights and facility responsibilities, and make
recommendations for changes or additions that will strengthen the facility's
policies and procedures as they affect consumer rights and facility
responsibilities.
5) The
council shall be a forum for:
A) Obtaining
and disseminating information;
B) Soliciting
and adopting recommendations for facility programming and improvements; and
C) Early
identification and for recommending orderly resolution of problems.
6) The
council may present complaints on behalf of a consumer to the Department or to
any other person it considers appropriate, without retaliation of any kind
from the facility or any facility employee. (Section 3-203 of the Act)
k) A
facility shall provide language assistance services in accordance with the
Language Assistance Services Act and the Language Assistance Services Code.
l) A facility shall inform a consumer of his or her right to
designate a substitute decision maker in writing and shall assist the consumer
in naming a substitute decision maker, if the consumer requests it.
m) Pursuant
to Section 380.600(g), all facilities shall conspicuously display a poster
informing consumers of their right to explore or decline community transition
and their right to be free from retaliation. This notice shall include a
telephone number for reporting retaliation to the Department and shall include
the steps a consumer should take if retaliation does occur.
n) All
facilities shall provide educational materials and information to all newly
admitted Williams Consent Decree Class Members within one to three days of
admission, informing them of their rights and services under the Williams
Consent Decree, as prescribed by the Williams Lead Defendant Agency. All
facilities shall provide verification that the educational materials and
information were given to a Williams Class Members, as requested by a Williams
Defendant Agency.
(Source: Amended at 46 Ill. Reg. 16870,
effective September 26, 2022)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.150 INFORMED CONSENT
Section 380.150 Informed Consent
a) For
the purposes of this Section and Section 380.160, the following definitions
shall apply:
1) Authorized
representative – a guardian with a court order granting authority to consent to
psychotropic medication or the use of restraints on behalf of a consumer, or a
person authorized to consent to psychotropic medication or the use of
restraints on behalf of a consumer pursuant to the Power of Attorney Act or the
Mental Health Treatment Preference Declaration Act.
2) Capable
consumer – a consumer who is able to understand the nature of the decision to
be made, the information relevant to making the decision and the possible
consequences of any decision, and to make a reasoned judgment based on this
information.
3) Informed
consent – written consent for specific medical care, given freely, without
coercion or deceit, by a capable consumer, or by a consumer's authorized
representative, after the consumer, or the consumer's authorized
representative, has been fully informed of, and had an opportunity to consider,
the nature of the care, the likely and possible benefits and risks to the
consumer of receiving the care, any other likely and possible consequences of
receiving or not receiving the care, and possible alternatives to the proposed
care. Written informed consent shall be obtained from a consumer or from a
consumer's authorized representative when he or she is admitted. Before
obtaining informed consent from a consumer, or from a consumer's authorized
representative, the facility shall inform the consumer or the consumer's
authorized representative that the potential consequences of an emergency situation
in a SMHRF may include temporary holding, restraint, or the use of medications
as ordered by the physician for safety purposes. For psychotropic medications,
the informed consent shall comply with subsection (d).
b) The
facility shall document in the consumer's record whether he or she is capable
of giving informed consent for medical care, including for receiving
psychotropic drugs. If the consumer is not capable of giving informed consent,
the identity of the consumer's authorized representative shall be placed in the
consumer's record.
c) No
psychotropic medication may be given to any consumer without the informed
consent of the consumer or, if the consumer is not capable, the informed
consent of a person authorized to consent for the consumer without capacity.
Informed consent shall be secured in compliance with the requirements of this
Section.
d) Procedure
for Securing Informed Consent for Psychotropic Medication
1) Prior
to initiating any detailed discussion designed to secure informed consent, a
licensed medical professional shall inform the consumer or the consumer's
authorized representative that the consumer's physician has prescribed a
psychotropic medication for the consumer, and that an informed decision is
required from the consumer or the consumer's authorized representative before
the consumer may be given the medication.
2) The
discussion designed to secure informed consent shall be private, between the
consumer or the consumer's authorized representative, and the resident's physician,
a registered pharmacist who is not a dispensing pharmacist for the facility
where the consumer is receiving services, or a licensed nurse. The consumer
shall be given the opportunity to ask questions throughout the discussion. The
consumer shall be given as much time as he or she needs to grant informed
consent, and shall be told that he or she is not required to make the decision
during the meeting.
3) The
discussion shall include information about:
A) The
name of the medication;
B) The
consumer's illness that the medication is intended to treat;
C) The
symptoms of the illness that the medication is intended to treat, and how those
symptoms are affecting the consumer;
D) How
the medication is intended to affect those symptoms;
E) Other
possible effects or side effects of the medication, and any reasons (e.g., age,
health status, other medications) that the consumer is more or less likely to
experience side effects;
F) Dosage
information, including how much medication would be administered, how often,
and the method of administration (e.g., orally or by injection; with, before,
or after food);
G) Any
tests and related procedures that are required for the safe and effective
administration of the medication;
H) Any
food or activities the consumer should avoid while taking the medication;
I) Any
possible alternatives to taking the medication that could accomplish the same
purpose; and
J) Any
possible consequences to the consumer of not taking the medication.
4) The
consumer or the consumer's authorized representative shall be told that his or
her informed consent may be withdrawn at any time, and that, even with informed
consent, the consumer may refuse to take the medication. The consumer or the
consumer's authorized representative shall be told whether stopping the
medication poses a risk of serious health consequences for the consumer, and
whether stopping the medication and resuming it will reduce the subsequent
effectiveness of the medication.
5) In
addition to the oral discussion, the consumer or his or her authorized
representative shall be given the information in subsection (d)(2) in writing.
The information shall be in plain language, understandable to the reader. If
the document is in a language not understood by the reader, the facility shall
provide a translator capable of communicating with the reader and the health
care professional conducting the discussion. The health care professional shall
guide the consumer through the written information. The document shall include
a place for the consumer or his or her authorized representative to give, or to
refuse to give, informed consent, or to request more time or more information
prior to making a decision. Informed consent is not secured until the consumer
or authorized representative has given oral and written informed consent.
6) If a
consumer has an authorized representative, the consumer may still be present at
the discussion required by this Section. If a consumer has an authorized
representative, that consumer shall still be given appropriate information
about the medication. The information shall include, at a minimum, written
information and an oral explanation of common side effects of the medication to
facilitate the consumer in identifying the medication and in communicating the
existence of side effects to the nursing staff. If the consumer is capable of
understanding, the explanation shall also include:
A) The
information in subsection (d)(3)(H);
B) Whether
stopping the medication poses a risk of serious health consequences for the
consumer; and
C) Whether
stopping the medication and resuming it will reduce the subsequent
effectiveness of the medication.
7) The
time period for informed consent for psychotropic medication shall not exceed
one year.
8) Informed
consent shall be given for a maximum daily dosage. Additional informed consent
is not required so long as the medication administered to the consumer remains
within the maximum daily dosage for which consent was given.
9) If a
consumer in a triage center has a current prescription for psychotropic
medication, the triage center shall take all reasonable steps to confirm that
the consumer has given informed consent for the medication.
10) A
consumer shall be asked to consent to the administration of a new psychotropic
medication in a dosage or frequency that exceeds the maximum recommended daily
dosage as found in the Physician's Desk Reference only when the reason for
exceeding the recommended daily dosage is explained to the consumer by a nurse,
physician, or psychiatrist, and the reason for exceeding the recommended daily
dosage is justified by the prescribing physician or psychiatrist in the
clinical record. The dosage and frequency shall be reviewed and rejustified by
the prescriber on a weekly basis and reviewed by a consulting pharmacist. The
justification for exceeding the recommended daily dosage shall be recorded in
the consumer's record and shall be approved, in writing, by the medical
director of the facility.
11) The
facility shall obtain informed consent using forms provided by the Department
pursuant to Section 2-106.1 of the Nursing Home Care Act.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.160 RESTRAINTS AND THERAPEUTIC SEPARATION
Section 380.160 Restraints and Therapeutic Separation
a) The
facility shall develop and implement a written plan to create coercion-free
environments as defined in the Mental Health and Developmental Disabilities
Code in recognition of the prevalence of trauma histories in the populations to
be treated in all levels of service in the facility. The plan shall address how
the facility will:
1) Use
leadership to create organizational change;
2) Use
data to inform practice;
3) Train
the workforce in policies and practices;
4) Use
restraint and therapeutic separation prevention tools;
5) Use
debriefing techniques following the use of restraints or therapeutic
separations; and
6) Create
appropriate spaces (e.g., comfort rooms) for therapeutic separations.
b) Restraints
1) A
physical restraint, or momentary physical restriction by direct
person-to-person contact, without the aid of material or mechanical devices,
shall be applied only by staff trained in the safe and humane application of
the particular type of restraint. Training shall be in a program administered
or approved by DHS-DMH.
2) A
restraint shall be used only in an emergency and when alternative interventions
cannot ensure safety.
3) Informed
consent shall be required for restraints consistent with the requirements
contained in Section 2-106(c) of the Nursing Home Care Act. (Section
3-115 of the Act)
A) Written
informed consent for the short-term emergency use of a restraint may be
obtained from a consumer when he or she is admitted or after admission. Before
obtaining informed consent, the facility shall inform the consumer that, in a
behavioral emergency, when necessary to protect the consumer or other people
from immediate physical harm, the staff may use the temporary holding, and, if
informed consent has been given, may use short-term restraint until the
consumer can be transported to a hospital.
B) Whenever
use of a physical restraint is initiated, the consumer shall be advised of his
or her right to have a person or organization of his or her choosing, including
the Guardianship and Advocacy Commission, notified of the use of the physical
restraint. A period of use is initiated when a physical restraint is applied
to a consumer for the first time under a new or renewed informed consent for
the use of physical restraints. A recipient who is under guardianship may
request that a person or organization of his or her choosing be notified of the
physical restraint, whether or not the guardian approves the notice. The
person or organization shall be notified whenever a consumer is restrained.
C) The
facility shall provide the following information in writing to the person or
organization named by the consumer. If the consumer requests that the
Guardianship and Advocacy Commission be contacted, the facility shall also
provide the following information in writing to the Guardianship and Advocacy
Commission:
i) The
reason the physical restraint was needed;
ii) The
type of physical restraint that was used;
iii) The
interventions used or considered prior to physical restraint and the impact of
these interventions;
iv) The
length of time the physical restraint was applied; and
v) The
name and title of the facility employee to be contacted for further
information.
D) Whenever
a physical restraint is used on a consumer whose primary mode of communication
is sign language, the consumer shall be permitted to have his or her hands free
from restraint for brief periods each hour, except when this freedom may result
in physical harm to the consumer or others.
4) The
use of a restraint is not permitted unless a consumer presents a behavioral
emergency. In these circumstances, restraints may be used for a brief period
until emergency care and physical transportation to a hospital can be
accomplished. In situations that are successfully resolved through manual
holding lasting less than five minutes, without physical hold to the ground or
undue force, and without injury, transport to an emergency room or hospital is
not required.
A) The
use of restraints in a behavioral emergency shall comply with the provisions of
Sections 380.150(a) and 380.610(d).
B) Restraint
use shall be limited to the least amount of physical restriction and the
briefest possible duration necessary to resolve the immediate danger.
C) The
limitation on allowable restraint use applies to any physical restraint,
including physical hold and prolonged restriction of movement by staff, as well
as the use of any mechanical restraint device. Gentle physical guidance,
prompting, and escorting a consumer are not considered restraints. Momentary
periods of physical restriction by direct person-to-person contact, without the
aid of material or mechanical devices, accomplished with limited force, and
that are designed to prevent a consumer from completing an act that would
result in potential physical harm to himself or herself or another shall not
constitute restraint, but shall be documented in the consumer's clinical
record, and may be used only by a person trained pursuant to subsection (b)(1).
D) Any
consumer being restrained shall be continuously monitored by a staff member,
who shall be present throughout the period of restraint use to ensure safety,
to avoid injury, and to minimize discomfort. The consumer's position shall be
monitored to ensure that breathing is unrestricted. Consumer hydration or
toileting needs shall be addressed unless precluded by immediate safety
concerns.
E) Nursing
staff shall examine the consumer as soon as possible, but no later than 10
minutes, after the start of the restraint use.
F) The
consumer's psychiatrist shall be contacted immediately for medical direction.
If the consumer's psychiatrist is unavailable, the psychiatric medical director
shall be contacted.
G) The
QMHP, pursuant to the facility's written policy, shall debrief the staff
involved in the restraint use regarding the events leading up to the restraint,
physical hold, or application, and the consumer's condition during the duration
of the restraint use. A consumer who was transported to a hospital shall be
debriefed upon return to the facility.
H) The
use of physical restraints shall be documented in the consumer's record,
including:
i) The
behavior emergency that prompted the use of restraints, including preceding
events, staff efforts to de-escalate the situation, and reasons for the use of
restraint;
ii) The
date and time that restraints were applied to the consumer, the methods used in
restraining the consumer, the duration of restraint use, the time of release,
and events surrounding release;
iii) The
names and titles of the staff responsible for applying the restraint and for
monitoring the consumer, and the names and titles of any other staff involved
in the incident;
iv) Orders
by the psychiatrist or psychiatric medical director who was notified of the
restraint;
v) The
emergency transportation that was used and the hospital to which the consumer
was taken;
vi) Any
injury or other negative impact sustained by the consumer; and
vii) The
date of the scheduled care planning conference and the results of the care plan
review in light of the use of emergency restraints.
I) Facility
staff, including safety personnel, shall receive a basic orientation in crisis
prevention and in safe physical hold and restraint methods. No facility staff
may use any physical hold or other restraint method unless trained pursuant to
subsection (b)(1).
J) The
facility shall maintain written records of training related to the use of
restraints and to de-escalation practices provided to staff.
c) Therapeutic
Separation
1) The
facility shall develop policies and procedures for the use of therapeutic
separation as a strategy for creating a coercion-free environment.
2) The
facility shall designate specific space (e.g., a comfort room) for therapeutic
separation that is designed in a way that calms the senses and provides a
temporary sanctuary from stress. The comfort room shall be:
A) Used
as a tool to teach individuals calming techniques to decrease agitation and
aggressive behavior;
B) Used
to prevent the use of emergency restraints;
C) Used
at the consumer's will, and shall remain unlocked;
D) Located
in an area that is easily accessible to those who will be using it and close to
a staffed area for adequate line of sight and supervision;
E) Used
before the onset of aggressive/uncontrolled behavior, and after as necessary; and
F) Developed
and furnished with input from staff and consumers.
3) Therapeutic
separation shall not be forced upon consumers and shall not be used as
punishment.
4) Supervised
therapeutic separation may be used for de-escalation of a potentially harmful
situation, provided that:
A) The
supervised separation lasts for no more than 30 minutes without the facility
contacting the psychiatric medical director in accordance with Section
380.610(d);
B) The
consumer is attended by an MHP or CRSS at all times in therapeutic separation
until the consumer can reasonably discuss the situation or event;
C) An MHP
or licensed nurse personally reviews the therapeutic separation situation at
least every 15 minutes while a consumer is in therapeutic separation; and
D) The
situation is entered into the consumer's record for review by the
Interdisciplinary Team.
d) The use of chemical
restraints is prohibited.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.170 CONSUMER BACKGROUND CHECKS
Section 380.170
Consumer Background Checks
a) Except
for triage centers, a facility shall, within 24 hours after admission,
request a criminal history background check pursuant to the Uniform Conviction
Information Act for all persons age 18 or older seeking admission to the
facility, unless a background check was initiated by a hospital pursuant to
subsection (d) Section 6.09(d) of the Hospital Licensing Act. Background
checks conducted pursuant to this Section shall be based on the consumer's
name, date of birth, and other identifiers as required by the Department of
State Police. (Section 2-104(a) of the Act)
b) The
facility shall check for the individual's name on the Illinois Sex Offender
Registration website at www.isp.state.il.us and the Illinois Department of
Corrections sex registrant search page at www.idoc.state.il.us to determine if
the individual is listed as a registered sex offender.
c) If
the results of the background check are inconclusive, the facility shall
initiate a fingerprint-based check, unless the fingerprint check is waived by
the Director of Public Health based on verification by the facility that the
consumer meets criteria related to the consumer's health or lack of potential
risk (Section 2-104(a) of the Act). The facility shall arrange for a
fingerprint-based background check or request a waiver from the Department
within five days after receiving inconclusive results of a name-based
background check. The fingerprint-based background check shall be conducted
within 25 days after receiving the inconclusive results of the name-based
check.
d) A
waiver issued pursuant to Section 2-104(a) of the Act shall be valid
only while the consumer is immobile or while the criteria supporting the waiver
exist. (Section 2-104(a) of the Act)
e) The
facility shall provide for or arrange for any required fingerprint-based checks
to be taken on the premises of the facility or off-site premises if
accompanied by staff. If a fingerprint-based check is required, the
facility shall arrange for it to be conducted in a manner that is respectful of
the consumer's dignity and that minimizes any emotional or physical hardship to
the consumer. (Section 2-104(a) of the Act)
f) If a
facility does not conduct a fingerprint-based background check in compliance
with this Section, then it shall provide conclusive evidence of the resident's
immobility or risk nullification of the waiver issued pursuant to Section
2-104(a) of the Act.
g) The
facility shall be responsible for taking all steps necessary to ensure the
safety of residents while the results of a name-based background check or a
fingerprint-based background check are pending; while the results of a request
for waiver of a fingerprint-based check are pending; and/or while the
Identified Offender Report and Recommendation prepared pursuant to Section
2-105(d) of the Act is pending.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.180 IDENTIFIED OFFENDERS
Section 380.180 Identified Offenders
a) The
facility shall review the results of the criminal history background checks
immediately upon receipt of the checks.
b) The
facility shall be responsible for taking all steps necessary to ensure the safety
of consumers while the results of a name-based background check or a
fingerprint-based check are pending.
c) If
the results of a consumer's criminal history background check reveal that the
consumer is an identified offender as defined in Section 1-102 of the
Act, the facility shall do the following:
1) Immediately
notify the Department of State Police, in the form and manner required by DSP,
in collaboration with the Department of Public Health, that the consumer is an
identified offender.
2) Within
72 hours, arrange for a fingerprint-based criminal history record inquiry to be
requested on the identified offender consumer. The inquiry shall be based on
the subject's name, sex, race, date of birth, fingerprint images, and other
identifiers required by DSP. The inquiry shall be processed through the
files of DSP and the Federal Bureau of Investigation to locate any
criminal history record information that may exist regarding the subject. The
Federal Bureau of Investigation shall furnish to DSP pursuant to an
inquiry under this subsection (c)(2) and Section 2-104(b) of the Act,
any criminal history record information contained in its files. (Section
2-104(b) of the Act)
d) The
facility shall comply with all applicable provisions contained in the Uniform
Conviction Information Act.
e) All
name-based and fingerprint-based criminal history record inquiries shall be
submitted to DSP electronically in the form and manner prescribed by DSP. DSP may
charge the facility a fee for processing name-based and fingerprint-based
criminal history record inquiries. The fee shall be deposited into the State
Police Services Fund. The fee shall not exceed the actual cost of processing
the inquiry.
f) If
identified offenders are consumers of a facility, the facility shall comply
with all of the following requirements:
1) The
facility shall inform the appropriate county and local law enforcement offices
of the identity of identified offenders who are registered sex offenders or are
serving a term of parole, mandatory supervised release or probation for a
felony offense who are consumers of the facility. If a consumer of a licensed
facility is an identified offender, any federal, State or local law enforcement
officer or county probation officer shall be permitted reasonable access to the
individual consumer to verify compliance with the requirements of the Sex
Offender Registration Act, to verify compliance with the requirements of the
Act and this Part, or to verify compliance with applicable terms of probation,
parole or mandatory supervised release. Reasonable access under this provision
shall not interfere with the identified offender's medical or psychiatric care.
2) The
facility staff shall meet with local law enforcement officials to discuss the
need for and to develop, if needed, policies and procedures to address the
presence of facility consumers who are registered sex offenders or are serving
a term of parole, mandatory supervised release or probation for a felony
offense, including compliance with Section 380.550.
3) Every
licensed facility shall provide to every prospective and current consumer and
consumer's guardian, and to every facility employee, a written notice,
prescribed by the Department, advising the consumer, guardian or employee of
his or her right to ask whether any consumers of the facility are identified
offenders. The facility shall confirm whether identified offenders are
residing in the facility.
A) The
notice shall also be prominently posted within every licensed facility.
B) The
notice shall include a statement that information regarding registered sex
offenders may be obtained from the DSP website, www.isp.state.il.us, and that
information regarding persons serving terms of parole or mandatory supervised
release may be obtained from the Illinois Department of Corrections website,
www.idoc.state.il.us.
4) If
the identified offender is on probation, parole or mandatory supervised
release, the facility shall contact the consumer's probation or parole officer,
acknowledge the terms of release, update contact information with the probation
or parole office, and maintain updated contact information in the consumer's
record. The record must also include the consumer's criminal history record.
g) Facilities
shall maintain written documentation of compliance with Section 380.170.
h) Recovery
and rehabilitation supports units and transitional living units shall annually
complete all of the steps required in subsection (f) for identified offenders.
This requirement does not apply to consumers who have not been discharged from
the facility during the previous 12 months.
i) For
current consumers who are identified offenders, the facility shall review the
security measures listed in the Identified Offender Report and Recommendation
provided by DSP.
j) Upon
admission of an identified offender to a facility or a decision to retain an
identified offender in a facility, the facility, in consultation with the
psychiatric medical director and law enforcement, shall specifically address
the consumer's needs in an individualized treatment plan.
k) The
facility shall incorporate the Identified Offender Report and Recommendation
into the identified offender's care plan (treatment plan) created
pursuant to 42 CFR 483.20. (Section 2-105(f) of the Act)
l) If
the identified offender is a convicted (see 730 ILCS 150/2) or
registered (see 730 ILCS 150/3) sex offender or if the Identified
Offender Report and Recommendation prepared pursuant to Section 2-105(d) of
the Act reveals that the identified offender poses a significant risk of
harm to others within the facility, the offender shall be required to have his
or her own room within the facility. (Section 2-105(d) of the Act)
m) The
facility's reliance on the Identified Offender Report and Recommendation shall
not relieve or indemnify in any manner the facility's liability or
responsibility with regard to the identified offender or other facility
consumers.
n) The
facility remains responsible for continuously evaluating the identified
offender and for making any changes in the treatment plan that are necessary to
ensure the safety of consumers.
o) Incident
reports shall be submitted to the Division of Long-Term Care Field Operations
in the Department's Office of Health Care Regulation in compliance with Section
380.530. The facility shall review its treatment plan and placement
determination of identified offenders based on incident reports involving the
identified offender. In incident reports involving identified offenders, the
facility shall identify whether the incident involves substance abuse,
aggressive behavior, or inappropriate sexual behavior, as well as any other
behavior or activity that would be reasonably likely to cause harm to the
identified offender or others. If the facility cannot protect the other
consumers from misconduct by the identified offender, or if, based on the
Identified Offender Report and Recommendation, a facility determines that it
cannot manage the identified offender consumer safely within the facility, it
shall commence involuntary transfer or discharge proceedings pursuant to
Section 3-402 of the Nursing Home Care Act. (Section 2-105(g) of the Act)
p) The
facility shall notify any appropriate local law enforcement agency, the
Illinois Prisoner Review Board, or the Department of Corrections of the
incident and whether it involved substance abuse, aggressive behavior, or
inappropriate sexual behavior that would necessitate relocation of that
consumer.
q) The
facility shall develop written procedures for implementing changes in consumer
care and facility policies when the consumer no longer meets the definition of
identified offender as defined in the Act and this Part.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.190 CONSUMER RECORDS
Section 380.190 Consumer Records
a) The
Department shall respect the confidentiality of a consumer's record and shall
not divulge or disclose the contents of a record in a manner that identifies a
consumer, except upon a consumer's death to a relative or guardian or under
judicial proceedings. This Section shall not be construed to limit the right of
a consumer to inspect or copy the consumer's own records, and the consumer
may inspect and copy his or her own records.
b) Confidential
medical, social, personal, or financial information identifying a consumer
shall not be available for public inspection in a manner that identifies a
consumer, or in a manner that violates the Mental Health and Developmental
Disabilities Confidentiality Act or the federal Health Insurance Portability
and Accountably Act. (Section 3-206 of the Act)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.200 ASSESSMENT, LEVEL OF SERVICE DETERMINATION, AND AUTHORIZATION
Section 380.200
Assessment, Level of Service Determination, and Authorization
a) Authorizations
for levels of service shall facilitate treatment in the least restrictive
settings. Authorization is not required for admission to triage centers.
Authorization is required for admission to crisis stabilization, transitional
living, and recovery and rehabilitation supports. Authorization shall be
limited in time based on the clinical status and needs of the consumer and the
maximum length of stay at each level of service. A facility may request
re-authorization if the initial authorization has expired and the consumer
still requires treatment at a specific level of service. Initial
authorizations shall be conducted by venders who are contracted with the State.
Re-authorizations may be conducted by the same vendor or by a managed care entity.
b) Admission
1) Except
for triage, each consumer shall receive an assessment prior to admission to a
facility. The assessment shall be used to determine the appropriate level of
service for service delivery and is required for authorization of services.
2) After
the provisional license period, no individual with mental illness whose service
plan provides for placement in community-based settings shall be housed or
offered placement in a facility at public expense unless, after being fully
informed, he or she declines the opportunity to receive services in a
community-based setting. (Section 4-107 of the Act)
3) To
ensure that consumers are fully informed of their options regarding
community-based services, the facility shall document, in writing, that
community-based providers were granted access to each consumer. Information to
be shared with consumers whose service plans provide for placement in a
community-based setting shall include those items included in subsections (f)
through (h) and:
A) An
introduction to community based settings, permanent supportive housing and
community-based services available to assist consumers in these settings and
the financial support consumers may receive in these settings; and
B) A
description of the benefits of placement in a community-based setting.
4) The
facility shall not admit any consumer or be compensated for services prior to
the completion of the assessment and the authorization by the State-designated
assessment and authorization entity. Authorizations are not required for
admission to a triage unit. Authorization is required prior to admission to:
A) Crisis
stabilization units;
B) Transitional
living units; and
C) Recovery
and rehabilitation supports units.
5) Authorization
shall be valid for a limited amount of time, determined by:
1) The
clinical status and needs of the consumer; and
2) The
length-of-stay limitations at each level of service.
c) Continued
Stay or Transfer between Units
1) Additional
authorizations may be requested by the interdisciplinary team if the initial
authorization has expired and the consumer continues to require treatment at a
specific level of service. Authorization shall be performed by entities authorized
by the Department of Healthcare and Family Services. Authorizing entities may
be, but are not required to be, managed care entities assigned as the consumer's
primary provider.
2) Any
transfer to a new level of service requires the authorization by the
State-designated assessment and authorization entity. The facility shall not
admit any consumer or be compensated for services in a new level of service
prior to authorization by the State-designated assessment and authorization
entity.
d) Assessment
Content for Assessments Conducted by the Facility
All initial assessments and annual
re-assessments conducted by the facility shall be person centered and focus on
the services and supports required for the consumer to live in permanent
supportive housing or another appropriate community-based setting. All assessments
shall include, but are not limited to, the consumer's:
1) Social
history and demographic background information;
2) Psychiatric
history and history of psychiatric hospitalizations;
3) Substance
use history, including a substance abuse assessment;
4) Cognitive
impairment screen;
5) Co-morbid
medical conditions, treatment and management;
6) Medication
history and compliance;
7) Strengths
and preferences;
8) Risk
indicators or potential;
9) Criminal
history;
10) ADL
and IADL self-management skills;
11) Medical
condition, including any medical condition that may have an impact on the
person's appropriateness for placement in a community-based setting;
12) History
of physical abuse or trauma, including childhood sexual or physical abuse,
intimate partner violence, sexual assault, or other forms of interpersonal
violence;
13) Goals
and objectives that the consumer will need to achieve to be discharged to
community living; and
14) Preference
to be placed in a gender-specific unit or bed. The facility shall provide this
placement if it is available.
e) The
assessment shall include a consultation with the treating psychiatrist or other
professional staff and other persons of the consumer's choosing.
f) The
assessments shall be completed by an LPHA and reviewed and signed by the
treating psychiatrist within 14 days after admission. The psychiatrist shall
complete an independent mental status exam and confirm or revise the initial
diagnosis.
g) Re-assessment
by the Department of Healthcare and Family Services
1) The
Department of Healthcare and Family Services or its designee may conduct
re-assessments to comply with the requirements of the Williams Consent Decree.
The re-assessments may be conducted:
A) Annually;
or
B) No more
than once every three months, upon request by the consumer who declined to move
to a community-based setting.
2) Annual
re-assessments shall document the reasons for the consumer's opposition to
transferring to a community-based setting.
h) Re-assessment
by the Facility
1) The
facility shall also conduct re-assessments:
A) To
develop or update a treatment plan; and
B) When
there is a change in the consumer's clinical functioning.
2) A
recovery and rehabilitation supports unit shall conduct re-assessments within
120 days following admission of a consumer.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.210 INDIVIDUALIZED TREATMENT PLAN
Section 380.210 Individualized Treatment Plan
a) Each
individualized treatment plan that is implemented by a facility shall be
developed with the following principles:
1) The
consumer shall be an active participant in the development and evaluation of
the treatment plan and progress.
2) All
diagnoses and treatment recommendations and options shall be shared and
explained to the consumer, within clinical limits.
3) The
facility shall seek and honor the consumer's preferences as the treatment plan
is developed.
4) The
individualized treatment plan shall focus on developing self-reliance, personal
decision making, and resiliency.
5) The
consumer's strengths shall be identified, and all treatment strategies shall
build upon and use these strengths to support the consumer's recovery.
6) The
consumer's needs shall be identified for home, community and work environments.
7) The
consumer's expressed values and culture shall be considered in the development
of the plan.
b) For
triage, the treatment plan shall be initiated on admission and shall be updated
prior to discharge. For crisis stabilization, the treatment plan shall be
updated at least once every seven days. For transitional living, the treatment
plan shall be updated at least once every 30 days. For recovery and
rehabilitation supports, the treatment plan shall be updated at least
quarterly. For crisis stabilization, transitional living, and recovery and
rehabilitation supports, the treatment plan shall be updated whenever there has
been a change in the consumer's clinical function that has prompted a
re-assessment. When updated, the treatment plan shall reflect:
1) Any
new interventions that are required to promote stabilization and recovery; and
2) Any
changes in the consumer's needs and preferences, including his or her desire to
move to a community-based setting.
c) For
recovery and rehabilitation supports units only, if a consumer declines to move
to a community-based setting, the new individualized treatment plan shall
incorporate appropriate services to assist in the acquisition of activities of
daily living and illness self-management.
d) The
treatment plan shall be reviewed by the treating psychiatrist, the medical
doctor, and the IDT, and signed by a physician.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.220 TRANSFER OR DISCHARGE
Section 380.220 Transfer or Discharge
a) Consumers
shall be free to leave at any time. If a consumer in a triage center expresses
a desire to contact a third party for any purpose, the facility staff shall
contact that third party on behalf of the consumer. (Section 3-108 of the
Act)
b) A
consumer may be discharged from a facility after he or she gives the executive
director, a physician, or a nurse of the facility written notice of the desire
to be discharged. If a guardian has been appointed for a consumer, the consumer
shall be discharged upon written consent of his or her guardian. In the event
of a requested consumer discharge, the facility is relieved from any
responsibility for the consumer's care, safety, and well-being upon the
consumer's discharge. (Section 3-111 of the Act) This requirement shall
not be construed to limit the consumer's right to leave the facility at any
time.
c) The
process for the involuntary transfer or discharge of a consumer from a facility
shall be conducted in accordance with Sections 3-401 through 3-423 of the
Nursing Home Care Act.
d) The
facility shall contact the community-based behavioral health provider following
the consumer's discharge from the facility to ensure that the consumer is
receiving follow-up care.
e) All
facilities shall provide educational materials and information to all Williams
Class Members voluntarily or involuntarily discharging from the facility at the
time of completing the discharge paperwork, informing them of their rights and
available services under the Consent Decree, as prescribed by the Williams Lead
Defendant Agency. All facilities shall provide written verification of
educational materials and information given to Williams Class Members, as
requested by a Williams Defendant Agency.
f) All
facilities shall notify any agency providing transition services to a Williams
Class Member of such Class Member’s discharge at least 48 hours prior to the
discharge taking place.
(Source: Amended at 46 Ill. Reg. 16870,
effective September 26, 2022)
SUBPART B: SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES PROGRAMS
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.300 TRIAGE CENTERS
Section 380.300 Triage Centers
a) Triage
centers shall provide an immediate assessment of consumers who present in
psychiatric distress, as an alternative to emergency room treatment or
hospitalization, and shall connect the consumer with community-based services
and treatment when considered necessary. Triage center staff shall determine
the continued treatment needs of the consumer and refer him or her to the
appropriate treatment services, if needed. A stay at a triage center shall not
exceed 23 hours.
b)
Consumers accepted at a triage center shall:
1) Have
acute symptoms of psychiatric crisis, requiring a structured assessment within
a safe, therapeutic environment; and
2) Be
expected to benefit from the treatment provided in a triage center.
c) Consumers
may self-refer to a triage center. Consumers may access a triage center
from a number of referral sources, including family, emergency rooms,
hospitals, community behavioral health providers, federally qualified health
providers, or schools, including colleges or universities. (Section 1-102
of the Act)
d) Triage
centers shall not accept for admission:
1) Consumers
who are directly referred by police;
2) Anyone
younger than 18 years of age;
3) Anyone
who is severely intoxicated, or who is at risk of severe withdrawal symptoms
from alcohol or other substances as indicated by a DHS-DMH screening
instrument;
4) Anyone
who has one of the medical conditions in Section 380.120(n), requiring active
intervention or treatment and a higher level of medical care beyond the
capabilities of the triage center;
5) Anyone
who presents an imminent risk of harm to himself or herself or to others
meeting the criteria of involuntary commitment in Section 1-119 of the Mental
Health and Developmental Disabilities Code;
6) Anyone
who is unable to care for himself or herself meeting the criteria of
involuntary commitment in Section 1-119 of the Mental Health and Developmental
Disabilities Code;
7) Consumers
who are non-ambulatory; or
8) Anyone
who falls under any other restrictions in the Act and this Part, including
exclusions from the definition of "consumer" in Section 380.100.
e) A
triage center shall call 911 for consumers who need immediate medical attention
and assess the need for basic life support, and administer the basic life
support as clinically indicated.
f) Service
Requirements
A consumer who presents at a
triage center shall be immediately assessed by an LPHA, or shall be assessed as
quickly as is practicable if the triage center is experiencing high consumer
traffic. Additional service requirements include:
1) Initial
service planning;
2) Case
management to provide linkage regarding a consumer's next level of services;
3) Brief
therapy interventions, as needed;
4) Assistance
with ADLs, as needed;
5) Safety
monitoring;
6) Medication
services;
7) Determining
whether a consumer may require additional services due to a dual diagnosis;
8) The
provision of basic medical assessments, including, but not limited to, vital
signs and blood sugar levels; and
9) Engagement
of family and natural supports, as practical.
g) Staffing
Requirements
The triage center shall maintain
the following staffing levels on site in the triage center at all times.
1) At
least one LPHA shall be on site at all times to provide clinical supervision
and assessment services.
2) A
psychiatrist, or a psychiatric advanced practice nurse (APN), shall be
immediately available by phone 24 hours per day, and shall be able to respond
on site within 90 minutes after being contacted by phone, when facility staff
considers this necessary.
3) At
least one registered nurse shall be on site at all times to provide health care
services.
4) At
least one CRSS shall be on site daily to provide recovery support services.
Whenever possible, each consumer shall have at least one individual
face-to-face discussion with a CRSS prior to discharge from the triage center.
5) At
least one MHP per every eight or fewer consumers shall be on site and available
to provide mental health services to individuals 24 hours per day.
6) Safety
personnel shall be available 24 hours per day, and shall be able to respond
within five minutes after being contacted by phone.
h) To
ensure rapid and priority access for referrals, a triage center shall maintain
collaborative agreements with psychiatric centers, detox centers, longer-term
residential substance abuse treatment centers, homeless shelters, hospitals,
ambulance departments, and outpatient mental health centers.
i) Discharge
Planning
1) Discharge
planning shall be conducted in conjunction with a community-based behavioral
health provider, a community mental health center, or other service provider
selected by the consumer.
2) In
conjunction with the consumer and any individual acting on behalf of the
consumer at the consumer's request, a minimum of a QMHP shall develop, or
supervise the development of, the discharge plan.
3) Depending
on the final assessment of the consumer, he or she may be discharged to home or
another living arrangement or, subject to authorization, a community-based
behavioral health provider residential program, a crisis stabilization unit, a
recovery and rehabilitation supports unit, a transitional living unit, or other
appropriate clinical treatment site.
j) A
triage center may be located in a building separate from the licensed location
of a facility, but shall not be more than 1,000 feet from the licensed location
of the facility and must meet all of the facility standards applicable to the
licensed location. If the triage center does operate in a separate building,
safety personnel shall be provided, on site, 24 hours per day and the triage
center shall meet all other staffing requirements without counting any staff
employed in the main facility building. (Section 1-102 of the Act)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.310 CRISIS STABILIZATION UNITS
Section 380.310 Crisis Stabilization Units
a) Crisis
stabilization units shall provide safety, structure and the support necessary,
including peer support, to help a consumer to stabilize a psychiatric episode.
The maximum length of stay at a crisis stabilization unit shall not exceed 21
days.
b) Consumers
admitted to a crisis stabilization unit shall:
1) Be
diagnosed as having a serious mental illness;
2) Be
experiencing an acute exacerbation of psychiatric symptoms;
3) Have
a need for assessment and treatment within a structured, supervised therapeutic
environment; and
4) Be
expected to benefit from the treatment provided.
c) A
consumer shall not be admitted to a crisis stabilization unit without approved
authorization by the State-designated assessment and authorization entity.
d) Visiting
family members who are younger than age 18 shall be accompanied by an adult.
e) Crisis
stabilization units shall not accept for admission:
1) Anyone
younger than 18 years of age;
2) Anyone
who is intoxicated, as manifested by unstable vital signs or neurologic
impairment, including but not limited to stupor, disorientation, or difficulty
with swallowing or breathing that requires medical monitoring to assure medical
safety, or who is at risk of severe withdrawal symptoms from alcohol or other
substances;
3) Anyone
who has one of the medical conditions in Section 380.120(n) requiring active
intervention or treatment and a higher level of medical care beyond the
capabilities of the crisis stabilization unit;
4) Anyone
who is an imminent risk of harm to himself or herself or others, or who is
unable to care for himself or herself, and who is eligible for involuntary
commitment under the Mental Health and Developmental Disabilities Code;
5) Consumers
who are non-ambulatory; or
6) Anyone
who falls under any other restrictions in the Act and this Part, including
exclusions from the definition of "consumer" in Section 380.100.
f) Service
Requirements
The crisis stabilization unit
shall ensure that all consumers who are admitted undergo an immediate
assessment that, in consultation with the consumer, identifies and prioritizes
the immediate and longer term services that the consumer needs. Additional
service requirements include:
1) Treatment
planning in accordance with Section 380.620(a);
2) Ongoing
assessment to determine the consumer's progress and readiness for discharge;
3) Case
management, including discharge planning, linkage to the community-based
behavioral health provider that has been identified as responsible for the
outpatient care for that consumer, referral and follow-up;
4) Therapeutic
interventions that use evidence-based practices;
5) Meal
services, in accordance with Section 380.650;
6) Assistance
with activities of daily living, as needed;
7) Support
and monitoring for safety, to include face checks as needed;
8) Skill
building to facilitate illness self-management through the identification,
development and use of individual strengths and natural supports;
9) Psychiatric
evaluations;
10) Medication
services; and
11) The
capability of providing dual diagnoses services for a consumer, if needed.
g) The
crisis stabilization unit shall provide 32 hours per week of group or
individual active treatment, as prescribed by each consumer's treatment plan.
The active treatment shall be documented in the consumer's record.
h) Discharge
Planning
1) In
conjunction with the consumer and any individual acting on behalf of the
consumer at the consumer's request, a minimum of a QMHP shall develop, or
supervise the development of, the discharge plan.
2) Discharge
planning shall be conducted in conjunction with a community mental health
center or other service provider selected by the consumer.
3) All
discharge planning shall commence on admission to the crisis stabilization
unit. If a consumer is homeless, the discharge planning shall include the
immediate identification of living arrangements.
4) The
crisis stabilization unit shall facilitate connection to the community-based
behavioral health provider or community-based provider prior to discharge to
foster the development of, or maintain the treatment relationship with, the
community-based behavioral health provider or community-based provider.
5) The
discharge plan shall be reviewed with the consumer and with any individual
acting on behalf of the consumer at the consumer's request, and it shall be
revised as progress indicates. At a minimum, the review shall occur once every
seven days until discharge.
6) A
consumer's supervision levels and his or her needed level of service shall be
part of the assessment in determining the discharge plan.
i) The
assessment of a consumer's need for face checks pursuant to subsection (f)(7)
shall be ongoing and adjusted as needed.
j) Staffing
Requirements
In no case shall the staffing
ratio in a crisis stabilization unit be less than 3.6
hours of direct care for each consumer. (Section 2-102(1) of the
Act) For the purposes of this Section, "on site" means being in the
crisis stabilization unit within a facility. The unit determines the work
hours of the employee. For the purpose of computing staff-to-resident ratios,
direct care staff shall include the following:
1) An
LPHA, to provide clinical supervision of the program. The LPHA shall spend at
least 50% of each full-time equivalent (FTE) work week on site at the crisis
stabilization unit;
2) At
least one QMHP per every 16 or fewer consumers, to provide assessment,
individual and group therapy, and other mental health services as needed;
3) A
psychiatrist or advance practice nurse who shall be immediately available by
phone 24 hours per day and who shall be able to respond on site within 90
minutes after being contacted by phone when facility staff considers this
necessary;
4) At
least one registered nurse to provide at least 15 minutes of nursing care per
day for each consumer;
5) At
least one CRSS, on duty and available for services four hours per day, seven
days per week. Each consumer shall have at least one individual,
face-to-face-discussion with a CRSS prior to discharge or transfer to another
level of service, as well as the opportunity for participation in group and
individual meetings to develop a consumer's Wellness Recovery Action Plan;
6) MHPs,
to provide mental health services to consumers 24 hours per day. The ratio of
individuals served to MHPs shall not exceed 16 to one;
7) RSAs,
to provide support and assistance to consumers 24 hours per day. The ratio of
individuals served to RSAs shall not exceed 16 to one.
k) The
staff of a crisis stabilization unit also shall include a dietetic service
supervisor and safety personnel, but these shall not be considered part of the
facility's direct care staff.
l) Safety
personnel shall be available 24 hours per day, and shall be able to respond
within five minutes after being contacted by phone. While crisis stabilization
units shall be secure, they are not required to be locked.
m) The
direct care staff shall meet weekly for cross-training to support professional
skill development.
n) A
crisis stabilization unit shall maintain collaborative agreements with:
1) Community-based
behavioral health providers to facilitate discharge planning; and
2) A
local psychiatric unit to assure rapid priority access when a consumer needs to
be admitted to the psychiatric unit.
o) Consumer
preferences shall be considered whenever possible.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.320 RECOVERY AND REHABILITATION SUPPORTS CENTERS
Section 380.320 Recovery and Rehabilitation Supports
Centers
a) Recovery
and rehabilitation supports centers shall facilitate a consumer's
longer-term symptom management and stabilization while preparing the consumer
for transitional living units or transition to the community by
improving living skills and community socialization. The duration of stay in this
setting shall be based on the clinical needs of the consumer, as
determined by the consumer's interdisciplinary team. (Section 1-102 of the Act)
b) Consumers
admitted to an RRS center shall be in need of RRS care as determined by
State-authorized assessment, level of service determination, and authorization
criteria.
c) A
consumer shall not be admitted to an RRS center without authorization and
without undergoing the authorization and background check requirements of
Sections 380.170 and 380.180.
d) RRS centers
shall not accept for admission:
1) Anyone
younger than 18 years of age;
2) Anyone
with a primary diagnosis of substance use disorder;
3) Anyone
who has one of the medical conditions in Section 380.120(n), requiring active
intervention or treatment and a higher level of medical care beyond the
capabilities of the RRS center;
4) Anyone
diagnosed with a traumatic brain injury or diagnosed with dementia;
5) Consumers
who are non-ambulatory;
6) Anyone
who presents an imminent risk of harm to himself or to herself, or to others
and is eligible for involuntary commitment under the Mental Health and
Developmental Disabilities Code; or
7) Anyone
who falls under any other restrictions in the Act and this Part, including
exclusions from the definition of "consumer" in Section 380.100.
e) The
determination that a consumer meets the requirements of subsections (d)(2)
through (d)(6) shall be made by the center's LPHA. The determination shall be
in writing, shall be kept on file at the center for no less than three years,
and shall be made available to the Department or to DHS-DMH upon request.
f) Service
Requirements
The recovery and rehabilitation
supports center shall ensure that:
1) Treatment
planning is conducted in accordance with Section 380.210;
2) The
continued stay of all consumers is subject to demonstrated medical necessity as
substantiated by regular authorization reviews pursuant to the assessment
timetables in Section 380.210(b);
3) The
facility is capable of performing dual diagnosis services for consumers,
including the engagement of services appropriate for the pre-contemplative
state of recovery;
4) The
facility provides consumers with assistance in identifying and developing
natural supports in the community;
5) Consumers
receive an initial assessment of their mental health treatment and training
needs as required in Section 380.200(d). The initial assessment shall occur within
the first two weeks after admission and shall be updated no less than
quarterly;
6) Consumers
receive adequate case management, including discharge planning and linkage,
referral and follow-up to all necessary supports needed to live safely in the community;
7) Consumers
receive appropriate therapeutic interventions, including evidence-based
practices of IMR, WRAP, motivational interviewing, cognitive training, and
wellness and resilience support development.
8) Consumers
are provided training in ADLs and IADLs, as clinically appropriate;
9) Consumers
receive regular psychiatric and medical evaluations as indicated by changing
conditions in their treatment plans, or as a part of other authorization
processes;
10) Consumers
receive 15 hours of treatment programming per week, and that the care is
documented in the consumer's medical record and is part of the consumer's
treatment plan; and
11) Consumers
receive adequate medication services, pursuant to Section 380.630.
g) Staffing
Requirements
In no case shall the staffing
ratios in a recovery and rehabilitation supports center be less
than a staffing ratio of 1.8 hours of direct care for each
consumer. (Section 2-102(2) of the Act) For the purposes of this Section, "on
site" means being present in the RRS unit within a facility. For the
purpose of computing staff-to-resident ratios, direct care staff shall include
the following:
1) An
LPHA, to provide clinical supervision of the program. The LPHA shall spend at
least 25% of each work week on site at the RRS center;
2) For
each consumer, a minimum of 15 minutes of nursing care per day by a registered
nurse or licensed practical nurse;
3) At
least one CRSS, on site eight hours per day, five days per week, to provide
recovery support services. Each consumer shall have at least one individual
face-to-face discussion with a CRSS within the first week after admission to
the RRS center, at least one additional individual, face-to-face discussion
prior to discharge or transfer, and the opportunity for participation in group
and individual meetings to develop a wellness recovery action plan;
4) MHPs,
on site and available to provide mental health services to consumers 24 hours
per day, seven days per week. The ratio of consumers to MHPs shall not exceed
32 to one;
5) RSAs,
on site and available to provide support and assistance to consumers, as
needed, 24 hours per day. The ratio of consumers to RSAs shall not exceed 16
to one;
6) An
LPHA, QMHP or MHP to provide clinical services, e.g., treatment planning and
therapy, for 60 minutes per consumer per week;
and
7) An
LPHA, QMHP, MHP, RSA or occupational therapy assistant, to provide group
recreational and rehabilitative services for 60 minutes
per consumer per week.
h) The RRS
center shall ensure that a psychiatrist makes monthly visits to each consumer.
In addition, the psychiatrist shall be on call each day and shall be available
to respond on site within 24 hours after being contacted by the center when
considered necessary by staff.
i) The
staff of an RRS center also shall include a dietetic service supervisor, who
shall not be considered part of the facility's direct care staff.
j) An RSS
center shall maintain collaborative agreements with community mental health
agencies to facilitate discharge planning.
k) Discharge
Planning
1) In
conjunction with the consumer or any individual acting on behalf of the
consumer at the consumer's request, a minimum of a QMHP shall develop, or
supervise the development of, the discharge plan.
2) Discharge
planning shall be conducted in conjunction with a community mental health
center or other service provider selected by the consumer, and shall commence
as early in the admission as practicable.
3) The
RSS unit shall facilitate connection to the community-based behavioral health
provider or community-based provider in order to begin discharge planning.
Discharge planning shall be part of, and based on, the initial assessment that
is conducted when the consumer is admitted to the RSS unit.
4) The
discharge plan shall be reviewed at least quarterly with the consumer and any
individual acting on behalf of the consumer at the consumer's request, and
revised as progress indicates.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.330 TRANSITIONAL LIVING UNITS
Section 380.330 Transitional Living Units
a) Transitional
living units shall provide assistance and support to consumers with mental
illnesses who have not yet acquired, or who have lost previously acquired,
skills needed for independent living and are in need of and can benefit from
services in a structured, supervised setting in which the consumer can acquire
and practice these skills. The maximum length of stay at a transitional living
unit shall be 120 days, and no unit shall be larger than 16 beds.
b) Consumers
admitted to a transitional living unit shall:
1) Be in
need of transitional living assistance and support as determined by
State-authorized assessment, level of service determination, and authorization
criteria;
2) Within
the past two years, have received a minimum of 60 days of psychiatric hospital
care or a minimum of 90 days of institutional care for an exacerbation of
serious mental illness;
3) As a
result of mental illness, lack critical ADLs or IADLs necessary for living in a
less restrictive environment, and require an ongoing structured, supervised
therapeutic environment to develop these skills; and
4) Demonstrate
an ability to generalize skills and to receive supports from a community
provider for transition to a community setting.
c) A
consumer who meets the requirements of subsection (b), except for subsection
(b)(2), and who receives authorization pursuant to Section 380.200, may be
referred to a transitional living unit by a community mental health agency or
managed care entity under an ongoing agreement under the following conditions:
1) The
referral includes a documented, specific list of skill sets that the consumer
needs to acquire;
2) The
consumer's documented attempts to develop ADLs and IADLs in the community have
been unsuccessful;
3) The
consumer has a documented history of chronic homelessness as defined in 24 CFR
578.3 and has been diagnosed with serious mental illness; and
4) The
consumer chooses to receive treatment in a transitional living unit, and the consumer's
choice has been documented.
d) If a
consumer is admitted as a result of a direct transfer from the RSS unit in the
facility, and has had a background check within the previous 365 days, a
background check under Section 380.180 is not required prior to admission to a
transitional living unit.
e) A
transitional living unit shall cooperate with a consumer's family, or other
persons identified by the consumer, with whom the consumer will live after
discharge.
f) A
transitional living unit may admit consumers who were hospitalized, if those
consumers meet the requirements of subsections (b)(1) through (b)(4) or
subsection (c).
g) Transitional
living units shall not accept for admission:
1) Anyone
younger than 18 years of age;
2) Anyone
with a demonstrated sufficient ability to perform ADLs and IADLs well enough to
function in a less restrictive environment;
3) Anyone
with a primary diagnosis of substance use disorder;
4) Anyone
who has one of the medical conditions in Section 380.120(n), requiring active
intervention or treatment and a higher level of medical care beyond the
capabilities of the transitional living unit;
5) Anyone
who is unable to participate in rehabilitation or engage in treatment and
services in the transitional living unit;
6) Anyone
diagnosed with a traumatic brain injury or diagnosed with dementia;
7) Anyone
who presents an imminent risk of harm to himself or to herself, or to others
and who is eligible for involuntary commitment under the Mental Health and
Developmental Disabilities Code;
8) Anyone
who is non-ambulatory; or
9) Anyone
who falls under any other restrictions in the Act and this Part, including
exclusions from the definition of "consumer" in Section 380.100.
h) Visiting
family members who are younger than age 18 shall be accompanied by an adult.
i) Service
Requirements
The transitional living unit shall
ensure that:
1) An
occupational therapist completes a face-to-face assessment within the first
week after each consumer's admission. All recommendations, including the
services to be offered to the consumer, shall be discussed with the consumer;
2) Each
consumer receives 90 minutes of individual occupational therapy or
rehabilitation per week, provided by an occupational therapy assistant or a
trained RSA and an MHP, and each consumer receives 18 hours of treatment
programming per week. The RSA and the MHP shall be trained in evidence-based
skills training. The occupational therapy, rehabilitation, and treatment
programming shall be documented in the consumer's record and shall be part of
each consumer's individualized treatment plan;
3) Treatment
planning is conducted in accordance with Section 380.620(a);
4) Consumers
receive an ongoing assessment, pursuant to the requirements in Section
380.210(b), of their mental health treatment and training needs related to the
ADLs and IADLs. These assessments shall include:
A) Risk
assessment and appropriate risk mitigation alternative strategies;
B) Assessing
the consumer's ability to manage money; and
C) A
cognitive screen related to skill development;
5) Consumers
receive adequate case management, including discharge planning, linkage,
referral and follow up;
6) Consumers
receive appropriate therapeutic interventions, including evidence-based
practices of IMR, WRAP, motivational interviewing, cognitive training, and
wellness and resilience support development;
7) Consumers
undergo intensive training in ADLs and IADLs, including the use of a dietitian or
dietetic services supervisor in meal planning and training for individuals with
medical diet needs;
8) Consumers
receive adequate skill building to facilitate illness self-management through
the identification, development and use of individual strengths and natural
supports;
9) Consumers
receive regular psychiatric evaluations as indicated by changing conditions in
the treatment plans, or as part of other authorization processes;
10) Consumers
receive adequate medication services, pursuant to the requirements in Section
380.630; and
11) The
transitional living unit is capable of performing dual diagnosis services for a
consumer, if needed.
j) Staffing
requirements
In no case shall the staffing
ratios in a transitional living unit be less than a staffing
ratio of 1.6 hours of direct care for each consumer [210 ILCS 49/2-102(3)].
For the purposes of this Section, "on site" means being present in
the transitional living unit within a facility. For the purpose of computing
staff-to-resident ratios, direct care staff shall include the following:
1) An
LPHA, who shall provide clinical supervision of the program. The LPHA shall
spend at least 30 minutes per week per consumer on site at the transitional
living unit and be on the unit at least three days per week;
2) For
every consumer, at least 15 minutes of nursing care per day by a registered or
licensed practical nurse;
3) At
least one CRSS on duty and available for services 90 minutes per consumer per
week. Each consumer shall have at least one individual face-to-face discussion
with a CRSS within the first week after admission to the transitional living
unit, and at least one additional individual, face-to-face discussion prior to
discharge or transfer, as well as the opportunity for participation in group
and individual meetings to develop his or her wellness recovery action plan.
An MHP may substitute for a CRSS if the facility has documented, unsuccessful
efforts, at least every six months, to employ a CRSS in compliance with Section
380.130(k);
4) MHPs,
who shall be on site and available 24 hours per day, seven days per week to
provide mental health and casework services to consumers. The ratio of
consumers to MHPs shall not exceed 16 to one.
k) Facility
staff shall make documented, scheduled rounds every two hours to the
transitional living unit whenever only one staff member is on duty. If the
transitional living unit has admitted a consumer who was not already residing
in the facility, the rounds when only one staff member is present shall be
every hour of the first week of the consumer's admission.
l) RSAs
and other staff shall be present as needed to fulfill the service requirements
of subsection (i) and any other service requirements of this Part.
m) The
transitional living unit shall develop a written emergency response plan that
requires, at a minimum that safety personnel be available 24 hours per day and
able to respond within five minutes after being contacted by phone. Overnight
staff in the transitional living unit shall be trained in the implementation of
the emergency response plan.
n) The
transitional living unit shall arrange for a psychiatrist to make routine
visits. In addition, a psychiatrist shall be on call to the transitional
living unit daily and respond on site within 24 hours when deemed necessary by
staff.
o) Each
transitional living unit shall have a dietitian available who conducts at least
one assessment of each consumer within the first week after admission. The
dietetic service supervisor shall function as a part of the treatment team,
participating in the development of treatment recommendations, advising staff
of any dietary concerns, and providing training to direct care staff regarding
the development of meal planning, budgeting and cooking skills.
p) The
treatment team shall conduct weekly meetings to facilitate cross training to
support skill development.
q) A
transitional living unit shall maintain collaborative agreements with community
mental health agencies, local psychiatric units, and substance abuse providers
to facilitate discharge planning.
r) Discharge
Planning
1) In
conjunction with the consumer and any individual acting on behalf of the
consumer at the consumer's request, a minimum of a QMHP shall develop, or
supervise the development of, the discharge plan.
2) Discharge
planning shall be conducted in conjunction with a community mental health
center or other service provider selected by the consumer and shall commence on
admission to the transitional living unit.
3) The
transitional living unit shall facilitate connection to the community-based
behavioral health provider or community-based provider to begin discharge
planning within the first month after admission to the transitional living unit
to foster the development of, or maintain the treatment relationship with, the
community-based behavioral health provider or community-based provider.
4) The
discharge plan shall be reviewed with the consumer and any individual acting on
behalf of the consumer at the consumer's request and revised as progress
indicates. This review shall be conducted a minimum of once every 30 days
until discharge.
SUBPART C: PROGRAM PERSONNEL
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.400 EMPLOYEE PERSONNEL POLICIES AND RECORDS
Section 380.400 Employee Personnel Policies and Records
a) Each
facility shall develop and maintain written personnel policies that are
followed in the operation of the facility. These policies shall include, at a
minimum, each of the requirements of this Section.
b) Employee
Records
1) Employment
application forms shall be completed for each employee and kept on file in the
facility. Completed forms shall be available to the Department for review.
2) Individual
personnel files for each employee, intern, unpaid staff and volunteer regularly
scheduled at least weekly to work directly with consumers shall contain date of
birth; home address; educational background; experience, including types and
places of employment; date of employment and position employed to fill in this
facility; and (if no longer employed in this facility) last date employed.
3) Individual
personnel files for each employee, intern, unpaid staff and volunteer regularly
scheduled at least weekly to work directly with consumers shall contain health
records, including the initial health evaluation and the results of the
tuberculin skin test, and any other pertinent health records.
4) Individual
personnel records for each employee, intern, unpaid staff and volunteer regularly
scheduled at least weekly to work directly with consumers shall contain records
of the employee's performance evaluations.
c) Prior
to employing any individual in a position that requires a State license or
certification, the facility shall contact the Illinois Department of Financial
and Professional Regulation or certifying entity to verify that the
individual's license is active. A copy of the verification shall be placed in
the individual's personnel file.
d) For
all non-licensed employees, interns, unpaid staff and volunteers regularly
scheduled at least weekly to work directly with consumers, the facility shall
comply with Section 380.420.
e) All
personnel shall have either training or experience, or both, in the job
assigned to them. Written documentation of this training shall be placed in
each employee's personnel file and shall be made available to the Department
upon request.
f) The
facility shall have a comprehensive set of written personnel policies and
procedures that include, but are not limited to:
1) Job
descriptions and qualifications and documentation of current licensure and
certification for all staff, including those on contract with the facility or
with an entity subcontracting with the facility. The facility shall also
maintain job descriptions for volunteers, interns and other unpaid personnel;
2) Documentation
that staff and interns who provide or supervise services pursuant to this Part
meet the staff qualifications defined in this Part and that their individual
performance is evaluated at least once every 12 months;
3) Documentation
that volunteers regularly scheduled at least weekly to work directly with
consumers and other unpaid personnel who provide services pursuant to this Part
meet the requirements in Section 380.130(m) and that their individual
performance is evaluated at least once every 12 months; and
4) Documentation
that the facility has written personnel policies concerning hiring, evaluating,
disciplining and terminating employees, interns, unpaid staff and volunteers
regularly scheduled at least weekly to work directly with consumers.
g) The
facility shall provide to the Department, upon request, written documentation
indicating that staff have engaged in professional development and continuing
education as prescribed by DHS-DMH. Acceptable documentation shall demonstrate
post-training competency, including copies of post tests or certificates of
completion. Annual in-service training programs approved by DHS-DMH shall
include the facility's policies, skill training and ongoing education to enable
all personnel to perform their duties effectively. The facility shall keep
written records of program content for each session and of personnel attending
each session, and the records shall be available to the Department upon
request.
h) Facilities
shall not allow any person to work in any capacity until the facility has
inquired of the Department's Health Care Worker Registry concerning the
person. If the Registry has information substantiating a finding of abuse or
neglect against the person, the facility shall not employ him or her in any
capacity.
i) Facilities
shall not allow volunteers regularly scheduled at
least weekly to work directly with consumers until the facility has
inquired of the Department's Health Care Worker Registry concerning the
person. If the Registry has information substantiating a finding of abuse or
neglect against the person, the facility shall not allow him or her to
volunteer in any capacity.
j) Each
facility shall develop, implement and maintain a plan for clinical supervision
of QMHPs, MHPs and RSAs who perform services under the Act and this Part.
Group supervision is acceptable, and the size of the group shall be conducive
to the provision of clinical supervision. Supervision shall be documented in
writing. Supervision of staff as noted in this subsection shall be for a
minimum of one hour per week through face-to-face, teleconference or
videoconference contact.
1) QMHPs shall be
supervised by an LPHA.
2) MHPs and RSAs shall be
supervised by, at a minimum, a QMHP.
3) LPHAs are not required
to have clinical supervision under this Section.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.410 INITIAL HEALTH EVALUATION FOR EMPLOYEES, INTERNS AND VOLUNTEERS
Section 380.410 Initial Health Evaluation for Employees,
Interns and Volunteers
a) Each
employee, intern, unpaid staff and volunteer regularly scheduled at least
weekly to work directly with consumers shall have an initial health evaluation,
which shall be used to ensure that employees are not placed in positions that
pose undue risk of infection to themselves, other employees, consumers or
visitors.
b) The
initial health evaluation shall be conducted within 90 days prior to employment
through 30 days after employment.
c) The
initial health evaluation shall include a health inventory. This inventory
shall be obtained from the employee and shall include the employee's
immunization status and any available history of conditions that would
predispose the employee to acquiring or transmitting infectious diseases. This
inventory shall include any history of exposure to, or treatment for,
tuberculosis. The inventory shall also include any history of hepatitis,
dermatologic conditions, chronically draining infections or open wounds.
d) The
initial health evaluation shall include a physical examination and shall
include a statement about the presence of any communicable disease that could pose a risk to the person, other employees,
consumers or visitors. The evaluation shall also determine whether the
employee is physically able to perform the job functions that the facility
intends to assign to the employee, intern, unpaid staff and volunteer regularly
scheduled at least weekly to work directly with consumers.
e) The
initial health evaluation shall include a tuberculin skin test that is
conducted in accordance with the Control of Tuberculosis Code. The facility
shall have a written policy on its tuberculin skin tests.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.420 HEALTH CARE WORKER BACKGROUND CHECK
Section 380.420 Health Care Worker Background Check
A facility shall comply with the Health Care Worker
Background Check Act and the Health Care Worker Background Check Code.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.430 EXECUTIVE DIRECTOR
Section 380.430 Executive Director
a) Each
facility shall employ an executive director to be responsible for the general
administration and supervision of the facility (Section 1-102 of the
Act), who is:
1) An
LPHA or QMHP with a minimum of at least two years of supervisory or management
experience and at least one year of relevant experience, e.g., working directly
with persons with serious mental illness; or
2) An
administrator licensed under the Nursing Home Administrators Licensing and
Disciplinary Act, with a minimum of at least two years of supervisory or
management experience and at least one year of experience working directly with
persons with serious mental illness.
A) At the
end of the three-year provisional license period, nursing home administrators who were acting
as executive directors of a specialized mental health rehabilitation facility as of July 22, 2013, and who had a minimum
of at least two years of supervisory or management experience and at least one
year of experience working directly with persons with serious mental illness
may serve as executive director of a facility licensed under the Act.
B) After
the provisional licensing period has ended, all newly hired executive directors of
specialized mental health rehabilitation facilities
shall meet the requirements listed in subsection
(a)(1).
b) The
licensee shall report any change in the executive director to the Department
within five days following the change.
c) The
executive director shall delegate, in writing, authority to a qualified
subordinate to act during the executive director's absence. This
administrative assignment shall not interfere with consumer care and
supervision. The Department will consider the executive director, or the person
designated by the executive director to be in charge of the facility in the
executive director's absence, to be the agent of the licensee for the purpose
of the Act and this Part. At the conclusion of any visit by Department
surveyors, the surveyors will provide the licensee with a copy of the report
before leaving the facility.
d) The
executive director shall arrange for facility supervisory personnel to annually
attend appropriate educational programs.
e) The
executive director shall appoint, in writing, a member of the facility staff to
coordinate the establishment of, and render assistance to, the consumers'
advisory council.
f) The
licensee and the executive director shall be familiar with the Act and this
Part and shall be responsible for ensuring that the applicable requirements are
met in the facility, and that employees are familiar with the requirements of
the Act and this Part relevant to their job duties.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.440 PSYCHIATRIC MEDICAL DIRECTOR
Section 380.440 Psychiatric Medical Director
a) The
facility shall have a psychiatric medical director who is licensed under the
Medical Practice Act of 1987 and who is board eligible or board certified in
psychiatry from the American Board of Psychiatry and Neurology. The
psychiatric medical director is responsible for advising the executive director
and the program LPHA on the overall psychiatric management of the consumers.
b) The
psychiatric medical director shall be the medical director of the facility. For
all non-mental illness related medical issues, the medical director shall
comply with Section 380.600(b)(3).
c) The
psychiatric medical director shall annually approve, in writing, the facility's
written policies and procedures applicable to the psychiatric programming.
d) The
psychiatric medical director shall be present at the facility for at least one
hour every week to meet with and observe consumers and staff and their
interactions and to make suggestions for changes in staff behavior and
training, including changes in the facility policies and procedures. The
facility shall keep records demonstrating that this requirement has been met.
SUBPART D: ADMINISTRATION
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.500 REQUIRED POLICIES AND PROCEDURES
Section 380.500 Required Policies and Procedures
a) The
licensee shall be responsible for compliance with licensing requirements and
for the organization, management, operation and control of the facility. The
delegation of any authority by the licensee shall not diminish the
responsibilities of the licensee.
b) A
facility shall establish written policies and procedures to implement the
responsibilities and rights provided under the Act and this Part. The
policies shall include the procedure for the investigation and resolution of
consumer complaints. The policies and procedures shall be clear and unambiguous
and shall be available for inspection by any person. A summary of the policies
and procedures, printed in not less than 12-point font, shall be distributed to
each consumer and representative. (Section 3-208 of the Act) Written
policies and procedures also shall be established and implemented for each of
the following:
1) The
administration and management of the facility;
2) Personnel
policies and procedures, which shall include:
A) Job
descriptions detailing qualifications and essential duties of each
classification of employee, available to all personnel;
B) Employee
orientation to the facility, job, consumer population, policies, procedures and
staff;
C) Employee
benefits;
D) Employee
health and grooming; and
E) Verification
of licensure, credentials, certification, education, training and references;
3) Policies
and procedures for consumer admission, transfer, day passes and weekend passes,
discharge and other care transitions; charge for services included in the basic
rate; charges for other services and causes for termination of services. The
facility shall comply with the rules of the State-designated assessment and
authorization entity;
4) Policies
and procedures governing consumer records, including, but not limited to:
A) Access
to, duplication of, and dissemination of information from consumer records,
with a specific policy and procedure for sharing information with behavioral
health providers and consumers pursuant to applicable federal and State laws;
and
B) Ensuring
confidentiality of consumer information, pursuant to applicable federal and
State laws and this Part;
5) Policies
and procedures for reporting incidents and accidents, the abuse and neglect of
consumers, and the theft of consumers' property and other data as required in
Section 380.530;
6) A
written organizational chart showing each program, the person in charge of each
program, the lines of authority, including responsibility and communication,
and the staff assignments, including information on the governing structure;
7) Policies
concerning the use of restraints only with informed consent, and other
restraint and therapeutic separation policies and procedures pursuant to the
Act and to Section 380.160;
8) Policies
concerning the administration of psychotropic medication only with informed
consent, and other informed consent to medical and psychiatric treatment
policies and procedures pursuant to the requirements in Section 380.150 of this
Part and Section 3-106(b) of the Act;
9) Policies
and procedures to ensure that experimental research and treatment on consumers
is conducted only in accordance with the oversight of an Institutional Review
Board, pursuant to the requirements in Section 380.580;
10) Dietary
services, policies and procedures; and
11) Environmental
services policies and procedures, including provision for the housekeeping and
maintenance of a safe, clean environment for consumers, employees and the
public.
c) Each
facility shall employ or otherwise provide an executive director, delegated by
the licensee to be responsible for the administration and management of the
facility. The executive director shall be responsible for the administration
and management of only one facility. If these responsibilities are delegated to
the executive director, liability shall remain with the licensee or the
facility's governing body.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.510 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT
Section 380.510 Quality Assessment and Performance
Improvement
a) The
licensee shall ensure that the facility's executive director and the governing
body develop, implement and maintain a data-driven quality assessment and
performance improvement (QAPI) program. The program shall emphasize quality
structures, processes and activities, with a goal of improved behavioral health
outcomes that enable consumers to transition to the most integrated
community-based settings possible. The written program shall be updated
annually and shall require the following:
1) An
ongoing program for quality improvement and consumer safety as a priority for
facility management that is communicated throughout the facility;
2) A
quality improvement committee that shall regularly review and evaluate all QAPI
activities and progress;
3) At
all levels of service in a facility, the priorities for improved quality of
care and consumer safety are identified and addressed, and all improvement
actions are evaluated for efficacy;
4) Written
benchmarks, targets and standards of care for safety and quality of care that,
for each indicator, shall be well established and communicated throughout the
facility. Outcomes shall be regularly reviewed to measure them against the
benchmarks and targets;
5) The
allocation of adequate resources for measuring, assessing, improving and
sustaining the facility's performance in complying with the Act and this Part;
6) A
method for investigating, monitoring and tracking incidents and accidents, with
a written action plan to prevent reoccurrences;
7) That
the facility share the results of the QAPI activities with the consumer's
advisory council. Results of data collections and performance improvement
projects (PIPs) shall be shared with the consumers' advisory council, and input
and recommendations from the consumers' advisory council shall be shared with
the governing body;
8) A
method for conducting annual PIPs, with the report of the PIP and
recommendations for process improvements shared with the executive director and
the governing body; and
9) A
data collection and reporting process that assures the submission, at least
quarterly, of all reports or other required data within prescribed time frames.
b) Quality
improvement indicators for triage, crisis stabilization, transitional living and
rehabilitation and recovery services shall include, at a minimum:
1) Verification
that prior-authorizations and re-authorizations were secured as applicable for
appropriate care and service delivery;
2) Verification
that assessments and treatment plans have been conducted to meet consumer
needs;
3) Verification
that evidence-based practices and person-centered treatment plans are being
performed to meet consumer needs as applicable;
4) Verification
that appropriate licensed and certified IDT professionals are performing duties
as required;
5) Verification
that planning and community linkage has occurred to facilitate
consumer-community integration;
6) Verification
that care coordination and case management systems are in place to achieve
quality treatment outcomes and community integration;
7) Verification
that facility policy and procedures are established, documented, implemented
and evaluated;
8) Verification
that consumer records contain all relevant information, including, but not
limited to, demographic information, historical information, medical
information, nutrition and dietary information, social information,
psycho-social information, treatment plans, therapy information, assessments,
discharge plans, and community support services; and
9) Verification
of training to the administration, to the supervisory staff, and to the direct
care staff.
c) The
quality improvement committee shall:
1) Review
all performance indicators, data from consumer quality of life surveys, staff
surveys, findings from root cause analyses, performance improvement projects,
and other relevant sources of data. The quality improvement committee shall
make recommendations to the facility leadership and governing body based on the
facility's performance of the indicators in subsection (b). The quality
improvement committee shall be composed of members of the facility management
team. Procedures for the operation of the quality improvement committee shall
be included in the written QAPI program plan; and
2) Conduct
a root cause analysis when an in-depth understanding is needed of an incident
or accident, or a violation, in the facility, including its causes and
implications. The quality improvement committee shall develop policies and
procedures for the use of root cause analyses to examine issues across systems
in the facility to prevent future serious incidents and accidents and
violations, and to promote sustained improvement. The findings of root cause
analyses shall be available to the Department, DHS-DMH and the Department of
Healthcare and Family Services upon request.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.515 REPORTABLE PERFORMANCE INDICATORS
Section
380.515 Reportable Performance Indicators
a) The
following information shall be made available to the Department upon entry to
the facility by a Department survey team:
1) Census
information;
2) Key
personnel of the facility and the facility's governing body;
3) A
roster of the facility's residents with room numbers;
4) Program
discharge summaries;
5) Accrediting
benchmark achievements;
6) Accrediting
performance improvement reports and compliance.
7) The
facility's staffing plan;
8) Staff
turnover rate;
9) The
facility's floor design;
10) The
facility's admissions and discharges;
11) Incident
reports prepared pursuant to Section 380.530;
12) The
facility's performance improvement project or projects;
13) Written
records on the facility's use of restraints;
14) Pharmacy
reports of adverse outcomes;
15) Medication
error reports;
16) The
facility's written policies and procedures; and
17) The
facility's identified offender list.
b) The
facility shall provide to the Department upon request all data elements that a
facility is required to submit to any State agency, managed care organization,
accrediting body, or any other third party.
c) The
facility shall submit the following reportable performance indicator information
concerning each level of service to the Department, DHS-DMH and the Department
of Healthcare and Family Services (HFS) at least monthly. Reportable
performance indicator information shall include, but not be limited to:
1) Admissions,
including referral sources and consumer living arrangements prior to admission;
2) Transfers
to other facilities, to facilities licensed under the Nursing Home Care Act, to
private hospitals for both medical and psychiatric treatment, and between
levels of service;
3) Discharges,
including the frequency of discharges to community-based behavioral health
providers, other community-based providers, private hospitals for both medical
and psychiatric treatment, State hospitals, detox centers, and involuntary
discharges;
4) All
emergency department visits for both medical and psychiatric treatment;
5) Re-admissions
to a facility within 30 days after discharge;
6) Suicides
and suicide attempts;
7) Deaths
of consumers, including deaths of consumers during hospital visits;
8) Incidents
of abuse, neglect, and maltreatment, including sexual assault; and
9) The
number of times restraints were used.
d) The
facility shall submit the results of consumer perception of care or quality of
life surveys to the Department, DHS-DMH and HFS at least biannually.
e) The
facility shall submit to the Williams Lead Defendant Agency an accurate census
of all Medicaid-eligible residents and the previous month’s voluntary and
involuntary discharges conducted under Section 380.220, including any voluntary
discharges and involuntary discharges scheduled within 48 hours of the end of
the reporting month. The monthly census must be submitted on the form
prescribed by the Williams Lead Defendant Agency using secure (encrypted)
email, no later than the fifth business day of each month.
(Source:
Amended at 46 Ill. Reg. 16870, effective September 26, 2022)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.520 INFORMATION TO BE MADE AVAILABLE TO THE PUBLIC
Section 380.520 Information to Be Made Available to the
Public
a) The
following information shall be conspicuously posted in a prominent location
accessible to the public:
1) A
listing of all services and programs provided directly by the facility and
those provided through written contracts;
2) Staffing
and personnel levels for each level of licensed service;
3) The
location of the most recent licensure and inspection information for the
facility, and the related plan of correction, if applicable, and that this
information is available for public review;
4) National
accreditation information;
5) Consumer
charges;
6) Consumer
complaint information;
7) State
specialized mental health rehabilitation facility benchmark performance percentages
for all certified programs provided by the facility;
8) That
the facility's written admission and discharge policies are available upon
request; and
9) A
notice of how to file a complaint with the Department's complaint hotline.
b) Procedures
for the public disclosure of information shall be in accordance with
provisions for inspection and copying of public records in the Freedom of
Information Act. (Section 3-205 of the Act)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.530 INCIDENTS, ACCIDENTS AND EMERGENCY CARE
Section 380.530 Incidents, Accidents and Emergency Care
a) The facility
shall have written policies and procedures for investigating, reporting, tracking and analyzing incidents,
accidents and emergency care situations through the facility's management
structure, up to and including the licensee
and governing body representatives.
The facility shall ensure that employees
demonstrate their knowledge of and follow,
these policies and procedures. A descriptive summary of each incident
and accident affecting a consumer shall also be recorded in the progress notes for
that consumer. For purposes of this Section, "serious" means any
incident or accident that causes physical harm or injury to a consumer and
requires medical treatment. Serious incidents, accidents and emergency care
situations shall include, but are not limited to, the following:
1) Sexual assault;
2) Abuse, neglect or other
maltreatment;
3) All
deaths, including deaths of consumers who have been transferred to a hospital;
4) Medication errors
that result in a consumer's unstable vital signs or referral to an emergency
room;
5) Physical injury;
6) Assault;
7) Battery;
8) Missing persons
after 24 hours;
9) Theft;
10) Criminal conduct, including arrests and other interaction
with police;
11) All
hospitalizations, both medical and psychiatric;
12) All
emergency department admissions, both medical and psychiatric; and
13) Fires.
b) The
facility shall notify the Department of any serious incident or accident
requiring emergency care situations and every consumer death.
c) Any
facility employee or agent who becomes aware of a serious incident or accident,
emergency care situation involving a consumer, or becomes aware of a consumer
death, shall report it immediately to the executive director. An executive
director who becomes aware of the incident, accident or emergency care
situation involving a consumer, or becomes aware of a consumer death, shall
immediately report the matter by telephone and in writing to the consumer's
guardian, the consumer's substitute decision maker, if any, any other
individual designated in writing by the consumer, and the Department. The
executive director shall report consumer allegations of abuse or neglect to the
Department within 24 hours after the allegation is made.
d) The
facility shall, by fax or phone, notify the Department central office within 24
hours after each serious incident, accident or emergency care situation. If a
reportable incident, accident or emergency care situation results in the death
of a consumer, the facility shall, after contacting local law enforcement
pursuant to Section 380.550, notify the Department central office by phone
only. For the purposes of this Section, "notify the Department central
office by phone only" means talk with a Department representative who
confirms over the phone that the requirement to notify the regional office by
phone has been met. If the facility is unable to reach a representative during
non-business hours, the facility shall notify the Department's toll free
complaint registry hotline.
e) As
soon as possible, but no later than 24 hours after the occurrence, the facility
shall report any incident that is subject to the Criminal Code of 2012 to local
law enforcement agencies.
f) The
facility shall send a written narrative summary of each serious incident,
accident or emergency care situation to the Department within seven days after
the occurrence.
g) The
facility shall maintain a log of incidents, accidents, or emergency care
situations that are not considered to be serious because the consumer has not
incurred physical or mental harm or injury requiring medical treatment, including
all physical altercations involving a consumer and all threats of physical violence
directed at a consumer or made by a consumer. The log shall be reviewed weekly
by the facility's internal clinical quality assurance staff and shall be
available to the Department upon request. The log shall include, at a minimum:
1) The
name of the perpetrator;
2) The
name of the victim, if any;
3) Any
injury sustained by the victim;
4) A
brief summary of the incident;
5) The
number of prior incidents involving the perpetrator;
6) The
number of prior incidents involving the victim;
7) Whether
a physician (and whose physician) was called and any orders entered as a
result; and
8) What
the staff did to prevent recurrence of the incident.
h) The
provisions under the Whistleblower Act shall apply to employees of facilities
licensed under the Act.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.540 ABUSE, NEGLECT AND THEFT
Section 380.540 Abuse, Neglect and Theft
a) A licensee, executive director, employee, or agent of a
facility shall not abuse or neglect a consumer. It is the duty of any facility
employee or agent who becomes aware of abuse or neglect of a consumer to
report it immediately to the executive director and to the Department, but
no later than within 24 hours after becoming aware of it. Facilities
shall comply with Section 3-610 and 3-810 of the Nursing Home Care Act. With
respect to theft or misappropriation of a consumer's property, and to
whistleblower protection, the provisions under Section 3-610 and 3-810 of
the Nursing Home Care Act shall apply to employees of facilities licensed under
the Act. (Section 3-107 of the Act)
b) An executive director who becomes aware of the abuse or
neglect of a consumer or theft of a consumer's property shall immediately
report the matter by telephone and in writing to the consumer's guardian, the
consumer's substitute decision maker, if any, or any other individual
designated in writing by the consumer, and to the Department, but no later than
within 24 hours after becoming aware of the abuse, neglect or theft.
c) Consumers shall not be subjected to verbal or physical abuse
of any kind. Corporal punishment of consumers is prohibited. The facility
shall not permit consumers to discipline other consumers. The facility shall
comply with this Section and with Section 380.550 in every instance of assault or
battery by a consumer of another consumer or of an employee.
d) A facility employee or agent who becomes aware of another
facility employee's or agent's theft or misappropriation of a consumer's
property shall immediately report the matter to the executive director. An
executive director who becomes aware of a facility employee's or agent's theft
or misappropriation of a consumer's property shall immediately report the
matter by telephone and in writing to the consumer's representative, the
Department, and the local law enforcement agency.
e) Consumer allegations of abuse shall be reported to the
Department within 24 hours after the allegation is made, and the facility shall
comply with the reporting requirements of Section 380.550. A full investigation
report shall be filed with the Department within seven days after the incident
occurred.
f) Employee as Perpetrator of Abuse. When an investigation of a
report of suspected abuse of a consumer indicates that an employee of the
facility is the perpetrator of the abuse, that employee shall immediately be
barred from any further contact with any consumer in the facility, pending the
outcome of any further investigation, prosecution or disciplinary action
against the employee.
g) Consumer as Perpetrator of Abuse. When an investigation of a
report of suspected abuse of a consumer indicates that another consumer residing
in the facility is the perpetrator of the abuse, the perpetrator's condition
shall be immediately evaluated to determine the most suitable therapy and
placement for that person, considering the safety of that person as well as the
safety of other consumers and of employees of and visitors to the facility.
g) The
provisions of the Whistleblower Act shall apply to
employees of facilities licensed under the Act.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.550 CONTACTING LOCAL LAW ENFORCEMENT
Section 380.550 Contacting Local Law Enforcement
a) For the purpose of this Section, the following definitions
shall apply:
1) 911 − an emergency answer and response system in which
the caller need only dial 9-1-1 on a telephone to obtain emergency services,
including police, fire, medical ambulance and rescue.
2) Sexual abuse − sexual penetration, intentional sexual
touching or fondling, or sexual exploitation (i.e., use of an individual for
another person's sexual gratification, arousal, advantage or profit).
b) The facility shall immediately contact local law enforcement
authorities (e.g., telephoning 911 where available) in the following
situations:
1) Physical abuse involving physical injury inflicted on a
consumer by a staff member or visitor;
2) Physical abuse involving serious physical injury inflicted on
a consumer by another consumer;
3) Sexual abuse of a consumer by a staff member, another
consumer, or a visitor;
4) Misappropriation or financial exploitation of a consumer's
property; or
5) When a crime has been committed in a facility by a person
other than a consumer.
c) When a consumer death other than by natural causes has
occurred, the facility shall call the coroner or medical examiner.
d) The facility shall develop and implement a written policy
concerning local law enforcement notification, including:
1) Ensuring the safety of consumers in situations requiring local
law enforcement notification;
2) Contacting local law enforcement in situations involving
physical abuse of a consumer by another consumer or staff;
3) Contacting police, fire, ambulance and rescue services in
accordance with recommended procedure;
4) Preservation of a potential crime scene; and
5) Facility investigation of the situation.
e) Facility staff shall be trained in implementing the policy
developed pursuant to subsection (d). The training shall be documented.
f) The facility shall also comply with other reporting
requirements of this Part.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.560 CARE AND TREATMENT OF SEXUAL ASSAULT SURVIVORS
Section 380.560 Care and Treatment of Sexual Assault Survivors
a) For the purposes of this Section, the following definitions
shall apply:
1) Sexual assault − an act of nonconsensual sexual conduct
or sexual penetration, as defined in Section 11-01 of the Criminal Code of
2012, including, without limitation, acts prohibited under Sections 11-1.20
through 11-1.60 of the Criminal Code of 2012.
2) Ambulance Provider − an individual or entity that owns
and operates a business or service using ambulances or emergency medical
services vehicles to transport emergency patients.
b) The facility shall adhere to the following protocol for the
care and treatment of consumers who are suspected of having been sexually
assaulted in the facility or elsewhere:
1) Notify local law enforcement pursuant to the requirements of
Section 380.550;
2) Call an ambulance provider if medical care is needed. The
facility shall always request transport to a hospital if sexual penetration
occurred or is suspected to have occurred and shall document whether a consumer
refuses treatment;
3) Move the survivor, as quickly as reasonably possible, to a
closed environment to ensure privacy while waiting for emergency or law
enforcement personnel to arrive. The facility shall ensure the welfare and
privacy of the survivor, including the use of incident code to avoid
embarrassment; and
4) Offer to call a friend or family member and a sexual assault
crisis advocate, when available, to accompany the survivor.
c) The facility shall take all reasonable steps to preserve
evidence of the alleged sexual assault, including encouraging the survivor not
to change clothes or bathe, if he or she has not done so since the sexual
assault, and to not launder or dispose of the consumer's clothing or bed linens
until local law enforcement can determine whether those items have evidentiary
value.
d) The facility shall notify the Department and draft a
descriptive summary of the alleged sexual assault pursuant to the requirements
of Section 380.530.
e) As much as is reasonably possible, the facility shall ensure
that the sexual assault survivor receives all appropriate follow-up care
pursuant to the Department's rules titled Sexual Assault Survivors Emergency
Treatment Code.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.570 FIRE SAFETY AND DISASTER PREPAREDNESS
Section 380.570 Fire Safety and Disaster Preparedness
a) For
the purpose of this Section only, "disaster" means an occurrence, as
a result of a natural force or mechanical failure such as water, wind or fire,
or a lack of essential resources such as electrical power, that poses a threat
to the safety and welfare of consumers, personnel and others present in the
facility.
b) Each
facility shall have policies covering disaster preparedness for staff,
consumers, and others to follow. The policy shall include, but not be limited
to, the following:
1) Proper
instruction in, and training on, the use of fire extinguishers for all
personnel employed on the premises;
2) A
diagram of the evacuation route, which shall be posted and made familiar to all
personnel employed on the premises;
3) A
written plan for moving consumers to safe locations within the facility in the
event of a tornado warning or severe thunderstorm warning; and
4) An
established means of facility notification when the National Weather Service
issues a tornado or severe thunderstorm warning that covers the area in which
the facility is located. The notification mechanism shall be other than
commercial radio or television. Approved notification measures include being
within range of local tornado warning sirens, maintaining an operable National
Oceanic and Atmospheric Administration weather radio in the facility, or
arrangements with local public safety agencies (police, fire, emergency
management agency) to be notified if a warning is issued.
c) The facility
shall develop, implement, maintain
and annually review a disaster preparedness
plan requiring that:
1) Records and reports of fire and disaster training are maintained;
2) A record of actions taken to correct noted deficiencies in fire and disaster drills or inspections is maintained;
3) Employees know and practice how to react to fire, severe weather, disasters, missing persons, psychiatric and medical emergencies, and
deaths;
4) Consumers receiving
supports on site know how to react to fire or severe
weather or are receiving training;
5) Employees and consumers are trained in the location of firefighting equipment, first aid kits, evacuation routes and procedures;
6) A land-line telephone is available with the listing
of telephone numbers of the nearest poison control
center, the police, the fire department and emergency medical personnel;
and
7) The
facility has a written plan for alternative arrangements
if the facility becomes uninhabitable.
d) The facility shall implement procedures for evacuation
ensuring that:
1) Evacuation drills are conducted at a frequency determined by the
facility to be appropriate based on the needs and abilities of the consumers receiving supports at the site, but no less than annually on each shift if 24-hour supports
are provided.
2) Special provision shall be made for those consumers who cannot evacuate the building
without assistance.
3) All employees are trained to carry out their assigned evacuation
tasks, and the training shall be documented.
4) Inefficiency or problems identified during an evacuation drill shall
result in specific corrective action.
5) Evacuation drills shall include actual evacuation of consumers to
safe areas.
6) A
written evaluation of each drill shall be submitted to the executive director
and shall be maintained for one year.
e) At least one approved fire extinguisher
shall be available in each
level of service within a facility,
inspected annually and recharged when necessary. If the facility
has multiple floors, one fire extinguisher
shall be available on each floor.
f) At least one first aid kit shall be available and inspected and re-supplied
regularly.
g) Disaster Reporting
1) Upon
the occurrence of any disaster requiring hospital service, police, fire
department or coroner, the executive director or designee shall provide a
preliminary report to the Department either by using the Department hotline or
by directly contacting the appropriate Department central office during
business hours. This preliminary report shall include, at a minimum:
A) The
name and location of the facility;
B) The
type of disaster;
C) The
number of injuries or deaths to consumers;
D) The
number of beds not usable due to the occurrence;
E) An
estimate of the extent of damages to the facility;
F) The type
of assistance needed, if any; and
G) A list
of other State or local agencies notified about the problem.
2) If
the disaster will not require direct Department assistance, the facility shall
provide a preliminary report within 24 hours after the occurrence. The facility
shall also submit a full written account to the Department within seven days
after the occurrence, which includes the information specified in subsection
(h)(1) and a statement of actions taken by the facility after the preliminary
report.
h) Each
facility shall establish and implement written policies and procedures to
provide for the health, safety, welfare and comfort of all consumers when
extreme temperatures are present within the facility for a prolonged period of
time, including a written temporary transfer plan.
i) Coordination with Local
Authorities
1) Each
facility shall annually forward copies of all disaster policies and plans
required under this Section to the local health authority and local emergency management
agency having jurisdiction.
2) Each
facility shall annually forward copies of its emergency water supply
agreements, required under Section 380.670(e)(1)(C), to the local health
authority and local emergency management agency having jurisdiction.
3) Each
facility shall provide a description of its emergency source of electrical
power, including the services connected to the source, to the local health
authority and local emergency management agency having jurisdiction. The
facility shall inform the local health authority and local emergency management
agency at any time that the emergency source of power or services connected to
the source are changed.
4) When
requested by the local health authority and the local emergency management
agency, the facility shall participate in emergency planning activities.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.580 RESEARCH
Section 380.580 Research
a) No consumer shall be subjected to research or treatment
without first obtaining his or her informed, written consent. The conduct of
any experimental research or treatment shall be authorized and monitored by an institutional
review board appointed by the executive director. No person who has received
compensation in the prior 3 years from an entity that manufactures, distributes
or sells pharmaceuticals, biologics, or medical devices may serve on the
institutional review board.
1) The membership of the institutional review board shall
include, at a minimum:
A) Director of the Department of Public Health or designee;
B) Director of DHS-DMH or designee;
C) An academic faculty member of a college or university who is in
a mental health field;
D) The DHS-DMH bureau chief of Evaluation and Services Research or
designee;
E) Two additional persons with a background in ethics, policy
development and research who may be from outside DHS-DMH or the Department; and
F) A representative from the Department's or DHS-DMH's legal
services staff as a non-voting member.
2) The operating procedures for the institutional review board
shall be jointly developed by the Department and by DHS-DMH and shall be
made available to the public upon request. The operating procedures shall
address:
A) The appointment protocol and tenure of the membership;
B) Conflict-of-interest policies;
C) The meeting schedule;
D) The application process, including university-initiated
applications;
E) Informed consent requirements, which shall reference 45 CFR 46 (Protection
of Human Subjects), Subparts B, C and D, and the Mental Health and
Developmental Disabilities Confidentiality Act;
F) Requirements for progress reports; and
G) The review process and expedited review process.
3) The
review criteria for the institutional review board shall be developed
jointly by the Department and by DHS-DMH and shall include:
A) Voting procedures;
B) A categorization of risks inherent in the conduct of the
research; and
C) A description of the categorical ratings that result from the
review.
b) No facility shall permit research or treatment to be
conducted on a consumer, or give access to any person or person's records for a
retrospective study without the prior written approval of the institutional
review board. No executive director, or person licensed by the State to
provide medical care or treatment to any person, may assist or participate in
any experimental research on or treatment of a consumer, including a
retrospective study that does not have the prior written approval of the
board. This conduct shall be grounds for professional discipline by the
Department of Financial and Professional Regulation.
c) Following a formal review, the institutional review board
may exempt from ongoing review research or treatment initiated on a consumer
before the individual's admission to a facility and for which the board
determines there is adequate ongoing oversight by another institutional review
board. Nothing in this Section or the Act shall prevent a facility, any
facility employee, or any other person from assisting or participating in any
experimental research on or treatment of a consumer, if the research or treatment
began before the person's admission to a facility, until the board has reviewed
the research or treatment and decided to grant or deny approval or to exempt
the research or treatment from ongoing review. (Section 3-116 of the Act)
SUBPART E: SUPPORT SERVICES AND ENVIRONMENT
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.600 REQUIRED SUPPORT SERVICES
Section 380.600 Required Support Services
a) For the purpose of this Section, "physician orders"
includes instructions from medical doctors (MD), doctors of osteopathy (OD), dentists, podiatrists,
advanced practice nurses (APN) in collaboration with an MD, and physician
assistants (PA) under the supervision of a physician for that physician's
patients.
b) Facilities shall provide, at a minimum, the following
services: physician, nursing, pharmaceutical, rehabilitative, and dietary services.
To provide these services, the facility shall adhere to the following:
1) Each
consumer shall be encouraged and assisted to achieve and maintain the highest
level of self-care and independence. Every effort shall be made to keep
consumers active and out of bed for reasonable periods of time, except where
contraindicated by physician orders.
2) Every
consumer shall participate in a person-centered planning process regarding his
or her total care and treatment, to the extent that his or her condition
permits.
3) All medical treatment and procedures shall be administered
as ordered by a physician. All new physician orders shall be reviewed by the
facility's director of nursing or charge nurse designee within 24 hours after the
orders have been issued to ensure facility compliance with the
orders. Every woman consumer of child bearing age shall receive routine
obstetrical and gynecological evaluations, as well as necessary prenatal care,
except in triage centers.
A) The frequency and administration of obstetrical, gynecological
and pre-natal care shall be according to the guidelines set forth in the
Guidelines for Women's Health Care, published by the American College of
Obstetricians and Gynecologists. The date of the consumer's last obstetrical,
gynecological or prenatal appointments shall be identified as part of the
treatment assessment, and pregnancy screening may be required before
medications are prescribed and administered.
B) If obstetrical and gynecological evaluations are performed in a
facility, the facility shall ensure that the examination room is adequately
equipped for these examinations.
C) If obstetrical and gynecological evaluations are not performed
in a facility, the facility shall arrange with a local OB/GYN practice or
clinic to have the evaluations performed at that location.
c) Each
consumer shall be provided with good nutrition and with necessary fluids for
hydration in accordance with the Food and Nutrition Board of the National
Research Council of the National Academy of Science's standard.
d) Each
consumer shall be provided visual privacy during treatment and personal care.
e) Every
consumer or consumer's guardian shall be permitted to inspect and copy all of
his or her clinical and other records concerning his or her care kept by the
facility or by his or her physician. The facility may charge a reasonable fee
for duplication of a record. (Section 3-104 of the Act)
f) A
facility with a pharmacy on premises shall comply with the Controlled
Substances Act. Facilities without pharmacies shall ensure that pharmacies they
make arrangements, or contract, with comply with the Controlled Substances Act.
g) Facilities
licensed under the Act and this Part shall provide transitional living
assistance to prepare those with serious mental illness to reintegrate
successfully into community living settings. (Section 1-101.3 of the Act)
(Source: Amended at 44 Ill. Reg. 18403,
effective October 29, 2020)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.610 PHYSICIAN MEDICAL SERVICES
Section 380.610 Physician Medical Services
a) The
licensee shall ensure sufficient physician services to meet the needs of all
consumers being served by the facility. Physician services shall be provided
by medical doctors who are under contract
with the facility or have been chosen by the consumer or by the consumer's
substitute decision maker to direct the consumer's medical care.
b) Physician
services shall include, but are not limited to:
1) The
initial health evaluation, including a written report of a physical
examination, and history, obtained within 72 hours after admission, unless a
health evaluation has been completed within 30 days prior to admission and is
in the consumer's record;
2) An
evaluation of the consumer and, upon change of physicians, a review of the
order for care and treatment;
3) Written
and signed orders for diet, diagnostic tests, consultation and medical
treatment of the consumer; and
4) Health
care progress notes and other appropriate entries in the consumer record.
c) Orders
for therapeutic separation shall comply with the requirements of Section
380.160.
d) Orders
for emergency treatment for the safety of the consumer without informed consent
shall meet the requirements of Section 380.150 and the Mental Health and
Developmental Disabilities Code.
e) Non-physician
practitioners may render those medical services that they are legally
authorized to perform.
f) The
executive director shall verify a physician's credentials by contacting a
hospital through which the doctor has practicing rights and by checking
applicable databases, including, but not limited to, the Illinois Department of
Financial and Professional Regulation License Lookup and the National
Practitioner Data Bank.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.620 HEALTH/NURSING SERVICES
Section 380.620 Health/Nursing Services
a) The
licensee shall ensure sufficient nursing services to meet the needs of all
consumers being served by the facility. Licensed nursing staff shall perform
nursing services within the scope of their licenses, and the nursing services
shall be consistent with the care requirements for each respective level of
service, including time frames, as described in Subpart B. Services shall
include, but not be limited to, the following:
1) Nursing
participation in the formulation of an interdisciplinary treatment plan, which
shall include identification of nursing care needs based upon an initial
written nursing evaluation of the consumer's needs with input, as necessary,
from health professionals involved in the care of the consumer. The initial
nursing care needs, including the physical evaluation required in Section
380.610(b)(1), shall commence at the time of admission of the consumer and be
completed within seven days after admission;
2) The
implementation of each consumer's treatment plan according to the methods
indicated, with ongoing monitoring and documentation of the effectiveness of
the plan, and participation in consumer treatment plan conferences for review
and modification of each consumer's treatment plans;
3) Ensuring
that the dietary department receives dietary orders that are prescribed by
physicians or dieticians;
4) Obtaining
and documenting physician orders for medical care, appointments and laboratory
workups and tests, administration of medications, including pro re nata (PRN)
and immediately authorized or emergency (STAT) medications;
5) Implementation
and evaluation of quality improvement policies and procedures;
6) The
writing, review and signoff of progress notes and notes regarding any change in
a consumer's condition; and
7) Notifying
the physician promptly of:
A) The
admission of a consumer;
B) Any
sudden, marked or adverse change in signs, symptoms or behavior exhibited by a
consumer;
C) An
unusual incident involving a consumer, as specified in Section 380.530;
D) Any
adverse response or reaction by a consumer to a medication or treatment;
E) Any
error in the administration of a medication or treatment to a consumer that is
life threatening or that presents a risk to a consumer; and
F) The
facility's inability to obtain or administer, on a prompt and timely basis,
drugs, equipment, supplies or services as prescribed.
b) All
attempts to notify physicians shall be noted in the consumer's record,
including the time and method of communication and the name of the person
acknowledging contact, if any. If the physician is not readily available,
emergency medical care shall be arranged immediately.
c) If
a facility orders transportation of a consumer of the facility by ambulance,
then the facility must maintain a written record that shows the name of the
person who placed the order for that transportation and the medical reason for
that transportation. (Section 3-212 of the Act)
d) Under
the supervision of licensed nursing staff, an RSA shall monitor the following:
1) Assisting
consumers with dressing, grooming, bathing and personal hygiene related
activities, as needed; and
2) Measuring
and recording a consumer's height, weight and vital signs, including
temperature, blood pressure and pulse, on admission. At a minimum, vital signs
and weight shall be taken weekly for four weeks and then monthly. Weights and
vital signs shall be charted in a format that allows for trending and
patterning over time. Any clinically significant worsening shall be reported
to the physician to assess the need for increased monitoring.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.630 PHARMACEUTICAL SERVICES AND MEDICATION ADMINISTRATION
Section 380.630 Pharmaceutical Services and Medication
Administration
a) All consumers shall be assessed for drug allergies, and drug
histories shall be documented and reported to the pharmacy and physician.
Pharmacies shall immediately notify the physician and the facility of any
potential drug interactions prior to dispensing the medication.
b) Pharmaceutical Treatment
1) A consumer shall not be given unnecessary drugs. An
unnecessary drug is any drug used in an excessive dose, including in
duplicative therapy; for excessive duration; without adequate monitoring;
without adequate indication for its use; or in the presence of adverse
consequences that indicate the drug should be reduced or discontinued.
2) No drug shall be administered except upon the order of a
person lawfully authorized to prescribe for and treat mental illness.
3) All drug orders shall be written, dated, and signed by the
person authorized to give the order. The name, quantity, or specific
duration of therapy, dosage, and time or frequency of administration of the
drug and the route of administration if other than oral shall be specific.
4) Verbal orders for drugs and treatment shall be received
only by those authorized under Illinois law to do so from their supervising
physician. Orders shall be recorded immediately in the consumer's record by
the person receiving the order and shall include the date and time of the
order. (Section 3-106 of the Act)
5) A facility with a pharmacy on the premises shall comply with
the Controlled Substances Act. Facilities without pharmacies shall ensure that
pharmacies with which they make arrangements, or contract, comply with the
Controlled Substances Act.
c) Medication Policies
1) Every facility shall adopt written policies and procedures for
properly and promptly obtaining, dispensing, administering, returning and
disposing of drugs and medications. These policies and procedures shall be
consistent with the Act and this Part and shall comply with all federal and
State laws and administrative rules relating to the procurement, storage,
dispensing, administration and disposal of medications.
2) The medication policies and procedures shall be developed with
the advice of a licensed pharmacist, the medical director and the director of
health services.
3) The facility shall ensure that pharmaceutical services are
arranged and their administration is supervised in accordance with the Medical
Practice Act of 1987 and the Nurse Practice Act. The facility shall ensure
that:
A) A physician is responsible for the medical services provided to
individuals and the management of consumers' medications;
B) A licensed prescriber prescribes and monitors all prescription
medications;
C) A psychiatrist performs an examination of the consumer prior to
the initiation of psychotropic medications;
D) Screening for and documentation of abnormal involuntary
movements, including tardive dyskinesia in individuals receiving prescribed
psychotropic medications, is completed at least every six months by employees
trained in performing this type of assessment;
E) A psychiatrist reviews all medications prescribed and shall be
available for consultation on the prescribed medications. Psychiatrist
documentation within the individual's record shall include, but is not limited
to, the rationale for continuing current medications and/or initiating new
medications, and medication side effects. When clinically indicated, a
psychiatrist and facility shall arrange for consultation with the appropriate
medical specialist.
i) A psychiatrist, a psychiatric nurse practitioner, or an
advanced practice nurse review medications and perform case management on
consumers as needed in triage centers.
ii) A psychiatrist review medications and see individuals three
times weekly in crisis stabilization units. In addition, a psychiatrist shall
be immediately available by phone 24 hours per day and respond on site within
24 hours.
iii) A psychiatrist review medications and see individuals at
least monthly in transitional living units and in RRS units;
F) In recovery and rehabilitation supports and transitional
living, a psychiatrist or registered professional nurse evaluates the ability
of each consumer to self-administer medications within the first three months
after admission, and then at least annually, after a consumer completes a
self-medication training program, prior to the consumer moving to
community-based services or prior to transition to community living;
G) A clinical pharmacist reviews each consumer's chart to evaluate
for unnecessary medications in accordance with the Drug Burden Index, and for
potential adverse drug events based upon the total pharmacotherapy regimen and
pre-existing medical conditions;
H) A psychiatrist provides the written order for a consumer to
self-administer medications or participate in a self-administration of
medication training program based on the results of the consumer's evaluation.
The order shall become part of the individual's record;
I) Consumers in transitional living units and recovery and
rehabilitation supports units who are able to independently self-administer
medications have access to their medications.
i) The facility has a written policy on determining the level of
independence, and documentation of the level of independence will be placed in
the consumer's treatment plan.
ii) Level I independence means that the consumer shall have a
secured medicine storage cabinet in his or her bedroom for which he or she has
the key or the combination to the lock.
iii) Level II independence means that the consumer shall be
responsible for independently requesting his or her medication from a central
medication area, which shall be staffed by a licensed medical professional, at
the appropriate times;
J) When facilities supervise the self-administration of
medication training programs, or administer the medications, medications are
secured from unauthorized access, and only a psychiatrist, pharmacist, or
registered or licensed practical nurse shall supervise the self-administration
of a medication training program or administer medications and have access to
medications. A psychiatrist, pharmacist or licensed nurse shall be available
at all times for consultation and supervision of the self-administration of
medications training program;
K) A physician or pharmacist is available to consult with the QMHP
or MHP in reference to staff's behavioral or other observations relating to the
individual's level, dosage and types of side effects from any prescribed
medications;
L) A physician or pharmacist makes available to consumers information
on expected consequences and the potential benefits and possible side effects
of any prescribed medication. If requested, this information will also be made
available to employees and families; and
M) All Schedule II controlled substances are stored so that two
separate locks, using two different keys, shall be unlocked to obtain these
substances.
d) Emergency Medication Kits
1) A facility shall not maintain a stock supply of controlled
drugs, except for those in the emergency medication kits, as described in this
subsection (d).
2) A facility may stock drugs that are regularly available
without prescription. These shall be administered to a consumer only upon the
order of a licensed prescriber. Administration shall be from the original
containers and shall be recorded in the consumer's clinical record.
3) A facility may keep emergency medication kits containing
medications to be used for initial doses.
4) Each emergency medication kit shall be the property, of and
under the control of the pharmacy that supplies the contents of the box, and it
shall be kept in a locked medicine room or cabinet. Schedule II controlled
substances shall not be kept in emergency medication kits.
5) The contents and number of emergency medication kits shall be
approved by the facility's pharmacist, medical director and director of health
services, and shall be available for immediate use at all times in locations
determined by them.
A) Each emergency medication kit shall be sealed after it has been
checked and refilled.
B) Emergency medication kits shall also contain all of the
equipment needed to administer the medications.
C) The contents of emergency medication kits shall be labeled on
the outside of each kit. The label shall include expiration dates of any medications
contained in the kit. The kits shall be checked and refilled by the pharmacy
after use and as otherwise needed. The pharmaceutical advisory committee shall
review the list of substances kept in emergency medication kits at least
quarterly. The facility shall maintain written documentation of this review.
D) The contents and number of emergency medication kits shall be
determined by the pharmacist, medical director and the director of health
services. The contents should include, at a minimum, but not be limited to,
behavioral medications and medications to specifically address anaphylactic and
dystonic reactions. The contents shall be listed on the outside of each box.
6) The facility shall comply with the following requirements when
controlled substances are kept as part of the emergency medication kits:
A) If an emergency medication kit is not stored in a locked room
or cabinet, or if the kit contains controlled substances that require
refrigeration, the controlled substances portion of the kit shall be stored
separately in a locked cabinet or room (or locked refrigerator or locked
container within a refrigerator, as appropriate) and labeled with a list of the
substances and a statement that they are part of the emergency medication kit.
The label of the emergency medication kit shall list the substances and the
specific location where they are stored.
B) Controlled substances for emergency medication kits shall be
obtained from a federal Drug Enforcement Administration registered hospital, pharmacy
or licensed prescriber.
C) Only the director of health services, a registered nurse on
duty, a licensed practical nurse on duty, a consultant pharmacist, or a
licensed prescriber shall have access to controlled substances stored in emergency
medication kits.
D) No more than 10 different controlled substances shall be kept
as part of an emergency medication kit, and there shall be no more than three
single doses of any one controlled substance.
E) Controlled substances in emergency medication kits shall be
administered only by persons licensed to administer medications, in compliance
with 21 CFR 1306.11 and 1306.21, and the Illinois Controlled Substances Act.
F) A proof-of-use sheet shall be stored with each controlled
substance. The nursing staff or licensed prescriber shall enter the date and
time that a drug was administered to a consumer, the dose, the name of the
consumer, and the name of the prescriber on the proof-of-use sheet when any
controlled substance from the kit is used. The completed proof-of-use sheets
shall be filed with the consultant pharmacist and shall be retained for two
years.
G) The consultant pharmacist shall be notified within 24 hours
after the controlled substance portion of an emergency medication kit is
opened. During any period when the kit is opened, a shift count shall be done
on all controlled substances until the kit is re-locked or the controlled
substance is replaced. Shift counts are not mandatory when the kit is sealed.
Forms for shift counts shall be kept with the controlled substances portion of
the emergency medication kit.
H) The consultant pharmacist shall check the controlled substances
portions of emergency medication kits at least monthly and document the check
on the outside of each kit.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.640 INFECTION CONTROL AND VACCINATIONS
Section 380.640 Infection
Control and Vaccinations
a) The
facility shall adopt, observe and implement written infection control policies
and procedures. These policies and procedures shall be reviewed at least
annually and revised as needed.
b) All
cases of reportable communicable diseases shall be reported to the Department
and to the local health department in accordance with the Control of
Communicable Diseases Code and the Control of Sexually Transmissible Infections
Code.
c) All
employees and consumers shall be screened for tuberculosis in accordance with
the Control of Tuberculosis Code.
d) When
consumers having a communicable disease, or presenting signs and symptoms that
suggest that diagnosis, are admitted, precautionary measures shall be taken to
avoid cross-infection to personnel, other consumers or the public.
e) Consumers
presenting with a communicable disease shall be treated in accordance with the
Control of Communicable Diseases Code and Control of Sexually Transmissible
Infections Code. When isolation is required, the facility shall implement
precautions (i.e., contact isolation) or provide temporary transfer to a
licensed entity that is capable of providing enhanced isolation techniques.
f) The
facility shall be responsible for developing, implementing, monitoring and
enforcing a hand hygiene program. For the purposes of this Section, "hand
hygiene" is a general term that applies to hand washing with plain soap
and water; antiseptic hand wash using soap containing antiseptic agents and
water; and antiseptic hand rub using a waterless antiseptic product, most often
alcohol based, rubbed on the surface of the hands.
g) A
facility shall annually administer and arrange for administration of a
vaccination against influenza to each consumer in a recovery and
rehabilitation supports unit who has been admitted for a least a year, in
accordance with the Prevention and Control of Influenza with Vaccines: Recommendations
of the Advisory Committee on Immunization Practices of the Centers for Disease
Control and Prevention that are most recent to the time of vaccination, unless
the vaccination is medically contraindicated or the consumer refuses the
vaccine. (Section 3-211(a) of the Act)
h) All
persons seeking admission to a facility shall be verbally screened for risk
factors associated with hepatitis B, hepatitis C, and the Human
Immunodeficiency Virus (HIV) according to the guidelines established by the
U.S. Centers for Disease Control and Prevention, the Sexually Transmitted
Diseases Treatment Guidelines. Persons who are identified as being at high
risk for hepatitis B, hepatitis C, or HIV shall be offered an opportunity to
undergo laboratory testing in order to determine infection status if they will
be admitted to the facility for at least 7 days and are not known to be
infected with any of the listed viruses. All HIV testing shall be conducted in
compliance with the AIDS Confidentiality Act. All persons determined to be
susceptible to the hepatitis B virus shall be offered immunization within 10
days after admission to any level of service except triage. A facility
shall document in the consumer's medical record that he or she was verbally
screened for risk factors associated with hepatitis B, hepatitis C, and HIV,
and whether or not the consumer was immunized against hepatitis B. (Section
3-211(b) of the Act)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.650 DIETETIC SERVICES
Section 380.650 Dietetic Services
a) The
facility shall arrange for each consumer to have available at least three meals
per day. Meals shall be brought in and served separately in the triage center
and crisis stabilization unit. Not more than 14 hours shall elapse between the
last and first meal.
b) Consumer
food preferences, including religious practices, shall be adhered to as much as
possible and shall be from appropriate food groups.
c) Between-meal
options shall be provided as requested or required by a diet order.
d) The
dietetic services programs shall be creatively focused on encouraging or
maintaining as much consumer responsibility, participation and independence as
possible in choice, preparation, purchasing and cleanup with regard to food
service. This may involve formal training programs, collaborative food
preparation and cleanup, family-style meal preparation with involvement of
consumers, or cafeteria or buffet-style service. Consumers with a communicable
disease shall be evaluated by a registered nurse or physician prior to being
allowed to assist in food preparation.
e) With
the exception of the triage centers and crisis stabilization units, the
consumer's discharge and transition plan shall address his or her menu planning
and food preparation level of knowledge and responsibility.
f) Within
the context of consumer food preparation training and choice, the total daily
diet for consumers shall be of the quality and in the quantity to meet the
nutritional needs of the consumers and be guided by the Food and Nutrition
Board of the National Research Council of the National Academy of Science's
standard, Recommended Dietary Allowances, adjusted to the age, activity and
environment of the group involved. All food shall be of good quality and be
selected, stored, prepared and served in a safe and healthful manner.
g) In
planning menus for the facility population, which includes consumers at risk
for certain chronic health conditions (e.g., diabetes and hypertension), the
food and beverage options provided in prepared meals, snacks and vending
machines shall include healthy choices to address these risks and conditions.
The facility shall obtain consumer feedback on the desirability of the
available healthy options at least twice per year and incorporate the results
in planning menu and vending options.
h) A
dietetic service supervisor shall manage and operate the food service in each
facility. If the dietetic service supervisor is not a dietitian, the dietetic
service supervisor shall have frequent and regularly scheduled consultation
from a dietitian.
i) Sufficient
staff shall be employed, oriented and trained, and their working hours
scheduled, to provide for the nutritional needs of the consumers and to
maintain the dietetic service areas. The facility shall consider having
facility consumers receive food service training and employment in the facility
dietary services.
j) Under
supervision, only consumers who have been screened for communicable diseases
pursuant to subsection (d) may assist in cooking and kitchen activities as part
of their skills training program.
k) Dietetic
service personnel, including consumers regularly participating in food service,
shall be trained in basic food sanitation techniques, shall wear clean clothing,
a cap or a hair net, and gloves, and shall be excluded from duty when affected
by skin infection or communicable diseases.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.660 DENTAL SERVICES
Section 380.660 Dental Services
a) The
facility shall have a dental program for stays over 21 days, which will provide
for in-service education to consumers in collaboration with dental personnel,
including, at a minimum, the following:
1) Information
regarding nutrition and diet control measures that are dental health oriented;
2) Instruction
on proper oral hygiene methods;
3) Instruction
concerning the importance of maintaining oral hygiene; and
4) Providing
dental supplies, including floss, toothpaste, and brushes.
b) The
facility shall arrange, from an outside resource, the following dental services
to meet the needs of each consumer:
1) Routine
dental services, to the extent covered under the State plan or other resources;
2) Emergency
dental services;
3) Assisting
the consumer in making appointments and arranging transportation to and from
the dentist's office; and
4) Prompt
referral to a dentist of a consumer with loose or damaged dentures, to the
extent covered under the State plan of other resources.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.670 PHYSICAL PLANT AND ENVIRONMENTAL REQUIREMENTS
Section 380.670 Physical Plant and Environmental
Requirements
a) Consumer
living areas shall be planned and arranged with an awareness of the prevalence
of trauma in people with mental health and substance abuse issues.
Evidence-based practices of trauma-informed care shall be adhered to in
residential settings.
b) Private
meeting space shall be available in each facility for consumers to meet with
outside service providers, assessors, family or other persons for other
professional purposes in accordance with the consumer's treatment plan.
c) Physical
Plant Requirements. The facility shall comply with locally adopted building
codes as enforced by local authorities and Chapter 33 of NFPA 101 (see Section
380.110 (a)(1)) and any local fire codes that are more stringent than the NFPA
as enforced by local authorities or the Office of the State Fire Marshal. New
construction shall comply with Chapter 32 of NFPA 101 (see Section
380.110(a)(1)). The facility shall make available to the Department, upon
request, the report of an inspection that has been made by the local
authorities or the Office of the State Fire Marshal. The facility shall comply
with the following additional NFPA standards:
1) No.
10: Standard for Portable Fire Extinguishers
2) No.
13: Standard for the Installation of Sprinkler Systems
3) No.
25: Standard for the Inspection, Testing and Maintenance of Water-Based Fire
Protection Systems
4) No.
54: National Fuel Gas Code
5) No.
70: National Electrical Code
6) No.
72: National Fire Alarm and Signaling Code
7) No.
80: Standard for Fire Doors and Other Opening Protectives
8) No.
90A: Standard for Installation of Air Conditioning and Ventilating Systems
9) No.
96: Standard for Ventilation Control and Fire Protection of Commercial Cooking
Operations
10) No.
99: Health Care Facilities Code
11) No.
110: Standard for Emergency and Standby Power Systems
12) No.
220: Standard on Types of Building Construction
13) No.
241: Standard for Safeguarding Construction, Alteration and Demolition
d) Living
arrangements shall meet the following additional requirements:
1) A
triage center shall provide a secure room within the facility, near the
facility entrance, for the assessment of incoming consumers. The triage center
shall provide the following:
A) A
staff member, available as needed at the entrance of the triage center;
B) A
centrally located nurse duty area that gives staff a direct line of site to the
consumer, permitting constant observation;
C) A
window to the outside that is secured from opening and contains glazing so
that, when broken, it will not produce shards of glass that can inflict injury
to the consumer or to staff;
D) Features
such as electrical outlets, sprinkler heads, doorknobs, light switches, etc.,
which shall be of a type that prevent a consumer from injuring himself or
herself, accidentally or deliberately;
E) Adequate
space and furnishings to permit staff to assess and diagnose consumers who
present for triage;
F) Separate
restroom facilities for men and women, complete with baths or showers and
hygiene supplies, including soap, shampoo and deodorant for consumers;
G) A
maximum of eight individual areas for interviews and assessment. The physical
arrangement of the rooms shall preserve the safety and privacy of each consumer
served;
H) Laundry
services for consumer use, including laundry detergent;
I) Clean
replacement clothing for both male and female consumers, if needed by the
consumer;
J) Kitchen
equipment to provide hot meals and snacks for consumers; and
K) A
toilet room that is accessible from within the triage center. The toilet room
shall be equipped with a water closet and lavatory. The door to the toilet
room shall be lockable from the outside only.
2) A crisis
stabilization unit shall be a separate unit within the facility, if the
facility provides more than one level of service. In addition, a crisis
stabilization unit shall provide the following:
A) Meeting
and therapy rooms that comply with the level of service. The rooms shall be of
adequate size and number to accommodate the maximum consumer population of the
unit and shall be furnished for the purpose intended;
B) A
maximum of 16 beds;
C) Visual
monitoring of consumers for safety reasons, when indicated in the consumer's
treatment plan;
D) As
much privacy for each consumer as is clinically appropriate.
E) Hallways
and common areas that are visible from the nurse duty area. If electronic
monitoring devices are used, the video recording must be kept for seven days;
and
F) Features
including, but not limited to, electrical outlets, sprinkler heads, doorknobs,
and light switches that prevent a consumer from injuring himself or herself
accidentally or deliberately.
3) RRS
units shall provide the following:
A) Meeting
and therapy rooms in accordance with the level of service. The rooms shall be
of adequate size and number to accommodate the maximum consumer population, and
shall be furnished for the purpose intended;
B) Bedroom
doors that are visible from the nurse duty area;
C) Adequate
common space for programming; and
D) Sufficient
private space for consumers to meet with assessors, transition staff, and
visitors.
4) RSS
unit maybe designated as all-male or all-female, for consumers who prefer
segregated living arrangements, or for treatment purposes.
5) Transitional
Living Units shall provide the following:
A) Meeting
and therapy rooms according to the level of service. The rooms shall be of adequate
size and number to accommodate the maximum consumer population and shall be
furnished for the purpose intended;
B) Bedroom
doors that are visible from the nurse duty area; and
C) A
distinct unit within a facility.
6) Nurse
Duty Area
A) The nurse
duty area shall be either a centralized cluster serving more than one level of
service in a facility or shall be used as a supportive area within a
self-contained level of service.
B) The
nurse duty area shall have adequate work counters, storage areas and
communication equipment.
C) A
hand-washing station convenient to the nurse duty area shall be provided.
D) A
lounge and toilet rooms for staff shall be provided.
E) Closets
or compartments shall be provided for the safekeeping of coats and personal
effects of nursing personnel.
F) Charting
facilities shall be provided for nurses and doctors, including work counter and
secured file storage.
G) At
least one tub or shower shall be provided for each 15 beds that do not have bathing facilities within the
consumer's room. Each tub or shower shall be in an individual room that
provides space for the private use of the bathing fixture and for drying and
dressing.
H) A
nourishment station with a sink equipped for hand washing, refrigerator,
storage cabinets, ice dispensing equipment, and other equipment/supplies as
necessary for serving nourishment between meals shall be provided.
I) A
clean utility/work room shall be provided in each nursing area. The clean
utility/work room shall contain a work counter, hand- washing sink and
storage. A separate designated area shall be provided for clean linen
storage. If a cart system is used, an alcove for storage of the cart may be
used.
J) A
soiled utility/workroom shall be provided and shall contain a hand-washing sink
and a waste receptacle.
K) A
locked janitor's closet shall be provided for each nurse duty area. The closet
shall be for the exclusive use of housekeeping staff and shall be equipped with
a floor receptor or service sink and adequate storage space for housekeeping
equipment and supplies.
L) Mops
and other cleaning supplies used and stored in the nurse areas shall not be
used or stored in the kitchen area.
7) The
facility shall have a smoke detection system that complies with the Smoke Detector
Act.
8) Bathrooms
shall be located and equipped to facilitate independence. When needed by the
consumer, special assistive devices shall be provided. Bathing and toilet
facilities shall provide privacy.
9) Each
single individual bedroom shall have at least 75 square feet of net floor area,
not including space for closets, bathrooms and clearly definable entryway
areas.
A) Each
multiple bedroom shall have at least 55 square feet of net floor area per
consumer, not including space for closets, bathrooms and clearly definable
entryway areas. A minimum of 3 feet of clearance at the foot and sides of each
bed shall be provided.
B) Each
bedroom within crisis stabilization units, recovery and rehabilitation supports
units, and transitional living units shall accommodate no more than two
consumers, with 5% of the rooms in the first 18 months, and 10% of the rooms in
the first three years, reserved for single occupancy.
C) Reasonable
storage space for clothing and other personal belongings shall be provided for
each consumer.
D) Each
bedroom shall have walls that extend from floor to ceiling, a fire-graded bed
that is suitable to the size of the consumer and that provides support and
comfort, if beds are provided by the agency, and at least one outside window.
The total window area to the outside shall be at least one-tenth of the floor
area of the room.
E) Each
toilet room shall be equipped with a water closet, a lavatory and a shower or
shower/tub combination.
10) The
facility shall ensure that living arrangements are free from vermin. Waste and
garbage shall be stored, transferred and disposed of in a manner that does not
permit the transmission of diseases. Water systems shall comply with the
Drinking Water Systems Code, and the facility shall maintain copies of
inspections performed by local and State inspectors in regard to health,
sanitation and environment.
e) Plumbing,
drainage facilities, and drinking water shall be maintained in compliance with
the Illinois Plumbing Code.
1) Each
facility shall be served by water from a municipal public water supply when
available.
A) When a
municipal public water supply is not available, the water supply shall comply
with the Drinking Water Systems Code.
B) If
water is supplied by a well that is not part of a municipal system, the well
shall be constructed and maintained in accordance with the Water Well
Construction Code and Illinois Water Well Pump Installation Code.
C) Each
facility shall have a written agreement with a water company, dairy or other
water purveyor to provide an emergency supply of potable water for drinking and
culinary purposes.
2) Hot
water temperature controls shall be maintained and regulated to prevent
scalding, so that the temperature of hot water delivered to the plumbing
fixtures that are used by consumers not exceed 115 degrees Farenheit.
3) Minimum
hot water temperature shall be maintained at the final rinse section of
dishwashing facilities as required by the Food Service Sanitation Code.
4) Suicide-resistant
grab bars (for crisis stabilization and triage centers) and other bathroom
fixtures shall be maintained at each community toilet, lavatory, shower and
bathtub used by consumers and as needed in individual consumer rooms.
5) Toilet,
hand-washing and bathing facilities shall be maintained in operating condition
and in the number and types specified in construction requirements in effect at
the time the building or unit was constructed.
6) If
the facility accepts physically handicapped consumers, bathing and toileting
appliances in the water closets shall be equipped for use by consumers with
physical handicaps. All handicapped accessible facilities shall meet the
minimum requirements of the Illinois Accessibility Code and the Americans With
Disabilities Act.
f) All
rooms, attics, basements, passageways and other spaces shall be provided with
artificial illumination in accordance with the National Electrical Code.
1) All
consumer rooms and accessible areas of corridors, storerooms, stairways, ramps,
exits and entrances shall have lighting for ease of reading, working and
passage.
2) The
facility shall provide and maintain an emergency electrical system in safe
operating condition.
g) Heating,
air conditioning and ventilating systems shall be maintained in normal
operating condition to provide a comfortable temperature and shall meet the
requirements of the American Society of Heating, Refrigerating, and Air
Conditioning Engineers Handbook of Fundamental Principles and Handbook of
Applications.
1) The
mechanical system shall be capable of maintaining a temperature of at least 75
degrees Fahrenheit.
2) The
air-conditioning system shall be capable of maintaining an ambient air
temperature of between 75 degrees Fahrenheit and 80 degrees Fahrenheit.
h) The
facility shall develop a written record of the maintenance history of the
heating, air conditioning and ventilation systems, which shall be available for
inspection by the Department.
1) A log
shall be used to document all maintenance work performed.
2) When
maintenance is performed by an equipment service company, the facility shall request
a certification that the required work has been performed in accordance with
acceptable standards. The certification shall be retained on file in the
facility for review by the Department.
i) The
facility shall have housekeeping procedures to routinely clean articles and
surfaces such as furniture, floors, walls, ceilings, supply and exhaust grills
and lighting fixtures.
j) Schedules
shall be posted and implemented that indicate areas of the facility that shall
be cleaned daily, weekly or monthly.
1) Cleaning
supplies and equipment shall be available to housekeeping staff and shall meet
the following requirements:
A) Cleaning
supplies and equipment shall be stored in rooms for housekeeping use only;
B) Appropriate
cleaning agents shall be used for all cleaning;
C) Mop
heads shall be removable and changed at least daily; and
D) Cleaning
supplies and equipment shall be kept in a secured location/area that is
accessed by authorized personnel only.
2) Housekeeping
personnel shall be employed to maintain the interior of the facility in a safe,
clean, orderly and attractive manner free from offensive odors.
3) Janitor
closets, service sinks and storage areas shall be clean and maintained to meet
the needs of the facility.
k) If
the facility operates a laundry that is separate from consumer-operated washers
and dryers for clothes, the facility laundry area shall be located in
relationship to other areas so that steam, odors, lint and objectionable noises
do not reach consumer areas.
1) The
facility laundry area shall be adequate in size, well lighted, ventilated to
meet the needs of the facility, and kept clean and sanitary.
2) Laundry
equipment shall be kept in good condition, be maintained in a sanitary
condition, and have suitable capacity.
3) Laundry
areas shall have, at a minimum, the following:
A) Separate
rooms for the storage of clean linen and soiled linen;
B) Hand-washing
facilities maintained at locations convenient for laundry personnel; and
C) Linen
carts labeled "soiled" or "clean" and constructed of
washable materials that shall be laundered or suitably cleaned as needed to
maintain sanitation.
4) The
facility shall implement written procedures for handling, storing, transporting
and processing linens. The written procedures shall be posted in the laundry.
5) If
the facility does not maintain a laundry service, the facility shall contract
only with a commercial laundry that meets the requirements of this Section.
l) The
facility, including the grounds, shall be maintained in a clean and sanitary
condition and in good condition at all times to ensure the safety and
well-being of consumers, staff and visitors.
1) Buildings
and grounds shall be free of environmental pollutants and nuisances that may
adversely affect the health or welfare of consumers to the extent that is
within the reasonable control of the facility.
2) All
buildings, fixtures, equipment and spaces shall be maintained in operable
condition.
3) Personnel
shall be employed to provide preventive maintenance and to carry out the
required maintenance program.
4) Equipment
shall meet all applicable Occupational Safety and Health Act requirements in
effect at the time of purchase. All portable electrical medical equipment
designed for 110-120 volts, 60 hertz current, shall be equipped with a
3-wire-grounded power cord with a hospital-grade 3‑prong plug. The cord
shall be an integral part of the plug.
5) The
facility shall be maintained free from vermin and rodents through operation of
a pest control program. The pest control program shall be conducted in the
main consumer buildings, all outbuildings on the property and all grounds.
m) The
facility shall be responsible for the regular inspection, cleaning or
replacement of all filters installed in heating, air conditioning and
ventilating systems, as necessary to maintain the systems in normal operating
conditions.
1) A
written record of inspection, cleaning or replacement shall be maintained and
available for inspection by the Department.
2) When
filter maintenance is performed by an equipment service company, the facility
shall request a certification that the filter has been inspected, cleaned or
replaced, with dates noted.
n) Emergency
Electrical Requirements
1) To
provide electricity during an interruption of the normal electric supply, an
emergency source of electricity shall be provided and connected to certain
circuits for lighting and power.
2) The
source of this emergency electrical service shall be one of the following:
A) A Type
3 Essential Electrical System, in accordance with NFPA 99, when the normal
service is supplied by only one central station transmission line; or
B) Automatic
battery-operated systems or equipment that will be effective for 90 minutes and will be capable of supplying power for
lighting for exit signs, exit corridors, stairways, nurses' areas, the communication
system, and all alarm systems.
3) The
facility shall provide emergency electrical service for:
A) Illumination
of a means of egress as necessary for corridors, passageways, stairways,
landings and exit doors and all ways of approach to and through exits,
including outside lights;
B) Exit
signs and exit directional signs;
C) Fire
alarm systems and detection systems;
D) Communication
systems that are used for issuing instructions; and
E) Task
illumination in the nurse duty area.
o) Kitchen
1) Floor
material in kitchens shall be easily cleanable and shall have wear resistance
that is appropriate for the location involved, and shall be water resistant and
greaseproof. The kitchen wall base shall be tightly sealed to the wall and
floor and shall be constructed without voids or gaps that can accumulate dirt
and grime and harbor vermin. Ceiling finishes shall be smooth, sanitary and
washable, and shall be able to withstand treatment with harsh chemicals. The
ceiling finish shall be capable of being thoroughly cleaned, including any
concealed spaces that may be present.
2) Mops
and all other cleaning supplies that are used in the kitchen shall not be used
or stored anywhere else in the facility. A janitor's closet, equipped with a
floor receptor or service sink and adequate storage space for housekeeping
equipment and supplies, shall be provided for the kitchen.
3) Equipment
and furnishing installations must meet all the requirements of the following:
A) NFPA
56 National Fuel Gas Code;
B) NFPA 70 National
Electrical Code; and
C) NFPA
96 Standard for Ventilation Control and Fire Protection of Commercial Cooking
Operations.
SUBPART F: LICENSURE REQUIREMENTS
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.700 LICENSURE APPLICATION REQUIREMENTS
Section 380.700 Licensure Application Requirements
a) The Act
provides for licensure of long term care facilities that are federally
designated as institutions for mental disease on July 22, 2013 and
specialize in providing services to individuals with a serious mental illness.
b) All
consent decrees that apply to facilities federally designated as institutions
for mental disease shall continue to apply to facilities licensed under the
Act and this Part. (Section 1-101.5 of the Act)
c) No
person may establish, operate, maintain, offer, or advertise a facility within
this State unless and until he or she obtains a valid license, which license
remains unsuspended, unrevoked, and unexpired. No public official or employee
may place any person in, or recommend that any person be in, or directly or
indirectly cause any person to be placed in any facility that is being operated
without a valid license. (Section 4-102 of the Act)
1) A
facility whose license has been successfully revoked is disqualified from
obtaining a provisional license under the Act and this Part.
2) A
facility with a pending Notice of Revocation and Opportunity for Hearing is
disqualified from obtaining a provisional license until the Notice of
Revocation is resolved, including, but not limited to, a voluntary withdrawal
of the Notice of Revocation by the Department or a successful appeal of the
Notice of Revocation by the facility.
d) All
licenses and licensing procedures established under Article III of the Nursing
Home Care Act, except those contained in Section 3-202 of the Nursing Home
Care Act, shall be deemed valid under the Act and this Part
until the Department establishes licensure. The Department is granted the
authority under the Act and this Part to establish provisional
licensure and licensing procedures under the Act and this Part.
(Section 4-102 of the Act)
1) All
facilities that are federally designated as institutions for mental disease,
and that were previously certified under Subpart T of 77 Ill. Adm. Code 300,
shall apply for provisional licensure under the Act and this Part.
2) All
facilities that are federally designated as institutions for mental disease
that are currently certified under Subpart S of 77 Ill. Adm. Code 300 shall
apply for provisional licensure under the Act and this Part.
e) The
Department shall be the sole agency responsible for licensure. Licensure
shall be in accordance with the Act for the purpose of:
1) Protecting
the health, welfare, and safety of consumers; and
2) Ensuring
the accountability for reimbursed care provided in facilities. (Section
4-101 of the Act)
f) Provisions
of this Part establishing requirements for provisional licenses are effective
for no more than three years pursuant to the Act and Section 380.710(b).
g) The
Department will issue no more than 24 licenses statewide for specialized mental
health rehabilitation facilities, in accordance with the Act and this Part.
h) Pursuant
to Section 4-102 of the Act, a new provisional license application is required
upon initial licensure as a specialized mental health rehabilitation facility
and whenever there is a change of ownership, in licensed bed capacity, in
services provided, or of location.
i) The
application shall be under oath, and the submission of false or misleading
information shall be a Class A misdemeanor. The application, in a form prescribed
by the Department, shall contain the following information:
1) The
name, or proposed name, and address of the facility;
2) The
name, residence and mailing address of the applicant;
3) If
the applicant is a partnership, the name and principal business address of each
partner;
4) If
the applicant is a corporation or association, the name, title and business
address of each officer and member of the governing board;
5) If,
at the time of application, the applicant is associated with a clinical or
operational management company, the name of the company, manager, principle
business address, and written copies of consulting arrangements.
A) For
the purposes of this Section, "associated" means employed by or in a
contractual relationship with a clinical or operational management company.
B) The
applicant shall submit to the Department written copies of all employment
agreements and contracts in effect between the applicant and a clinical or
operational management company. If, following the time of application, an
applicant becomes employed by or enters into a contractual relationship with a
clinical or operational management company, he or she shall inform the
Department and submit all required documentation to the Department;
6) The
name and address of the owner or owners of the facility premises, if the
applicant is leasing or renting;
7) A
written plan of operation as specified in Section 380.720;
8) A
financial statement setting forth the financial condition of the applicant,
demonstrating that the applicant's ability to maintain the minimum financial
or other resources necessary to meet the standards established under the Act
and this Part (Section 2-101(7) of the Act);
9) Documentation
that a needs assessment survey was performed within the community in which the
facility is located, justifying the levels of service to be provided; and
10) A
non-refundable license fee of $5,700.
(Source:
Amended at 43 Ill. Reg. 1651, effective January 18, 2019)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.710 APPLICATION PROCESS AND REQUIREMENTS FOR A PROVISIONAL LICENSE
Section 380.710 Application Process and Requirements for
a Provisional License
a) A
provisional license shall be valid upon fulfilling the requirements established
by the Department in this Part. The license shall remain valid as long
as a facility remains in compliance with the licensure provisions established
in this Part. (Section 4-105 of the Act)
b) Provisional
licenses issued upon initial licensure as a specialized mental health
rehabilitation facility shall expire at the end of a 3-year period, which
commences on the date the provisional license is issued. Issuance of a
provisional license for any reason other than initial licensure (including, but
not limited to, change of ownership, location, number of beds, or services)
shall not extend the maximum 3-year period, at the end of which a facility must
be licensed pursuant to the Act and this Part. (Section 4-105 of the Act)
c) Notwithstanding
any other provision of the Act or this Part to the contrary, if a
facility has received notice from the Department that its application for
provisional licensure to provide recovery and rehabilitation services has been
accepted as complete and the facility has attested in writing to the Department
that it will comply with the staff training plan approved by DHS-DMH,
then a provisional license for recovery and rehabilitation services will
be issued to the facility within 60 days after the Department determines that
the facility is in compliance with the requirements of Chapter 33 of NFPA
101 in accordance with Section 4-104.5 of the Act. (Section
4-105 of the Act)
d) When
an application for a provisional license and certification of any of the four
programs identified in the Act and in Subpart B is submitted pursuant to this
Part, the Department will notify the applicant in writing within 30 days after
receipt of the application as to whether the application is complete and
accepted for filing, or whether the application is incomplete, and what
specific information or documentation is required to complete the application.
e) If
the applicant fails to respond within 30 days after being notified that the
Department needs additional information or documentation, the applicant shall
be considered to have withdrawn the application. Any applicant considered to
have withdrawn an application may reapply by submitting a new application.
f) The
Department shall notify an applicant in writing, within 60 days following the
acceptance of an application, of the Department's decision to approve or deny
the application.
g) If
the Department fails to notify an applicant by the end of the 60-day time
period, the applicant may request, in writing, a review by the Director. The
written request shall include:
1) An
identification of the applicant;
2) The
date the application was submitted;
3) A
copy of any correspondence between the Department and the applicant regarding
the application; and
4) Any
other information the applicant wishes to submit regarding the timeliness of
the Department's consideration of the application.
h) The
Department shall notify an applicant immediately upon denial of any application
for provisional licensure. The notice shall be in writing and shall include:
1) A
clear and concise statement of the basis of the denial. The statement shall
include a citation to the provisions of the Act and this Part under which the
application is being denied.
2) A
notice of the opportunity for a hearing. If the applicant desires to contest
the denial of a license, it shall provide written notice to the Department of a
request for a hearing within 10 days after receipt of the notice of denial. The
hearing will be conducted pursuant to Sections 3-704 through 3-712 of the
Nursing Home Care Act.
i) Requirements
for Provisional Licensure
1) DHS-DMH
will advise the applicants of the training that shall be completed prior to the
issuance of the provisional license. Limited trainings may be conducted over a
three-month period following the issuance of the provisional license.
2) All
staff shall be hired in accordance with the requirements for each level of
service prior to the beginning of clinical operations for the respective levels
of service after the issuance of the provisional license.
3) Crisis
stabilization, transitional living units and recovery and rehabilitation
supports units shall comply with the physical plant standards in Subpart E
within three years after the date they are issued their provisional licenses by
the Department. Triage centers shall comply with all physical plant standards
prior to the beginning of clinical operations, after the issuance of a provisional
license.
(Source:
Amended at 43 Ill. Reg. 1651, effective January 18, 2019)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.720 PLAN OF OPERATION
Section 380.720 Plan of Operation
a) The
license applicant shall submit, with the license application, the plan of
operation, including, but not limited to, the following components of the
facility, respective of the level or levels of service to be provided:
1) A
proposal of certification for each level of service to be provided by a
facility;
2) A
summary of administration requirements as specified in Subpart D;
3) Services
and staffing:
A) Clinical
level of service and staffing, as appropriate to each level of service
provided, and pursuant to the respective level of service requirements in
Subpart B;
B) Documentation
of the required training for each staffing classification in each level of
service; and
C) Any
contractual arrangements;
4) Admission
process and criteria;
5) Discharge
planning and transition process;
6) Network
linkages with community-based behavioral health providers;
7) Contents
of consumer health and treatment records;
8) Consumer
rights and empowerment;
9) Pharmaceutical
services and self-medication program;
10) Program
space allocation;
11) Restraint
and therapeutic separation policies and procedures;
12) Physical
plant or buildings, and fire safety;
13) Health
services program;
14) Interdisciplinary
treatment teams;
15) Psychiatric
and psychological services; and
16) Quality
improvement plan.
b) The
plan of operation shall specify each target population group and service that
the facility plans to offer, as referenced in Subpart A. The description shall
identify:
1) Eligibility
for services;
2) The
number of consumers to be served;
3) An
identification of the particular needs of the population;
4) How
the facility's respective levels of service are designed to meet the needs of
the population; and
5) The
method and frequency of evaluating consumer progress.
c) The
plan of operation shall include a description of how a facility's respective
levels of service meet identified mental health needs in its service area. The
description shall demonstrate what makes the facility's levels of service
innovative compared to existing programs in the service area pursuant to
Section 380.700(i)(9).
d) The
plan of operation shall specify how a facility expects to obtain accreditation
via achieving the components in subsections (a), (b) and (c) for each year of
provisional licensure. Each provider shall, annually, specify operational
benchmarks toward achieving accreditation status for each year of the
provisional license period, with the correlating documentation for verification
of compliance.
1) During
the provisional licensure period, the Department will conduct surveys to
determine facility compliance with timetables and benchmarks, and with the
facility's provisional licensure application plan of operation. Timetables and
benchmarks shall comply with the requirements for accreditation by the national
accreditation entities listed in Section 380.730 and shall include, but not be
limited to, the following:
A) The
training of new and existing staff;
B) The
establishment of a data collection and reporting program for the facility's
QAPI program, pursuant Sections 380.510 and 380.515; and
C) Compliance
with NFPA Chapter 33 and with Section 380.670.
2) As
part of the surveys required in subsection (d)(1), the Department will conduct
reviews to determine compliance with timetables and benchmarks associated with
the accreditation process. Facilities shall meet timetables and benchmarks in
accordance with a facility's preferred accrediting entity's conformance
standard and recommendations to include, but not be limited to, a comprehensive
facility self-evaluation in accordance with one of the established national
accreditation programs listed in Section 380.730.
3) Facilities
shall submit all reporting and outcome data required by their preferred
accrediting entity to the Department upon request.
4) Except
for incidents involving the potential for serious harm as described in Section
380.750(c)(5), or death, or a facility's consistent and repeated failure to
take necessary corrective actions as described in Section 380.750(c)(6) within
60 days, findings in the facility's root cause analysis and the facility's QAPI
program in accordance with Section 4-104(22) of the Act and Section 380.510
shall not be used as a basis for non-compliance.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.730 REQUIREMENTS FOR ACCREDITATION
Section 380.730 Requirements for Accreditation
a) At
the end of the provisional licensure period established in the Act, the
Department shall license a facility as a specialized mental health
rehabilitation facility under the Act that successfully completes and
obtains valid national accreditation in behavioral health from a recognized
national accreditation entity and complies with this Part. (Section
4-201 of the Act The license shall be good for one year and shall be renewable
annually provided the facility is in substantial compliance with the Act, this
Part.
b) To
achieve accreditation, all levels of service that are operated by the licensee
and funded in whole or in part by the State shall comply with nationally
recognized standards of care as set by one of the following or their successor
accreditation standards:
1) Standards
for Behavioral Health Care (Joint Commission);
2) Behavioral
Health Standards Manual (Commission on Accreditation of Rehabilitation
Facilities (CARF)); or
3) Accreditation
Requirements for Behavioral Health Centers (Healthcare Facilities Accreditation
Program).
c) The
facility shall demonstrate current accreditation status by submission of a
certificate of accreditation and the most recent accreditation report to the
certifying State agency and to the Department.
d) If
the facility's accreditation is suspended, lost or discontinued, the provider
shall notify the certifying State agency and the Department of that change
immediately.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.740 SURVEYS AND INSPECTIONS
Section 380.740 Surveys and Inspections
a) Upon
receipt of a completed application and verification of the facility's
compliance with the Act and this Part, and a licensure fee of $5,700, and the
completion of an initial survey as described in subsection (b), the Department
will issue a provisional license for one or more of the four levels of service
identified in the Act and in Section 380.100 of this Part (definition for
facility), as requested by the licensee in the application.
b) Prior
to the issuance of the initial provisional license, and then at least annually,
the Department shall conduct surveys of licensed facilities and their
certified programs and services. The Department shall review the records or
premises, or both, as it deems appropriate for the purpose of determining
compliance with the Act and this Part. The Department shall have
access to and may reproduce or photocopy any books, records, and other
documents maintained by the facility to the extent necessary to carry out the
Act and this Part. In addition, the Department will:
1) Conduct
staff interviews;
2) Conduct
consumer interviews;
3) Review
evidence-based program outcomes; and
4) Confirm
that the posters required by Section 380.140(m) are conspicuously posted in the
facility.
c) Any
holder of a license or applicant for a license shall be deemed to have given
consent to any authorized officer, employee, or agent of the Department to
enter and inspect the facility in accordance with the Act. Refusal to
permit entry or inspection shall constitute grounds for denial, suspension, or
revocation of a license under the Act. (Section 4-108 of the Act)
The Department's access to the facility's books, records and any other
documents maintained by the facility includes, but is not limited to:
1) Verifying
whether the facility complies with all of the requirements for authorization
and review of treatment appropriateness for each consumer, based on the service
level or levels for which the facility is licensed. The facility shall ensure
that State-designated authorization agents and other authorized State personnel
are provided with timely and unfettered access to consumers, records, facility
staff and consultants who are part of the facility's treatment team; and
2) Verifying
whether, for all programs except for triage centers, the facility has admitted
any consumer prior to completing the required authorization. The Department may
revoke a facility's license for admission of consumers into crisis
stabilization units, transitional living units, or recovery and rehabilitation
supports units without pre-authorization for that program. Admission of a
consumer without pre-authorization violates this Part and the Department of
Healthcare and Family Services' rate requirements. Facilities will not receive
retroactive payment for services provided prior to pre-authorization through
the required authorization.
(Source: Amended at 44 Ill. Reg. 18403,
effective October 29, 2020)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.750 LICENSE SANCTIONS AND REVOCATION
Section 380.750 License
Sanctions and Revocation
a) The Department may revoke a license for any failure to
substantially comply with the Act and this Part, including, but
not limited to, the following behavior by a licensee:
1) Fails to correct deficiencies identified as a result of an
on-site survey by the Department and fails to submit a plan of correction
within 30 days after receipt of the notice of violation;
2) Submits false information on Department forms, required
certifications or plans of correction during an on-site inspection;
3) Refuses to permit or participate in a scheduled or
unscheduled survey;
4) Willfully violates any rights of individuals being served
(Section 4-109(a) of the Act); or
5) Fails to comply with Section 4-107 of the Act and with Section
380.200(a)(2) of this Part.
b) The Department may refuse to license or relicense a
facility if the owner or authorized representative or licensee has been
convicted of a felony related to the provision of healthcare or mental health
services, as shown by a certified copy of the order of the court of
conviction. (Section 4-109(b) of the Act)
c) Facilities, as a result of an on-site survey, shall be
recognized according to levels of compliance with standards as set forth in the
Act and this Part. Facilities with findings from Level 1 to Level 3
will be considered to be in good standing with the Department. Findings from
Level 3 to Level 5 will result in a notice of violations, a plan of correction
and sanctions as defined in subsecton (f). Findings resulting in Level
6 will result in a notice of violations and sanction as defined in subsection
(f). The levels of compliance are:
1) Level 1 is full compliance with the Act and
this Part. Full compliance means meeting the requirements except for variances
from the strict and literal performance that results in unimportant omissions
or defects, given the particular circumstances involved.
2) Level 2 is acceptable compliance with the Act
and this Part. No written plan of correction will be required from the
licensee. Acceptable means enough in either quantity or quality, and within
the professional standards applicable to the subject under review, to meet the
needs of the consumers of a facility under the particular set of circumstances
in existence at the time of review.
3) Level 3 is partial compliance with the Act
and this Part. An administrative warning is issued by the
Department. The licensee shall submit a written plan of correction
pursuant to subsection (a)(1). Partial compliance is a condition or occurrence
relating to the operation and maintenance of a facility that creates a
substantial probability that less than minimal physical or mental harm to a
consumer will result.
4) Level 4 is minimal compliance with the Act
and this Part. The licensee shall submit a written plan of correction
pursuant to subsection (a)(1), and the Department will issue a probationary
license. A re-survey shall occur within 90 days after the Department
receives the written plan of correction from the facility. Minimal compliance
is a condition or occurrence relating to the operation and maintenance of a
facility that is more likely than not to cause more than minimal physical or
mental harm to a consumer.
5) Level 5 is unsatisfactory compliance with the
Act and this Part. The facility shall submit a written plan of
correction pursuant to subsection (a)(1), and the Department will issue
a restricted license. A re-survey shall occur within 60 days after the
Department receives the written plan of correction from the facility.
Unsatisfactory compliance is a condition or occurrence relating to the
operation and maintenance of a facility that creates a substantial probability
that the risk of death or serious mental or physical harm to a consumer will
result, or has resulted in, actual physical or mental harm to a consumer.
6) Level 6 is revocation of the license to provide
services. Revocation may occur as a result of a licensee's consistent and
repeated failure to take necessary corrective actions to rectify documented
violations, or the failure to protect consumers from situations that produce an
imminent risk, creating a condition relating to the operation and
maintenance of a facility that proximately caused a consumer's death. (Section
4-109(c) of the Act) Revocation also may occur for failure to comply with all
consent decrees that apply to facilities federally designated as institutions
for the mentally diseased and that continue to apply to facilities
licensed under the Act, or to otherwise obstruct a consumer from
transferring from a facility to a community-based setting. (Section 1-101.5(b)
of the Act)
d) In determining the level of a violation, the Director or his
or her designee will consider the following criteria:
1) The degree of danger to the consumer, consumers or community
that is posed by the condition or occurrence in the facility. The following
factors will be considered in assessing the degree of danger:
A) Whether the consumer or consumers of the facility are able to
recognize conditions or occurrences that may be harmful and are able to take
measures for self-preservation and self-protection. The extent of nursing care
required by the consumers, as indicated by review of consumer needs, will be
considered in relation to this determination.
B) Whether the consumer or consumers have access to the area of
the facility in which the condition or occurrence exists and the extent of
access. A facility's use of barriers, warning notices, instructions to staff
and other means of restricting consumer access to hazardous areas will be
considered.
C) Whether the condition or occurrence was the result of
inherently hazardous activities or negligence by the facility.
D) Whether the consumer or consumers of the facility were notified
of the condition or occurrence and the promptness of the notice. Failure of
the facility to notify consumers of potentially harmful conditions or
occurrences will be considered. The adequacy of the method of the notification
and the extent to which the notification reduced the potential danger to the
consumers will also be considered.
2) The directness and imminence of the danger to the consumer,
consumers, or the community by the condition or occurrence in the facility. In
assessing the directness and imminence of the danger, the following factors
will be considered:
A) Whether actual harm, including death, physical injury or
illness, mental injury or illness, distress or pain to a consumer or consumers
resulted from the condition or occurrence and the extent of the harm.
B) Whether available statistics and records from similar
facilities indicate that direct and imminent danger to the consumer or
consumers has resulted from similar conditions or occurrences, and the
frequency of this danger.
C) Whether professional opinions and findings indicate that direct
and imminent danger to the consumer or consumers will result from the condition
or occurrence.
D) Whether the condition or occurrence was limited to a specific
area of the facility or was widespread throughout the facility. Efforts taken
by the facility to limit or reduce the scope of the area affected by the
condition or occurrence will be considered.
E) Whether the physical, mental or emotional state of the consumer
or consumers who are subject to the danger would facilitate or hinder harm
actually resulting from the condition or occurrence.
e) Prior to initiating formal action to sanction a license,
the Department shall allow the licensee an opportunity to take corrective
action to eliminate or ameliorate a violation of the Act or this
Part except in cases in which the Department determines that emergency
action is necessary to protect the public or individual interest, safety or
welfare. (Section 4-109(d) of the Act)
f) Subsequent to an on-site survey, the Department shall issue
a written notice to the licensee. The Department shall specify the particular
Sections of the Act or this Part, if any, with which the facility
is not compliant. The Department's notice shall require any corrective actions
be taken within a specified time period as required by the Act and subsections
(a)(1) and (c)(4) and (5) of this Section, as applicable. (Section
4-109(e) of the Act)
g) Sanctions shall be imposed according to the following
definitions:
1) Administrative notice – A written notice issued by the
Department that specifies violations of the Act and this Part requiring
a written plan of correction with time frames for corrections to be made and a
notice that any additional violation of the Act and this Part may
result in a higher level sanction. (Level 3)
2) Probation – Compliance with the Act and this
Part is minimally acceptable and necessitates immediate corrective action.
Individuals' life safety or quality of care is not in jeopardy. The
probationary period is limited to 90 days after the Department receives the
written plan of correction from the facility. During the probationary
period, the facility must make corrective changes sufficient to bring the
facility back into good standing with the Department. Failure to make
corrective changes within that given time frame may result in a determination
by the Department to initiate a higher-level sanction. The admission
of new individuals shall be prohibited during the probationary period. (Level
4)
3) Restricted license – A licensee is sanctioned for
unsatisfactory compliance. The admission of new individuals shall be
prohibited during the restricted licensure period. Corrective action
sufficient to bring the licensee back into good standing with the Department
must be taken within 60 days after the Department receives a written plan
of correction from the facility. During the restricted licensure period a
monitor will be assigned to oversee the progress of the facility in taking
corrective action. If corrective actions are not taken, the facility will be
subject to a higher-level sanction. (Level 5)
4) Revocation – Revocation of the license is withdrawal by
formal actions of the licensee. The revocation shall be in effect until the
provider submits a re-application and the licensee can demonstrate its ability
to operate in good standing with the Department. The Department has the right
not to reinstate a license. If revocation occurs as a result of imminent risk,
all individuals will be immediately relocated and all funding will be
transferred. (Level 6)
5) Financial penalty (fines) – A financial penalty may
be imposed upon finding of violation in any one or combination of the
provisions of the Act and this Part. In determining an
appropriate financial penalty, the Department may consider the deterrent effect
of the penalty on the organization and on other providers, the nature of the
violation, the degree to which the violation resulted in a benefit to the
organization and/or harm to the public and any other relevant factors to be
examined in mitigation or aggravation of the organization's conduct. The
financial penalty may be imposed in conjunction with other sanctions or
separately. Higher-level sanctions may be imposed in situations where there
are repeat violations. (Section 4-109(f) of the Act) Fines for single
violations and multiple violations shall be consistent with Section 3-305 of
the Nursing Home Care Act.
h) The
Department may revoke a facility's certification for an individual level of
service without interrupting the operation of other certified levels of service
offered by the facility.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.760 CITATION REVIEW AND APPEAL PROCEDURES
Section 380.760 Citation Review and Appeal Procedures
a) Upon
receipt of Level 3 to 6 citations, the licensee may provide additional written
information and argument disputing the citation within 10 working days
following the receipt of the citations. The Department shall respond to the
licensee's disputation within 20 days following receipt of the disputation.
(Section 4-110 of the Act)
b) If
a licensee contests the Department's decision regarding a Level 4 to 6 citation
or penalty, it can request a hearing by submitting a written request within 20
working days after it receives the Department's dispute resolution
decision. The Department shall notify the licensee of the time and place of
the hearing not less than 14 days prior to the hearing date. (Section
4-110 of the Act)
c) A
license may not be denied or revoked unless the licensee is given written
notice of the grounds for the Department's action. Except when revocation of a
license is based on imminent risk, the facility or program whose license has
been revoked may operate and receive reimbursement for services during the
period preceding the hearing, until a final decision is made. (Section
4-110 of the Act)
d) All
hearings will be conducted in accordance with Practice and Procedures in
Administrative Hearings.
e) Notwithstanding
the existence or pursuit of any other remedy, the Director may, in the manner
provided by law, upon the advice of the Attorney General who shall represent
the Director in the proceedings, maintain an action in the name of the State
for injunction or other process against any person or government unit to
restrain or prevent the establishment of a facility without a license issued
pursuant to the Act and this Part, or to retrain or prevent the
opening, conduction, operating, or maintaining of a facility without a license
issued pursuant to the Act or this Part. In addition, the
Director may, in the manner provided by law, in the name of the People of the
State and through the Attorney General who shall represent the Director in the
proceedings, maintain an action for injunction or other relief or process
against any licensee or other person to enforce and compel compliance with the
provisions of the Act and this Part and any order entered for any
response action pursuant to the Act and this Part. (Section
4-111 of the Act)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.770 SAFETY, ZONING AND BUILDING CLEARANCES
Section 380.770 Safety, Zoning and Building Clearances
a) A
license will not be issued to any facility that does not conform to the State
Fire Marshal's requirements for fire and life safety and for local fire safety,
zoning and building ordinances. All handicapped accessible facilities shall
meet the minimum requirements of the Illinois Accessibility Code and the
Americans With Disabilities Act. Facilities shall maintain a written policy
for reasonable modification for the admission of consumers unable to access the
facility's sites due to physical inaccessibility.
b) The
licensee shall maintain the facility in a safe structural condition. If the
Department determines that an evaluation of the structural condition of a
facility building is necessary, the licensee shall submit a report by a
licensed structural engineer that shall establish a basis for eliminating or
correcting the structural conditions that are found to be hazardous.
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 380
SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.780 SPECIAL DEMONSTRATION PROGRAMS AND SERVICES
Section 380.780 Special Demonstration Programs and
Services
a) All
licensees shall maintain compliance with all requirements of the Act and this
Part.
b) Based
on data from community needs health assessments conducted by facilities, in
cooperation with local health departments, the State may engage specific
providers to participate in a special demonstration program.
c) When
a facility initiates a special demonstration program, the facility shall obtain
approval from the Department prior to the use of concepts, methods, procedures,
techniques, equipment, personnel qualifications, or the conducting of pilot
projects that are alternative to the Act and this Part, provided that
alternatives are carried out with provision for safe and adequate care. This
approval shall provide for the terms and conditions under which the alternative
is granted.
d) A
written request and substantiating information and documents supporting the
request, which the facility may obtain from the local health department, shall
be submitted by the applicant or licensee to the Department.
e) Any
approval by the Department granted under this Section shall be posted adjacent
to the facility license.
f) Information
concerning the availability of demonstration programs and services shall be
provided to the designated assessment and authorization entity to inform the
admission decisions by the consumer.
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