Illinois Compiled Statutes
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210 ILCS 45/3-212
(210 ILCS 45/3-212)
(from Ch. 111 1/2, par. 4153-212)
(a) The Department, whenever it deems necessary in
accordance with subsection (b), shall inspect, survey and evaluate every
facility to determine compliance with applicable licensure requirements and
standards. Submission of a facility's current Consumer Choice Information Report required by Section 2-214 shall be verified at time of inspection. An inspection should occur within 120 days prior
to license renewal. The Department may periodically visit a facility for the
purpose of consultation. An inspection, survey, or evaluation, other than
an inspection of financial records, shall be conducted without prior notice
to the facility. A visit for the sole purpose of consultation may be
The Department shall provide training to surveyors about the appropriate
assessment, care planning, and care of persons with mental illness (other than
Alzheimer's disease or related disorders) to enable its surveyors to
determine whether a facility is complying with State and federal requirements
about the assessment, care planning, and care of those persons.
(a-1) An employee of a State or unit of local government agency
charged with inspecting, surveying, and evaluating facilities who directly
or indirectly gives prior notice of an inspection, survey, or evaluation,
other than an inspection of financial records, to a facility or to an
employee of a facility is guilty of a Class A misdemeanor.
An inspector or an employee of the Department who intentionally prenotifies
orally or in writing, of a pending complaint investigation or inspection shall
be guilty of a Class A misdemeanor.
Superiors of persons who have prenotified a facility shall be subject to the
same penalties, if they have knowingly allowed the prenotification. A person
found guilty of prenotifying a facility shall be subject to disciplinary action
by his or her employer.
If the Department has a good faith belief, based upon information that comes
to its attention, that a violation of this subsection has occurred, it must
file a complaint with the Attorney General or the State's Attorney in the
county where the violation
took place within 30 days after discovery of the information.
(a-2) An employee of a State or unit of local government agency charged with
inspecting, surveying, or evaluating facilities who willfully profits from
violating the confidentiality of the inspection, survey, or evaluation
process shall be guilty of a Class 4 felony and that conduct shall be deemed
unprofessional conduct that may subject a person to loss of his or her
professional license. An action to prosecute a person for violating this
subsection (a-2) may be brought by either the Attorney General or the State's
Attorney in the county where the violation took place.
(a-3) The Department shall, by rule, establish guidelines for required continuing education of all employees who inspect, survey, or evaluate a facility. The Department shall offer continuing education opportunities at least quarterly. Employees of a State agency charged with inspecting, surveying, or evaluating a facility are required to complete at least 10 hours of continuing education annually on topics that support the survey process, including, but not limited to, trauma-informed care, infection control, abuse and neglect, and civil monetary penalties. Qualifying hours of continuing education intended to fulfill the requirements of this subsection shall only be offered by the Department. Content presented during the continuing education shall be consistent throughout the State, regardless of survey region. At least 5 of the 10 hours of continuing education required under this subsection shall be separate and distinct from any continuing education hours required for any license that the employee holds. Any continuing education hours provided by the Department in addition to the 10 hours of continuing education required under this subsection may count towards continuing education hours required for any license that the employee holds.
(b) In determining whether to make more than the required number of
unannounced inspections, surveys and evaluations of a facility the
Department shall consider one or more of the following: previous inspection
reports; the facility's history of compliance with standards, rules and
regulations promulgated under this Act and correction of violations,
penalties or other enforcement actions; the number and severity of
complaints received about the facility; any allegations of resident abuse
or neglect; weather conditions; health emergencies; other reasonable belief
that deficiencies exist.
(b-1) The Department shall not be required to determine whether a
facility certified to participate in the Medicare program under Title XVIII of
the Social Security Act, or the Medicaid program under Title XIX of the Social
Security Act, and which the Department determines by inspection under this
Section or under Section 3-702 of this Act to be in compliance with the
certification requirements of Title XVIII or XIX, is in compliance with any
requirement of this Act that is less stringent than or duplicates a federal
certification requirement. In accordance with subsection (a) of this Section
or subsection (d) of Section 3-702, the Department shall determine whether a
certified facility is in
compliance with requirements of this Act that exceed federal certification
requirements. If a certified facility is found to be out of compliance with
federal certification requirements, the results of an inspection conducted
pursuant to Title XVIII or XIX of the Social Security Act may be used as the
basis for enforcement remedies authorized and commenced, with the Department's discretion to evaluate whether penalties are warranted, under this Act.
Enforcement of this Act against a certified facility shall be commenced
pursuant to the requirements of this Act, unless enforcement remedies sought
pursuant to Title XVIII or XIX of the Social Security Act exceed those
authorized by this Act. As used in this subsection, "enforcement remedy"
means a sanction for violating a federal certification requirement or this
(c) Upon completion of each inspection, survey and evaluation, the
appropriate Department personnel who conducted the inspection, survey or
evaluation shall submit a physical or electronic copy of their report to the licensee upon exiting
the facility, and shall submit the actual report to the appropriate
regional office of the Department. Such report and any recommendations for
action by the Department under this Act shall be transmitted to the
appropriate offices of the associate director of the Department, together
with related comments or documentation provided by the licensee which may
refute findings in the report, which explain extenuating circumstances that
the facility could not reasonably have prevented, or which indicate methods
and timetables for correction of deficiencies described in the report.
Without affecting the application of subsection (a) of Section 3-303, any
documentation or comments of the licensee shall be provided within 10
days of receipt of the copy of the report. Such report shall recommend to
the Director appropriate action under this Act with respect to findings
against a facility. The Director shall then determine whether the report's
findings constitute a violation or violations of which the facility must be
given notice. Such determination shall be based upon the severity of the
finding, the danger posed to resident health and safety, the comments and
documentation provided by the facility, the diligence and efforts to
correct deficiencies, correction of the reported deficiencies, the
frequency and duration of similar findings in previous reports and the
facility's general inspection history. Violations shall be determined
under this subsection no later than 75 days after completion of each
inspection, survey and evaluation.
(d) The Department shall maintain all inspection, survey and evaluation
reports for at least 5 years in a manner accessible to and understandable
by the public.
(e) Revisit surveys. The Department shall conduct a revisit to its licensure and certification surveys, consistent with federal regulations and guidelines.
(f) Notwithstanding any other provision of this Act, the Department shall, no later than 180 days after the effective date of this amendatory Act of the 98th General Assembly, implement a single survey process that encompasses federal certification and State licensure requirements, health and life safety requirements, and an enhanced complaint investigation initiative.
(1) To meet the requirement of a single survey
process, the portions of the health and life safety survey associated with federal certification and State licensure surveys must be started within 7 working days of each other. Nothing in this paragraph (1) of subsection (f) of this Section applies to a complaint investigation.
(2) The enhanced complaint and incident report
investigation initiative shall permit the facility to challenge the amount of the fine due to the excessive length of the investigation which results in one or more of the following conditions:
(A) prohibits the timely development and
implementation of a plan of correction;
(B) creates undue financial hardship impacting
the quality of care delivered to the resident;
(C) delays initiation of corrective training; and
(D) negatively impacts quality assurance and
patient improvement standards.
This paragraph (2) does not apply to complaint
investigations exited within 14 working days or a situation that triggers an extended survey.
(Source: P.A. 102-947, eff. 1-1-23