AUTHORITY: Implementing and authorized by the ID/DD Community Care Act [210 ILCS 47].

SOURCE: Emergency rules adopted at 4 Ill. Reg. 10, p. 495, effective March 1, 1980, for a maximum of 150 days; amended at 4 Ill. Reg. 30, p. 1, effective July 28, 1980; amended at 5 Ill. Reg. 1657, effective February 4, 1981; amended at 6 Ill. Reg. 5981, effective May 3, 1982; amended at 6 Ill. Reg. 6453, effective May 14, 1982; amended at 6 Ill. Reg. 8198, effective June 29, 1982; amended at 6 Ill. Reg. 14544, effective November 8, 1982; amended at 6 Ill. Reg. 14675, effective November 15, 1982; amended at 6 Ill. Reg. 15556, effective December 15, 1982; amended at 7 Ill. Reg. 278, effective December 22, 1982; amended at 7 Ill. Reg. 1919 and 1945, effective January 28, 1983; amended at 7 Ill. Reg. 7963, effective July 1, 1983; amended at 7 Ill. Reg. 15817, effective November 15, 1983; amended at 7 Ill. Reg. 16984, effective December 14, 1983; amended at 8 Ill. Reg. 15574 and 15578 and 15581, effective August 15, 1984; amended at 8 Ill. Reg. 15935, effective August 17, 1984; amended at 8 Ill. Reg. 16980, effective September 5, 1984; codified at 8 Ill. Reg. 19806; amended at 8 Ill. Reg. 24214, effective November 29, 1984; amended at 8 Ill. Reg. 24680, effective December 7, 1984; amended at 9 Ill. Reg. 142, effective December 26, 1984; amended at 9 Ill. Reg. 331, effective December 28, 1984; amended at 9 Ill. Reg. 2964, effective February 25, 1985; amended at 9 Ill. Reg. 10876, effective July 1, 1985; amended at 11 Ill. Reg. 14795, effective October 1, 1987; amended at 11 Ill. Reg. 16830, effective October 1, 1987; amended at 12 Ill. Reg. 979, effective December 24, 1987; amended at 12 Ill. Reg. 16838, effective October 1, 1988; emergency amendment at 12 Ill. Reg. 18705, effective October 24, 1988, for a maximum of 150 days; emergency expired March 23, 1989; amended at 13 Ill. Reg. 6040, effective April 17, 1989; amended at 13 Ill. Reg. 19451, effective December 1, 1989; amended at 14 Ill. Reg. 14876, effective October 1, 1990; amended at 15 Ill. Reg. 466, effective January 1, 1991; amended at 16 Ill. Reg. 594, effective January 1, 1992; amended at 16 Ill. Reg. 13910, effective September 1, 1992; amended at 17 Ill. Reg. 2351, effective February 10, 1993; emergency amendment at 17 Ill. Reg. 2373, effective February 3, 1993, for a maximum of 150 days; emergency expired on July 3, 1993; emergency amendment at 17 Ill. Reg. 7948, effective May 6, 1993, for a maximum of 150 days; emergency expired on October 3, 1993; emergency amendment at 17 Ill. Reg. 9105, effective June 7, 1993, for a maximum of 150 days; emergency expired on November 4, 1993; amended at 17 Ill. Reg. 15056, effective September 3, 1993; amended at 17 Ill. Reg. 16153, effective January 1, 1994; amended at 17 Ill. Reg. 19210, effective October 26, 1993; amended at 17 Ill. Reg. 19517, effective November 4, 1993; amended at 17 Ill. Reg. 21017, effective November 20, 1993; amended at 18 Ill. Reg. 1432, effective January 14, 1994; amended at 18 Ill. Reg. 15789, effective October 15, 1994; amended at 19 Ill. Reg. 11481, effective July 29, 1995; emergency amendment at 20 Ill. Reg. 512, effective January 1, 1996, for a maximum of 150 days; emergency expired May 29, 1996; amended at 20 Ill. Reg. 10065, effective July 15, 1996; amended at 20 Ill. Reg. 12049, effective September 10, 1996; amended at 21 Ill. Reg. 14990, effective November 15, 1997; amended at 22 Ill. Reg. 4040, effective February 13, 1998; amended at 22 Ill. Reg. 7172, effective April 15, 1998; amended at 22 Ill. Reg. 16557, effective September 18, 1998; amended at 23 Ill. Reg. 1052, effective January 15, 1999; amended at 23 Ill. Reg. 7970, effective July 15, 1999; amended at 24 Ill. Reg. 17254, effective November 1, 2000; amended at 25 Ill. Reg. 4879, effective April 1, 2001; amended at 25 Ill. Reg. 6499, effective May 15, 2001; amended at 26 Ill. Reg. 4878, effective April 1, 2002; amended at 26 Ill. Reg. 10611, effective July 1, 2002; emergency amendment at 27 Ill. Reg. 2238, effective February 1, 2003, for a maximum of 150 days; emergency expired June 30, 2003; emergency amendment at 27 Ill. Reg. 5489, effective March 25, 2003, for a maximum of 150 days; emergency expired August 21, 2003; amended at 27 Ill. Reg. 5924, effective April 1, 2003; emergency amendment at 27 Ill. Reg. 14237, effective August 15, 2003, for a maximum of 150 days; emergency expired January 11, 2004; amended at 27 Ill. Reg. 15924, effective September 25, 2003; amended at 27 Ill. Reg. 18160, effective November 15, 2003; expedited correction at 28 Ill. Reg. 3552, effective November 15, 2003; amended at 28 Ill. Reg. 7653, effective May 24, 2004; amended at 28 Ill. Reg. 11217, effective July 22, 2004; emergency amendment at 29 Ill. Reg. 11971, effective July 12, 2005, for a maximum of 150 days; emergency rule modified in response to JCAR Recommendation at 29 Ill. Reg. 15247, effective September 23, 2005, for the remainder of the maximum 150 days; emergency expired December 8, 2005; amended at 29 Ill. Reg. 12954, effective August 2, 2005; amended at 30 Ill. Reg. 1460, effective January 23, 2006; amended at 30 Ill. Reg. 5338, effective March 2, 2006; amended at 30 Ill. Reg. 13876, effective August 7, 2006; amended at 31 Ill. Reg. 6119, effective April 3, 2007; amended at 31 Ill. Reg. 8850, effective June 6, 2007; amended at 33 Ill. Reg. 9393, effective June 17, 2009; amended at 34 Ill. Reg. 19224, effective November 23, 2010; amended at 35 Ill. Reg. 3461, effective February 14, 2011; amended at 39 Ill. Reg. 5490, effective March 25, 2015; amended at 42 Ill. Reg. 7950, effective April 30, 2018; emergency amendment at 44 Ill. Reg. 8555, effective May 5, 2020, for a maximum of 150 days; emergency amendment to emergency rule at 44 Ill. Reg. 16298, effective September 15, 2020, for the remainder of the 150 days; emergency rule as amended expired October 1, 2020; emergency amendment at 44 Ill. Reg. 16908, effective October 2, 2020, for a maximum of 150 days; emergency expired February 28, 2021; emergency amendment at 44 Ill. Reg. 19012, effective November 19, 2020, for a maximum of 150 days; emergency expired April 17, 2021; emergency amendment at 45 Ill. Reg. 435, effective December 18, 2020, for a maximum of 150 days; emergency amendment to emergency rule at 45 Ill. Reg. 2108, effective January 27, 2021, for the remainder of the 150 days; emergency rule as amended expired May 16, 2021; emergency amendment at 45 Ill. Reg. 3060, effective March 1, 2021, for a maximum of 150 days; emergency amendment repealed by emergency rulemaking at 45 Ill. Reg. 10102, effective July 25, 2021; emergency amendment at 45 Ill. Reg. 5594, effective April 18, 2021, for a maximum of 150 days; emergency rule expired September 14, 2021; emergency amendment at 45 Ill. Reg. 6729, effective May 17, 2021, for a maximum of 150 days; emergency expired October 13, 2021; emergency amendment at 45 Ill. Reg. 12012, effective September 15, 2021, for a maximum of 150 days; emergency amendment to emergency rule at 45 Ill. Reg. 14616, effective November 5, 2021, for the remainder of the 150 days; emergency expired February 11, 2022; emergency amendment at 45 Ill. Reg. 13735, effective October 14, 2021, for a maximum of 150 days; emergency expired March 12, 2022; emergency amendment at 46 Ill. Reg. 3315, effective February 12, 2022, for a maximum of 150 days; emergency expired July 11, 2022; emergency amendment at 46 Ill. Reg. 5367, effective March 13, 2022, for a maximum of 150 days; emergency expired August 9, 2022; amended at 46 Ill. Reg. 10519, effective June 2, 2022; emergency amendment at 46 Ill. Reg. 13451, effective July 15, 2022, for a maximum of 150 days; emergency amendment to emergency rule at 46 Ill. Reg. 16467, effective September 19, 2022, for the remainder of the 150 days; emergency amendment to emergency rule at 46 Ill. Reg. 18279, effective October 31, 2022, for the remainder of the 150 days; emergency rule as amended expired December 11, 2022; emergency amendment at 46 Ill. Reg. 20313, effective December 12, 2022, for a maximum of 150 days; emergency expired May 10, 2023; amended at 47 Ill. Reg. 14492, effective September 26, 2023; amended at 48 Ill. Reg. 2546, effective January 30, 2024.

SUBPART A: GENERAL PROVISIONS

 

Section 350.110  General Requirements

 

a)         This Part applies to the operator/licensee of facilities, or distinct parts of facilities, that are to be licensed and classified to provide intermediate care for persons with developmental disabilities, pursuant to the terms and conditions of the ID/DD Community Care Act (Act).

 

b)         The license issued to each operator/licensee shall designate the licensee's name, the facility name and address, the classification by level of service authorized for that facility, the number of beds authorized for each level, the date the license was issued and the expiration date.  Licenses will be issued for a period of not less than 6 months nor more than 18 months for facilities with annual licenses and not less than 18 months nor more than 30 months for facilities with 2-year licenses.  The Department will set the period of the license based on the license expiration dates of the facilities in the geographical area surrounding the facility in order to distribute the expiration dates as evenly as possible throughout the calendar year.  (Section 3-110 of the Act)

 

c)         An applicant may request that the license issued by the Department of Public Health (the Department) have distinct parts classified according to levels of services. The distinct part shall satisfactorily meet the physical plant standards of this Part based on a level of service classification sought for that distinct part.  If necessary to protect the health, welfare and safety of residents in a distinct part who require higher standards, the facility shall comply with whatever additional physical plant standards are necessary in any distinct part, to achieve this protection, as required by the highest level of care being licensed. Administrative, supervisory, and other personnel may be shared by the entire facility, if the total needs of the residents of the facility are met.

 

d)         A facility shall admit only that number of residents for which it is licensed.  (Section 2-209 of the Act) 

 

e)         No person shall:

 

1)         Willfully file any false, incomplete or intentionally misleading information required to be filed under this Act, or willfully fail or refuse to file any required information (Section 3-318(a)(6) of the Act); or

 

2)         Open or operate a facility without a license.  (Section 3-318(a)(7) of the Act)

 

f)         A violation of subsection (e) is a business offense, punishable by a fine not to exceed $10,000, except as otherwise provided in subsection (2) of Section 3-103 of the Act and Section 350.120(c) as to submission of false or misleading information in a license application. (Section 3-318(b) of the Act)

 

g)         A facility shall not use in its title or description "Hospital", "Sanitarium", "Sanatorium", "Rehabilitation Center", or any other word or description in its title or advertisements that indicates that a type of service is provided by the facility that the facility is not licensed to provide or, in fact, does not provide.

 

h)         Any person establishing, constructing or modifying a health care facility or portion of a health care facility without obtaining the required permit from the Health Facilities and Services Review Board shall not be eligible to apply for any necessary operating licenses or be eligible for payment by any State agency for services rendered in that facility until the required permit is obtained.  (Section 13.1 of the Illinois Health Facilities Planning Act)

 

i)          Any owner of a facility licensed under the Act shall give 90 days' notice prior to voluntarily closing a facility or closing any part of a facility, or prior to closing any part of a facility if closing the part will require the transfer or discharge of more than 10% of the residents.  Notice shall be given to the Department, to any resident who must be transferred or discharged, to the resident's representative, and to a member of the resident's family, where practicable. Notice shall state the proposed date of closing and the reason for closing.  The facility shall offer to assist the resident in securing an alternative placement and shall advise the resident on available alternatives.  Where the resident is unable to choose an alternate placement and is not under guardianship, the Department shall be notified of the need for relocation assistance.  The facility shall comply with all applicable laws and regulations until the date of closing, including those related to transfer or discharge of residents.  The Department may place a relocation team in the facility as provided under Section 3-419 of the Act.  (Section 3-423 of the Act)

 

j)          If a licensee wishes to designate a portion of its licensed beds as MC/DD, the licensed beds shall be located in a distinct part (as defined in Section 350.330) of the facility.

 

k)         Each facility shall notify the Department electronically at DPH.StrikePlan@illinois.gov within 24 hours after receiving a notice of impending strike of staff providing direct care.  The facility shall submit a strike contingency plan to the Department no later than three calendar days prior to the impending strike.

 

l)          Each facility shall provide the Department with a facility-specific email address. The facility shall not change the email address without prior notice to the Department.

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.120  Application for License

 

a)         Application for a license to establish or operate an ID/DD facility shall be made in writing and submitted to the Department on forms furnished by the Department. (Section 3-103(1) of the Act)  The facility shall provide a written description of the proposed program and other information that the Department may require to determine the appropriate level of licensure.  The application form and other required information shall be submitted and approved prior to surveys of the physical plant or review of building plans and specifications.

 

b)         An application for a new facility shall be accompanied by a permit as required by the Illinois Health Facilities Planning Act.

 

c)         The application shall be under oath and the submission of false or misleading information shall be a Class A misdemeanor.  The application shall contain the following information:

 

1)         The name and address of the applicant if an individual, and if a firm, partnership, or association, of every member thereof, and in the case of a corporation, the name and address thereof and of its officers and its registered agent, and in the case of a unit of local government, the name and address of its chief executive officer;

 

2)         The name and location of the facility for which a license is sought;

 

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

 

4)         The number and type of residents for which maintenance, personal care, or nursing is to be provided; and

 

5)         Information relating to the number, experience, and training of the employees of the facility, any management agreements for the operation of the facility, and of the moral character of the applicant and employees as the Department may deem necessary.  (Section 3-103(2) of the Act)

 

d)         Ownership Change or Discontinuation

 

1)         The license is not transferable.  It is issued to a specific licensee and for a specific location.  The license and the valid current renewal certificate immediately become void and shall be returned to the Department when the facility is sold or leased; when operation is discontinued; when operation is moved to a new location; when the licensee (if an individual) dies; when the licensee (if a corporation or partnership) dissolves or terminates; or when the licensee (whatever the entity) ceases to be.

 

2)         A license issued to a corporation shall become null, void and of no further effect upon the dissolution of the corporation.  The license shall not be revived if the corporation is subsequently reinstated.  A new license shall be obtained.

 

e)         Each initial application shall be accompanied by a financial statement setting forth the financial condition of the applicant and by a statement from the unit of local government having zoning jurisdiction over the facility's location stating that the location of the facility is not in violation of a zoning ordinance.  An initial application for a new facility shall be accompanied by a permit as required by the Illinois Health Facilities Planning Act.  After the application is approved, the applicant shall advise the Department every 6 months of any changes in the information originally provided in the application.  (Section 3-103(3) of the Act)

 

f)         The Director may issue licenses or renewals for periods of not less than 6 months nor more than 18 months for facilities with annual licenses and not less than 18 months nor more than 30 months for facilities with 2-year licenses in order to distribute the expiration dates of such licenses throughout the calendar year.  (Section 3-110 of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.130  Licensee

 

a)         The licensee is the corporate body, political subdivision, individual, or individuals responsible for the operation of the facility and upon whom rests the responsibility for meeting the licensing requirements.  The licensee does not have to own the building being used.

 

b)         If the licensee does not own the building, a lease or management agreement between the licensee and the owner of the building is required.  A copy of the lease or management agreement shall be furnished to the Department.  The Department shall also be provided with a copy of all new lease agreements or any changes to existing agreements within 30 days of the effective date of such changes.

 

c)         If the licensee is not a corporation or a political subdivision of the State of Illinois, each person responsible for the operation of the facility and upon whom rests the responsibility for meeting the licensing Minimum Standards shall be at least l8 years of age.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.140  Issuance of an Initial License for a New Facility

 

a)         Upon receipt and review of an application for a license and inspection of the applicant facility, the Director shall issue a probationary license if he or she finds:

 

1)         That the individual applicant, or the  corporation, partnership or other entity if the applicant is not an individual, is a person responsible and suitable to operate or to direct or participate in the operation of a facility by virtue of financial capacity, appropriate business or professional experience, a record of compliance with lawful orders of the Department and lack of revocation of a license during the previous 5 years and is not the owner of a facility designated pursuant to Section 3-304.2 of the Act and Section 350.185 as a distressed facility;

 

2)         That the facility is under the supervision of an administrator who is licensed, if required, under the Nursing Home Administrators Licensing and Disciplinary Act; and

 

3)         That facility is in substantial compliance with the Act and this Part.  (Section 3-109 of the Act)

 

b)         The Department will issue a probationary license for 120 days from date of issuance.

 

c)         Within 30 days prior to the termination of a probationary license, the Department shall fully and completely inspect the facility and, if the facility meets the applicable requirements for licensure, shall issue a license under Section 3-109 of the Act. (Section 3-116 of the Act)  If the facility is not in substantial compliance and satisfactory progress toward substantial compliance is not being made, the Department will allow the probationary license to expire.

 

d)         If the Department finds that the facility does not meet the requirements for licensure but has made substantial progress toward meeting those requirements, the license may be renewed once for a period not to exceed 120 days from the expiration date of the initial probationary license. (Section 3-116 of the Act)  The Department will not issue more than two successive probationary licenses.

 

e)         The licensee shall qualify for issuance of a two-year license if the licensee has met the criteria contained in Section 3-110(b) of the Act for the last 24 consecutive months.

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.150  Issuance of an Initial License Due to a Change of Ownership

 

a)         Upon receipt and review of an application for a license, the Director will issue a probationary license if he or she finds:

 

1)         That the individual applicant, or the corporation, partnership or other entity if the applicant is not an individual, is a person responsible and suitable to operate or to direct or to participate in the operation of a facility by virtue of financial capacity, appropriate business or professional experience, a record of compliance with lawful orders of the Department and lack of revocation of a license during the previous 5 years and is not the owner of a facility designated pursuant to Section 3-304.2 of the Act and Section 350.185 as a distressed facility;

 

2)         That the facility is under the supervision of an administrator who is licensed, if required, under the Nursing Home Administrators Licensing and Disciplinary Act; and

 

3)         That the facility is in substantial compliance with the Act and this Part. (Section 3-109 of the Act)

 

b)         Whenever ownership of a facility is transferred from the person named in the license to any other person, the transferee must obtain a new probationary license.  The transferee shall notify the Department of the transfer and apply for a new license at least 30 days prior to final transfer.  The Department will not approve the transfer of ownership to an owner of a facility designated pursuant to Section 3-304.2 of the Act and Section 350.185 as a distressed facility. (Section 3-112 of the Act)

 

c)         The transferor shall notify the Department at least 30 days prior to final transfer.  The transferor shall remain responsible for the operation of the facility until such time as the license is issued to the transferee.  (Section 3-112 of the Act)

 

d)         The license granted to the transferee shall be subject to the plan of correction submitted by the previous owner and approved by the Department and any conditions contained in a conditional license issued to the previous owner.  If there are outstanding violations and no approved plan of correction has been implemented, the Department may issue a conditional license and plan of correction as provided in Sections 3-311 through 3-317 of the Act.  (Section 3-113 of the Act)

 

e)         The transferor shall remain liable for all penalties assessed against the facility which are imposed for violations occurring prior to transfer of ownership.  (Section 3-114 of the Act)

 

f)         The Department will issue a probationary license for 120 days from date of issuance.

 

g)         Within 30 days prior to the termination of a probationary license, the Department will fully and completely inspect the facility and, if the facility meets the applicable requirements for licensure, shall issue a license under Section 3-109 of the Act. (Section 3-116 of the Act)  If the facility is not in substantial compliance and satisfactory progress toward substantial compliance is not being made, the Department will allow the probationary license to expire.

 

h)         If the Department finds that the facility does not meet the requirements for licensure but has made substantial progress toward meeting those requirements, the license may be renewed once for a period not to exceed 120 days from the expiration date of the initial probationary license. (Section 3-116 of the Act)  The Department will not issue more than two successive probationary licenses.

 

i)          The issuance date of the probationary license to the new owner will be the date the last licensure requirement is met as determined by the Department.

 

j)          The licensee shall qualify for issuance of a two-year license if the licensee has met the criteria contained in Section 3-110(b) of the Act for the last 24 consecutive months.

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.160  Issuance of a Renewal License

 

a)         At least 120 days, but not more than 150 days, prior to license expiration, the licensee shall submit an application for renewal of the license in such form and containing such information as the Department requires.  If the application is approved, and the facility is in compliance with all other licensure requirements, the license shall be renewed in accordance with Section 3-110 of the Act.

 

b)         The renewal application for a facility will not be approved unless the applicant has provided to the Department an accurate disclosure document in accordance with the Alzheimer's Disease and Related Dementias Special Care Disclosure Act.  (Section 3-115 of the Act)

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.165  Criteria for Adverse Licensure Actions

 

a)         Adverse licensure actions are determinations to deny the issuance of an initial license, to deny the issuance of a renewal of a license, or to revoke the current license of a facility.

 

b)         A determination by the Director to take adverse licensure action against a facility will be based on a finding that one or more of the following criteria are met:

 

1)         There has been a substantial failure to comply with the Act or this Part.  A substantial failure by a facility shall include, but not be limited to, any of the following:

 

A)        Termination of Medicare or Medicaid certification by the Centers for Medicare and Medicaid Services; or

 

B)        A failure by the facility to pay any fine assessed under the Act after the Department has sent to the facility and licensee at least 2 notices of assessment that include a schedule of payments as determined by the Department, taking into account extenuating circumstances and financial hardships of the facility. (Section 3-119(a)(1) of the Act)

 

2)         Conviction of the licensee, or of the person designated to manage or supervise the facility, of a felony, or of 2 or more misdemeanors involving moral turpitude, during the previous 5 years as shown by a certified copy of the record of the court of conviction.  (Section 3-119(a)(2) of the Act)

 

3)         The moral character of the licensee, administrator, manager, or supervisor of the facility is not reputable.  Evidence to be considered will include, but not be limited to, verifiable statements by residents of a facility or law enforcement officials.  In addition, the definition afforded to the terms "reputable," "unreputable," and "irreputable" by the circuit courts of the State of Illinois shall apply when appropriate to the given situation.  For purposes of this Section, a manager or supervisor of the facility is an individual with responsibility for the overall management, direction, coordination, or supervision of the facility or the facility staff. 

 

4)         Personnel is insufficient in number or unqualified by training or experience to properly care for the number and type of residents served by the facility.  Requirements in this Part concerning personnel, including Sections 350.810, 350.820, 350.1220, 350.1230 and 350.1240, will be considered in making this determination.  (Section 3-119(a)(3) of the Act)

 

5)         Financial or other resources are insufficient to conduct and operate the facility in accordance with the Act and this Part.  Financial information and changes in financial information provided by the facility under Section 350.120(e) and under Section 3-208 of the Act will be considered in making this determination.  (Section 3-119(a)(4) of the Act)

 

6)         The facility is not under the direct supervision of a full-time administrator as required by Section 350.510 who is licensed, if required, under the Nursing Home Administrators Licensing and Disciplinary Act.  (Section 3-119(a)(5) of the Act)

 

7)         The facility has committed 2 Type "AA" violations within a 2-year period.  (Section 3-119(a)(6) of the Act)

 

8)         The facility has committed a Type "AA" violation while the facility is listed as a "distressed facility".  (Section 3-119(a)(7) of the Act)

 

9)         The facility has violated the rights of residents of the facility by any of the following actions:

 

A)        A pervasive pattern of cruelty or indifference to residents has occurred in the facility.

 

B)        The facility has appropriated the property of a resident or has converted a resident’s property for the facility's use without written consent of the resident or the resident's legal guardian.

 

C)        The facility has secured property, or a bequest of property, from a resident by undue influence.

 

10)       The facility knowingly submitted false information either on the licensure or renewal application forms or during the course of an inspection or survey of the facility.

 

11)       The facility has refused to allow an inspection or survey of the facility by agents of the Department.

 

c)         The Director will consider all available evidence at the time of the determination, including the history of the facility and the applicant in complying with the Act and this Part, notices of violations that have been issued to the facility and the applicant, findings of surveys and inspections, and any other evidence provided by the facility, residents, law enforcement officials and other interested individuals.

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.170  Denial of Initial License

 

a)         A determination by the Director to deny the issuance of an initial license shall be based on a finding that one or more of the criteria outlined in Section 350.165 or the following criteria are met.

 

1)         Conviction of the applicant, or if the applicant is a firm, partnership or association, of any of its members, or if a corporation, the conviction of the corporation or any of its officers or stockholders, or of the person designated to manage or supervise the facility, of 2 or more misdemeanors involving moral turpitude, during the previous 5 years as shown by a certified copy of the record of the court of conviction. (Section 3-117(2) of the Act)

 

2)         Prior license revocation.  Both of the following conditions shall be met:

 

A)        Revocation of a facility license during the previous 5 years, if such prior license was issued to the individual applicant, a controlling owner or controlling combination of owners of the applicant; or any affiliate of the individual applicant or controlling owner of the applicant and such individual applicant, controlling owner of the applicant or affiliate of the applicant was a controlling owner of the prior license.  Operation for the purposes of this provision shall include individuals with responsibility for the overall management, direction, or supervision of the facility.

 

B)        The denial of an application for a license pursuant to this subsection (a)(2) must be supported by evidence that the prior revocation renders the applicant unqualified or incapable of meeting or maintaining a facility in accordance with the Act and this Part.  This determination will be based on the applicant's qualifications and ability to meet the criteria outlined in Section 350.165(b) as evidenced by the application and the applicant's prior history.  (Section 3-117(5) of the Act)

 

3)         Personnel insufficient in number or unqualified by training or experience to properly care for the proposed number and type of residents. (Section 3-117(3) of the Act)

 

4)         Insufficient financial or other resources to operate and conduct the facility in accordance with this Part and the Act. (Section 3-117(4) of the Act)

 

5)         That the facility is not under the direct supervision of a full time administrator, as defined in this Part, who is licensed, if required, under the Nursing Home Administrators Licensing and Disciplinary Act. (Section 3-117(6) of the Act)

 

6)         That the facility is in receivership and the proposed licensee has not submitted a specific detailed plan to bring the facility into compliance with the requirements of the Act and with federal certification requirements, if the facility is certified, and to keep the facility in such compliance. (Section 3-117(7) of the Act)

 

7)         The applicant is the owner of a facility designated pursuant to Section 3-304.2 of the Act and Section 350.185 as a distressed facility. (Section 3-117(8) of the Act)  The individual applicant, an owner or combination of owners of the applicant; or any affiliate of the individual applicant or owner of the applicant or affiliate of the applicant has an interest in any facility currently listed on the quarterly list of distressed facilities in accordance with Section 350.185.

 

b)         The Department shall notify an applicant immediately upon denial of any application.  The notice shall be in writing and shall include:

 

1)         A clear and concise statement of the violations of Section 3-117 of the Act on which denial is based.  The statement shall include a citation to the provisions of Section 3-117 of the Act and the provisions of this Part under which the application is being denied.

 

2)         A notice of the opportunity for a hearing under Section 3-703 of the Act. 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.  (Section 3-118 of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.175  Denial of Renewal of License

 

a)         Application for renewal of a license of a facility shall be denied and the license of the facility shall be allowed to expire when the Director finds that a condition, occurrence, or situation in the facility meets any of the criteria specified in Section 350.165(b) and in Section 3-119(a) of the Act.  Pursuant to Section 10-65 of the Illinois Administrative Procedure Act, licensees who are individuals are subject to denial of renewal of licensure if the individual is more than 30 days delinquent in complying with a child support order.

 

b)         When the Director determines that an application for renewal of a license of a facility is to be denied, the Department shall notify the facility.  The notice to the facility shall be in writing and shall include:

 

1)         A clear and concise statement of the violations on which the nonrenewal is based.  The statement shall include a citation to the provisions of the Act and this Part on which the application for renewal is being denied.

 

2)         A statement of the date on which the current license of the facility will expire as provided in subsection (c) and Section 3-119(d) of the Act.

 

3)         Notice of the opportunity for a hearing under Section 3-703 of the Act.  (Section 3-119(b) of the Act)

 

c)         The effective date of the nonrenewal of a license shall be as provided in Section 3-119(d) of the Act.

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.180  Revocation of License

 

a)         The license of a facility shall be revoked when the Director finds that a condition, occurrence or situation in the facility meets any of the criteria specified in Section 350.165(b) and in Section 3-119(a) of the Act.  In addition, the license of a facility will be revoked when the facility fails to abate or eliminate a Type A violation as provided in Section 350.282(b) or when the facility has committed 2 type “AA” violations within a 2-year period.  (Section 3-119(a)(6) of the Act)  Pursuant to Section 10-65 of the Illinois Administrative Procedure Act, licensees who are individuals are subject to revocation of licensure if the individual is more than 30 days delinquent in complying with a child support order.

 

b)         When the Director determines that the license of a facility is to be revoked, the Department shall notify the facility.  The notice to the facility shall be in writing and shall include:

 

1)         A clear and concise statement of the violations on which the revocation is based, and the statute or rule violated.

 

2)         A statement of the date on which the revocation will take effect as provided in subsection (c) and Section 3-119(d) of the Act.

 

3)         Notice of the opportunity for a hearing under Section 3-703 of the Act.  (Section 3-119(b) of the Act).

 

c)         The effective date of the revocation of a license shall be as provided in Section 3-119(d) of the Act.

 

d)         The Department may extend the effective date of license revocation or expiration in any case in order to permit orderly removal and relocation of residents. (Section 3-119(d)(3) of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.185  Designation of Distressed Facilities

 

a)         The Department will publish a quarterly list of distressed facilities.  No facility shall be identified as a distressed facility unless it has committed violations or deficiencies that have actually harmed residents.  (Section 3-304.2(a) of the Act) Facilities that have committed violations or deficiencies that resulted in harm to a resident will be added to the quarterly list of distressed facilities using the following methodology:

 

1)         Facility histories will be reviewed for the preceding 24 months.  Violations will be assigned a point value as follows:

 

A)        Type B violation:  10 points;

 

B)        Repeat Type B violation:  20 points;

 

C)        Type A violation:  35 points;

 

D)        Repeat Type A violation:  50 points;

 

E)        Type AA violation:  50 points: and

 

F)         Repeat Type AA violation:  75 points.

 

2)         The Department will review all facilities on a quarterly basis.  The points assigned to a facility by the Department will be calculated on the last day of every quarter in a calendar year.  Violations from the 24 months prior to the current quarter will be scored based on the criteria in subsection (a)(1).

 

3)         Any facility with a total score of 100 points or above and that has committed violations or deficiencies that resulted in harm to a resident will be included in the quarterly list of distressed facilities.

 

4)         For the purposes of this Section, facilities will not accrue points for harm to a resident while the resident is at a day training program or other entity or activity outside the facility that is not under the control or supervision of the facility.  Facilities shall notify the Department and the Department of Human Services – Division of Developmental Disabilities when a resident is injured, or is subject to alleged abuse or neglect, at a day training program.

 

b)         A distressed facility may contract with an independent consultant meeting criteria established by the Department. If the distressed facility does not seek the assistance of an independent consultant, the Department shall place a monitor or a temporary manager in the facility, depending on the Department's assessment of the condition of the facility.  (Section 3-304.2(e) of the Act) An independent consultant contracted by the facility shall:

 

1)         Possess a baccalaureate degree, a nursing license or a nursing home administrator’s license, and a minimum of two years of full-time work experience in the long-term care industry, including one year of experience working directly with individuals with a developmental disability diagnosis, or shall have a professional background that best meets the needs of the facility;

 

2)         Have no professional or financial relationship with the facility, or have any reportable ownership interest in the facility, or any related parties. In this subsection, "related parties" has the meaning attributed to it in the instructions for completing Medicaid cost reports.  (Section 3-304.2(d) of the Act); and

 

3)         Have no ownership interest, or be employed by, another facility on the quarterly list of distressed facilities.  This provision is not intended to prevent an independent consultant from providing consultation to more than one distressed facility.

 

c)         If a facility elects to not contract with a qualified independent contractor, the Department may place a temporary manager or monitor in the facility based on the following factors:

 

1)         The severity of deficiencies and violations cited against the facility;

 

2)         Whether the deficiencies and violations show a pattern of non-compliance or demonstrate an impact on a number of facility systems; and

 

3)         Whether the facility was issued a notice of any high risk violations in the prior 12 months.

 

d)         In addition to any other sanctions in the Act and this Part, facilities not in compliance with the Act and this Part shall be subject to a ban on new admissions until they implement the plan of correction, as certified by a follow-up visit from the Department.

 

e)         To be removed from the distressed facilities list, a facility shall not receive any Type AA violations, or any A violations with harm, and shall not have received any combination of violations, that harmed residents, that equals or exceeds 100 points as determined by the point values in Section 350.185 (a)(1)(A) through (F) for a period that includes at least two consecutive annual surveys and any intervening complaint investigations or other surveys.

 

(Source:  Added at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.190  Experimental Program Conflicting with Requirements

 

a)         Any facility desiring to conduct an experimental program or do research that is in conflict with this Part shall submit a written request to the Department and secure prior approval.  The Department will not approve experimental programs that would violate residents' rights under the Act or this Part. Experimental programs in facilities shall comply with the following:

 

1)         No facility shall permit experimental research or treatment to be conducted on a resident or give access to any person or person's records for a retrospective study about the safety or efficacy of any care or treatment without the prior written approval of the institutional review board;

 

2)         No administrator, 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 resident, including a retrospective study, that does not have the prior written approval of the board. Such conduct shall be grounds for professional discipline by the Department of Financial and Professional Regulation; and

 

3)         The institutional review board may exempt from ongoing review research or treatment initiated on a resident before the individual's admission to a facility and for which the board determines there is adequate ongoing oversight by another institutional review board.

 

b)         Nothing in the Act or this Section shall prevent a facility, any facility employee, or any other person from assisting or participating in any experimental research on or treatment of a resident 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 2-104(a) of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.200  Inspections, Surveys, Evaluations and Consultation

 

a)         The terms survey, inspection, and evaluation are synonymous.  These terms refer to the overall examination of compliance with the Act and this Part. All facilities to which this Part applies shall be subject to and shall be deemed to have given consent to annual inspections, surveys or evaluations by properly identified personnel of the Department, or by other properly identified persons, including local health department staff, as the Department may designate.  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 announced.  (Section 3-212(a) of the Act) The licensee, or person representing the licensee in the facility, shall provide access and entry to the premises or facility for obtaining information required to carry out the Act and this Part.  In addition, the Department shall have access to and may reproduce or photocopy at its cost any books, records, and other documents maintained by the facility, the licensee or their representatives to the extent necessary to carry out the Act and this Part.  (Section 3-213 of the Act) A facility may charge the Department for photocopying at a rate determined by the facility not to exceed the rate in Access to Public Records of the Department of Public Health.

 

b)         No person shall:

 

1)         Intentionally prevent, interfere with, or attempt to impede in any way any duly authorized investigation and enforcement of the Act or this Part (Section 3-318(a)(2) of the Act);

 

2)         Intentionally prevent or attempt to prevent any examination of any relevant books or records pertinent to investigations and enforcement of the Act or this Part (Section 3-318(a)(3) of the Act);

 

3)         Intentionally prevent or interfere with the preservation of evidence pertaining to any violation of this Act or the rules promulgated under the Act or this Part (Section 3-318(a)(4) of the Act); or

 

4)         Intentionally retaliate or discriminate against any resident or employee for contacting or providing information to any state official, or for initiating, participating in, or testifying in an action for any remedy authorized under the Act or this Part.  (Section 3-318(a)(5) of the Act)

 

c)         A violation of subsection (b) is a business offense, punishable by a fine not to exceed $10,000, except as otherwise provided in subsection (2) of Section 3-103 of the Act and Section 350.120(c) as to submission of false or misleading information in a license application.  (Section 3-318(b) of the Act)

 

d)         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:

 

1)         Previous inspection reports;

 

2)         The facility's history of compliance with the Act and this Part and correction of violations, penalties or other enforcement actions;

 

3)         The number and severity of complaints received about the facility;

 

4)         Any allegations of resident abuse or neglect;

 

5)         Weather conditions;

 

6)         Health emergencies;

 

7)         Other reasonable belief that deficiencies exist; (Section 3-212(b) of the Act) and

 

8)         Requirements pursuant to the "1864 Agreement" (42 U.S.C.A. 1395aa) between the Department and the U.S. Department of Health and Human Services (HHS) (e.g., annual and follow-up certification inspections, life safety code inspections and any inspections requested by the Secretary of HHS).

 

e)         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 to be in compliance with the certification requirements of Title XVIII or XIX, is in compliance with any requirement of the Act and this Part that is less stringent than or duplicates a federal certification requirement. (Section 3-212(b-1) of the Act)

 

f)         The Department shall, in accordance with Section 3-212(a) of the Act, determine whether a certified facility is in compliance with requirements of the Act that exceed federal certification requirements (Section 3-212 (b-1) of the Act).

 

g)         If a certified facility is found to be out of compliance with federal certification requirements, the results of the inspection conducted pursuant to Title XVIII or XIX of the Social Security Act (Section 3-212(b-1) of the Act) shall be reviewed to determine which, if any, of the results shall be considered licensure findings, as follows:

 

1)         The result identifies potential violations of the Act and this Part; and

 

2)         The result, based on available information, would likely represent a Type AA, a Type A, or a Type B violation if tested against the factors described in Sections 350.272 and 350.274.

 

h)         All results of an inspection conducted pursuant to Title XVIII or XIX of the Social Security Act that the Department considers licensure findings shall be provided to the facility at the time of exit or by mail in accordance with subsection (i).

 

i)          Upon the completion of each inspection, survey and evaluation, the appropriate Department personnel who conducted the inspection, survey or evaluation shall submit a copy of their report to the licensee or the licensee's representative, upon exiting the facility or upon considering results of an inspection conducted pursuant to Title XVIII or XIX of the Social Security Act as licensure findings. A copy of the information gathered during a complaint investigation will not be provided upon exiting the facility.  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 shall be provided to the Department within ten days of receipt of the copy of the report.  (Section 3-212(c) of the Act)

 

j)          Consultation consists of providing advice or suggestions to the staff of a facility at their request relative to specific matters of the scope of regulation, methods of compliance with the Act or this Part or general matters of patient care.  A request for consultation by a facility or facility staff does not obligate Department personnel to provide consultation.  A facility that requests and obtains consultation from the Department retains legal responsibility for compliance with the Act and this Part.

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.210  Filing an Annual Attested Financial Statement

 

a)         Each licensee shall file annually, or more often as the Director shall prescribe, an attested financial statement. The Director may order an audited financial statement of a particular facility by an auditor of the Director's choice. The Department will pay the cost of extra audits ordered by the Director.  The time period covered in the financial statement shall be a period determined by the Department for the initial filing, and after the initial filing shall coincide with the facility's fiscal year or the calendar year.  (Section 3-208(a) of the Act)

 

b)         The financial statement shall be filed with the Department within 90 days following the end of the designated reporting period. The financial statement will not be considered as having been filed unless all sections of the prescribed forms have been properly completed.  Those sections which do not apply to a particular facility shall be noted "not applicable" on the forms.

 

c)         The information required to be submitted in the financial statement will include, but is not limited to, the following:

 

1)         Facility information, including:  facility name and address, licensure information, type of ownership, licensed bed capacity, date and cost of building construction and additions, date and cost of acquisition of buildings, building sizes, equipment costs and dates of acquisition.

 

2)         Resident information, including:  number and level of care of residents by source of payment, income from residents by level of care.

 

3)         Cost information by level of care, including:

 

A)        General service costs; such as dietary, food, housekeeping, laundry, utilities, and plant operation and maintenance.

 

B)        Health care costs; such as medical director, nursing, medications, oxygen, activities, medical records, other medical services, social services, and utilization reviews.

 

C)        General administration; such as administrative salaries, professional services, fees, subscriptions, promotional costs, insurance, travel, clerical costs, employee benefits, license fees, and inservice training and education.

 

D)        Ownership; such as depreciation, interest, taxes, rent, and leasing.

 

E)        Special Service cost centers; such as habilitative and rehabilitative services, therapies, transportation, education, barber and beauty care, and gift and coffee shops.

 

4)         Income information, including operating and nonoperating income.

 

5)         Ownership information, including balance sheet and payment to owners.

 

6)         Personnel information, including the number and type of people employed and salaries paid.

 

7)         Related organization information, including related organizations from which services are purchased.

 

d)         The new owner or a new lessee of a previously licensed facility may file a projection of capital costs at the time of closing or signing of the lease.

 

e)         The new owner or new lessee of a facility that is licensed for the first time (a newly constructed facility) shall file a projection of capital costs.

 

f)         The owner or lessee in subsections (d) and (e) shall file a full cost report within nine months after acquisition (covering the first six months of operation).  Each shall also file a cost report within 90 days after the close of its first complete fiscal year.

 

g)         No public funds shall be expended for the maintenance of any resident in a facility which has failed to file the financial statement, and no public funds shall be paid to, or on behalf of a facility which has failed to file a statement.  (Section 3-208(b) of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.220  Information to Be Made Available to the Public by the Department

 

a)         The Department shall respect the confidentiality of a resident's record and shall not divulge or disclose the contents of a record in a manner which identifies a resident, except upon a resident's death to a relative or guardian, or under judicial proceedings.  This Section shall not be construed to limit the right of a resident or a resident's representative to inspect or copy the resident's records. (Section 2-206(a) of the Act)

 

b)         Confidential medical, social, personal or financial information identifying a resident shall not be available for public inspection in a manner which identifies a resident. (Section 2-206(b) of the Act)

 

c)         The following information is subject to disclosure to the public from the Department or the Department of Healthcare and Family Services:

 

1)         Information submitted under Section 3-103 and 3-207 of the Act, except information concerning the remuneration of personnel licensed, registered, or certified by the Department of Financial and Professional Regulation and monthly charges for an individual private resident;

 

2)         Records of license and certification inspections, surveys, and evaluations of facilities, other reports of inspections, surveys, and evaluations of resident care, whether a facility is designated a distressed facility and the basis for the designation, and reports concerning a facility prepared pursuant to Titles XVIII and XIX of the Social Security Act, subject to the provisions of the Social Security Act;

 

3)         Cost and reimbursement reports submitted by a facility under Section 3-208 of the Act, reports of audits of facilities, and other public records concerning the cost incurred by, revenues received by, and reimbursement of facilities; and

 

4)         Complaints filed against a facility and complaint investigation reports, except that a complaint or complaint investigation report shall not be disclosed to a person other than the complainant or complainant's representative before it is disclosed to a facility under Section 3-702 of the Act, and, further, except that a complainant or resident's name shall not be disclosed except under Section 3-702 of the Act. (Section 2-205 of the Act)

 

d)         The Department shall disclose information under this Section in accordance with provisions for inspection and copying of public records required by the Freedom of Information Act.

 

e)         However, the disclosure of information described in subsection (c)(1) shall not be restricted by any provision of the Freedom of Information Act. (Section 2-205 of the Act)

 

f)         Copies of reports available to the public may be obtained by making a written request to the Department in accordance with Access to Records of the Department of Public Health.

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.230  Information to Be Made Available to the Public by the Licensee

 

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

 

1)         Its current license;

 

2)         A description, provided by the Department, of complaint procedures established under the Act and the name, address, and telephone number of a person authorized by the Department to receive complaints;

 

3)         A copy of any order pertaining to the facility issued by the Department or a court; and

 

4)         A list of the material available for public inspection under Section 3-210 of the Act.  (Section 3-209 of the Act)

 

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

 

1)         A complete copy of every inspection report of the facility received from the Department during the past 5 years;

 

2)         A copy of every order pertaining to the facility issued by the Department or a court during the past 5 years;

 

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

 

4)         A copy of the statement of ownership required by Section 3-207 of the Act;

 

5)         A record of personnel employed or retained by the facility who are licensed, certified or registered by the Department of Financial and Professional Regulation;

 

6)         A complete copy of the most recent inspection report of the facility received from the Department; and

 

7)         A copy of the current Consumer Choice Information Report required by Section 2-214 of the Act.  (Section 3-210 of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.240  Municipal Licensing

 

a)         Municipalities that have adopted a licensing ordinance as provided under Section 3-104 of the Act and this Part shall adopt this Part by complying with Article I, Division 3, of the Illinois Municipal Code.

 

b)         Municipalities shall issue licenses so that the expiration dates are distributed throughout the calendar year.  The month the license expires shall coincide with the date of original licensure of the licensee.

 

c)         The municipality shall notify the Department within 10 days following the date of issuance or denial of a license that the municipal license has been issued or denied.  If the license is issued, the notice shall include the facility name, address, the date of issuance and the number of beds by level of care for which the license was issued.  If the license is denied, the notice shall indicate the reason for denial and the current status of the licensee's (applicant's) application for a municipal license.

 

d)         The municipality shall use the same licensing classifications as the Department, and a municipality shall not issue a license to a facility for a different classification from the license issued by the Department.

 

e)         The Department and the city, village or incorporated town shall have the right at any time to visit and inspect the premises and personnel of any facility for the purpose of determining whether the applicant or licensee is in compliance with the Act or with the local ordinances which govern the regulation of the facility. The Department may survey any former facility which once held a license to ensure that the facility is not again operating without a license. Municipalities may charge a reasonable license or renewal fee for the regulation of facilities, which fees shall be in addition to the fees paid to the Department.  (Section 3-107 of the Act)

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.250  Ownership Disclosure

 

a)         As a condition of the issuance or renewal of the license of any facility, the applicant shall file a statement of ownership.  The applicant shall update the information required in the statement of ownership within 10 days after any change.  (Section 3-207(a) of the Act)

 

b)         The statement of ownership shall include the following:

 

1)         The name, address, telephone number, occupation or business activity, business address and business telephone number of the person who is the owner of the facility and every person who owns the building in which the facility is located, if other than the owner of the facility, that is the subject of the application or license;

 

2)         If the owner is a partnership or corporation, the name of every partner and stockholder of the owner (3-207(b) of the Act);

 

3)         The percent of direct or indirect financial interest of those persons who have a direct or indirect financial interest of five percent or more in the legal entity designated as the operator/licensee of the facility which is the subject of the application or license;

 

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

 

5)         The name and address of any facility, wherever located, any financial interest that is owned by the applicant, if the facility were required to be licensed if it were located in this State.  (Section 3-207(b) of the Act)

 

(Source:  Amended at 42 Ill. Reg. 7950, effective April 30, 2018)

 

Section 350.260  Issuance of Conditional License

 

a)         The Director may issue a conditional license under Section 3-305 of the Act to any facility if the Director finds that either a Type "A" or Type "B" violation exists in such facility.  The issuance of a conditional license shall revoke any license held by the facility. (Section 3-311 of the Act)

 

b)         Prior to the issuance of a conditional license, the Department shall review and approve a written plan of correction.  The Department shall specify the violations which prevent full licensure and shall establish a time schedule for correction of the deficiencies.  Retention of the license shall be conditional on the timely correction of the deficiencies in accordance with the plan of correction.  (Section 3-312 of the Act)

 

c)         Written notice of the decision to issue a conditional license shall be sent to the applicant or licensee together with the specification of all violations of the Act and this Part that prevent full licensure and which form the basis for the Department's decision to issue a conditional license and the required plan of correction. The notice shall inform the applicant or licensee of its right to a full hearing under Section 3-315 of the Act to contest the issuance of the conditional license. (Section 3-313 of the Act)

 

d)         If the applicant or licensee desires to contest the basis for issuance of a conditional license, or the terms of the plan of correction, the applicant or licensee shall send a written request for hearing to the Department within 10 days after receipt by the applicant or licensee of the Department's notice and decision to issue a conditional license. The Department shall hold the hearing as provided under Section 3-703 of the Act.  The terms of the conditional license shall be stayed pending the issuance of the Final Order at the conclusion of the hearing, and the facility may operate in the same manner as with an unrestricted license. (Section 3-315 of the Act)

 

e)         A conditional license shall be issued for a period specified by the Department, but in no event for more than one year. The effective date of the conditional license shall not begin until the applicant or licensee has had the opportunity to request a hearing pursuant to subsection (d), and if a hearing is requested in a timely manner, then the terms of the conditional license shall be stayed as provided for in subsection (d).  The Department shall periodically inspect any facility operating under a conditional license.  If the Department finds substantial failure by the facility to timely correct the violations which prevented full licensure and formed the basis for the Department's decision to issue a conditional license in accordance with the required plan of correction, the conditional license may be revoked as provided under Section 3-119 of the Act. (Section 3-316 of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.270  Monitor and Receivership

 

a)         The Department may place an employee or agent to serve as a monitor in a facility or may petition the circuit court for appointment of a receiver for a facility, or both, when any of the following conditions exist:

 

1)         The facility is operating without a license;

 

2)         The Department has suspended, revoked or refused to renew the existing license of the facility;

 

3)         The facility is closing or has informed the Department that it intends to close and adequate arrangements for relocation of residents have not been made at least 30 days prior to closure;

 

4)         The Department determines that an emergency exists, whether or not it has initiated revocation or nonrenewal procedures, if because of the unwillingness or inability of the licensee to remedy the emergency the Department believes a monitor is necessary; as used in this subsection, "emergency" means a threat to the health, safety or welfare of a resident that the facility is unwilling or unable to correct;

 

5)         The Department receives notification that the facility is terminated or will not be renewed for participation in the federal reimbursement program under either Title XVIII (Medicare) or Title XIX (Medicaid) of the Social Security Act;

 

6)         The facility has been designated a distressed facility by the Department and does not have a consultant employed pursuant to Section 3-304.2 of the Act and Section 350.185 and an acceptable plan of improvement, or the Department has reason to believe the facility is not complying with the plan of improvement. Nothing in this subsection shall preclude the Department from placing a monitor in a facility if otherwise justified by law; or

 

7)         At the discretion of the Department when a review of facility compliance history, incident reports, or reports of financial problems raises a concern that a threat to resident health, safety, or welfare exists.  (Section 3-501 of the Act)

 

b)         The monitor shall meet the following minimum requirements:

 

1)         Be in good physical health, as evidenced by a physical examination by a physician within the last year, and have had a TB test;

 

2)         Have an understanding of the needs of ID/DD facility residents as evidenced by one year of experience in working, as appropriate, with developmentally disabled individuals in programs such as patient care, social work or advocacy;

 

3)         Have an understanding of the provisions of the Act and this Part that are the subject of the monitors' duties as evidenced in a personal interview of the candidate;

 

4)         Not be related to the owners of the involved facility either through blood, marriage or common ownership of real or personal property except ownership of stock that is traded on a stock exchange;

 

5)         Have successfully completed a baccalaureate degree or possess a nursing license or a nursing home administrator's license; and

 

6)         Have two years of full-time work experience that is relevant to the reason the monitor has been placed in the facility.

 

c)         The monitor shall be under the supervision of the Department; shall perform the duties of a monitor delineated in Section 3-502 of the Act; and shall accomplish the following actions:

 

1)         Visit the facility as directed by the Department;

 

2)         Review all records pertinent to the condition for the monitor's placement under subsection (a);

 

3)         Provide written and oral reports to the Department detailing the observed conditions of the facility; and

 

4)         Be available as a witness for hearings involving the condition for placement as monitor.

 

d)         All communications, including, but not limited to, data, memoranda, correspondence, records and reports, shall be transmitted to and become the property of the Department.  In addition, findings and results of the monitor's work done under this Part shall be strictly confidential and not subject to disclosure without written authorization from the Department, or by court order subject to disclosure only in accordance with the Freedom of Information Act, subject to the confidentiality requirements of the Act.

 

e)         The Department may terminate the monitor assignment as monitor at any time.

 

f)         Through consultation with the long-term care industry associations, professional organizations, consumer groups and health care management corporations, the Department will maintain a list of receivers. Preference on the list shall be given to individuals possessing a valid Illinois nursing home administrator’s license and experience in financial and operations management of a long-term care facility and to individuals with access to consultative experts with this experience.  To be placed on the list, individuals shall meet the following minimum requirements:

 

1)         Be in good physical health as evidenced by a physical examination by a physician within the last year, and have had a TB test;

 

2)         Have an understanding of the needs of ID/DD facility residents and the delivery of the highest possible quality of care as evidenced by one year of experience in working with developmentally disabled individuals in programs such as patient care, social work or advocacy;

 

3)         Have an understanding and working knowledge of the Act and this Part as evidenced in a personal interview of the candidate;

 

4)         Have successfully completed a baccalaureate degree, or possess a nursing license or a nursing home administrator's license; and

 

5)         Have two years of full-time working experience providing care to persons with developmental disabilities that is relevant to the reason the monitor has been placed in the facility.

 

g)         Upon a court appointment of a receiver for a facility, the Department will inform the individual of all legal proceedings to date that concern the facility.

 

h)         The receiver may request that the Director authorize expenditures from monies appropriated, pursuant to Section 3-511 of the Act, if incoming payments from the operation of the facility are less than the costs incurred by the receiver.

 

i)          In the case of Department-ordered patient transfers, the receiver may:

 

1)         Assist in providing for the orderly transfer of all residents in the facility to other suitable facilities or make other provisions for their continued health;

 

2)         Assist in providing for transportation of the resident, and the resident's medical records and the resident's belongings if the resident is transferred or discharged; assist in locating alternative placement; assist in preparing the resident for transfer; and permit the resident's legal guardian to participate in selecting the resident's new location;

 

3)         Unless emergency transfer is necessary, explain alternative placements to the resident and provide orientation to the place chosen by the resident or resident's guardian.

 

j)          In any action or special proceeding brought against a receiver in the receiver's official capacity for acts committed while carrying out powers and duties set forth in this Section, the receiver shall be considered a public employee under the Local Governmental and Governmental Employees Tort Immunity Act.  A receiver may be held liable in a personal capacity only for the receiver's own gross negligence, intentional acts or breach of fiduciary duty. (Section 3-513 of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.271  Presentation of Findings

 

a)         If it is probable that findings will be presented that could be issued as violations of regulations that represent a direct threat to the health, safety or welfare of residents, surveyors shall notify the administrator or designee during the course of the survey of such possible findings.

 

b)         The Department will conduct an exit conference with the administrator or other facility designee at the conclusion of each on-site inspection at the facility, whether or not the investigation has been completed.  If the investigation has been completed, findings shall be presented during the exit conference.  If the investigation has not been completed at the time of the facility exit conference, the Department will inform the facility administrator or designee that the investigation is not complete and that findings may be presented to the facility at a later date.  Presentation of any additional findings may be conducted at the facility, at the Department's regional office, or by telephone.

 

c)         With the assistance of the administrator, surveyors shall schedule a time and place for the exit conference to be held at the conclusion of the survey.

 

d)         At the exit conference, surveyors shall present their findings and resident identity key and identify regulations related to the findings.  The facility administrator or designee shall have an opportunity at the exit conference to discuss and provide additional documentation related to the findings.  The Department's surveyors conducting the exit conference may, at their discretion, modify or eliminate any or all preliminary findings in accordance with any facts presented by the facility to the Department during the exit conference.

 

e)         Additional comments or documentation may be submitted by the facility to the Department during a 10-day comment period as allowed by the Act.

 

f)         If the Department determines, after review of the comments submitted pursuant to subsection (d) of this Section, that the facility may have committed violations of the Act or this Part different than or in addition to those presented at the exit conference and the violations may be cited as either Type A or repeat Type B violations, the Department will so inform the facility in writing.  The facility shall then have an opportunity to submit additional comments addressing the different violations of additional Sections of the Act or this Part presented by the Department at the exit conference.  The surveyors will be advised of any code changes made after their recommendations are submitted.

 

g)         The facility shall have five working days after receipt of the notice required by subsection (f) to submit its additional comments to the Department.  The Department will consider the additional comments in determining the existence and level of violation of the Act and this Part in the same manner as the Department considers the facility's original comments.

 

h)         If desired by the facility, an audio-taped recording may be made of the exit conference provided that a copy of the recording is provided, at facility expense, to the surveyors at the conclusion of the exit conference. Video-taped recordings are prohibited.

 

i)          Surveyors will not conduct an exit conference under the following conditions:

 

1)         The facility administrator or designee requests that an exit conference not be held;

 

2)         During a scheduled exit conference, facility staff or their guests create an environment that is not conducive to a meaningful exchange of information.

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.272  Determination to Issue a Notice of Violation or Administrative Warning

 

a)         Upon receipt of a report of an inspection, survey or evaluation of a facility, the Director shall review the findings contained in the report to determine whether the report's findings constitute a violation or violations of which the facility must be given notice.  All information, evidence, and observations made during an inspection, survey or evaluation shall be considered findings or deficiencies.  (Section 3-212(c) of the Act)

 

b)         In making this determination, the Director shall consider any comments and documentation provided by the facility within 10 days after receipt of the report in accordance with Section 350.200(c). (Section 3-212(c) of the Act)

 

c)         In determining whether the findings warrant the issuance of a notice of violation, the Director shall consider the following factors:

 

1)         The severity of the finding.  The Director will consider whether the finding constitutes a merely technical non-substantial error or whether the finding is serious enough to constitute an actual violation of the intent and purpose of the standard.

 

2)         The danger posed to resident health and safety.  The Director will consider whether the finding could pose any direct harm to the residents.

 

3)         The diligence and efforts to correct deficiencies and correction of reported deficiencies by the facility.  Consideration will be given to any evidence provided by the facility in its comments and documentation that steps have been taken to reduce noted findings and to insure a reduction of deficiencies.

 

4)         The frequency and duration of similar findings in previous reports and the facility's general inspection history.  The Director will consider whether the same finding or a similar finding relating to the same condition or occurrence has been included in previous reports and whether the facility has allowed the condition or occurrence to continue or to recur.  (Section 3-212(c) of the Act)

 

d)         If the Director determines that the report's findings constitute a violation or violations that do not constitute a Type "AA", Type "A", Type "B", or Type "C" violation, the Department shall issue an administrative warning as provided in Section 350.277. (Section 3-303.2(a) of the Act)

 

e)         The Department shall determine the violation under the Act and this Section no later than 90 days after completion of each inspection, survey and evaluation.  (Section 3-212(c) of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.274  Determination of the Type of a Violation

 

a)         After determining that issuance of a notice of violation is warranted and prior to issuance of the notice, the Director will review the findings that are the basis of the violation and any comments and documentation provided by the facility to determine the level of the violation.  Each violation shall be determined to be either a Type "AA", a Type " A", a Type "B", or a Type "C" violation based on the criteria in this Section.

 

b)         The following definitions of Types of violations shall be used in determining the Type of each violation:

 

1)         A "Type AA violation" is a violation of the Act or this Part that creates a condition or occurrence relating to the operation and maintenance of a facility that proximately caused a resident's death.  (Section 1-128.5 of the Act)

 

2)         A Type "A" violation" is a violation of the Act or this Part that creates 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 resident will result therefrom or has resulted in actual physical or mental harm to a resident.  (Section 1-129 of the Act)

 

3)         A "Type B violation" is a violation of the Act or this Part that creates 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 resident or is specifically designated as a Type "B" violation in the Act.  (Section 1-130 of the Act)

 

4)         A "Type C violation" is a violation of the Act or this Part that creates 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 resident will result therefrom. Section 1-132 of the Act)

 

c)         In determining the Type of a violation, the Director shall consider the following criteria:

 

1)         The degree of danger to the resident or residents 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 resident or residents 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 residents as indicated by a review of patient needs will be considered in relation to this determination.

 

B)        Whether the resident or residents 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 resident 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 resident or residents of the facility were notified of the condition or occurrence and the promptness of the notice.  Failure of the facility to notify residents of potentially harmful conditions or occurrences will be considered.  The adequacy of the method of notification and the extent to which notification reduced the potential danger to the residents will also be considered.

 

2)         The directness and imminence of the danger to the resident or residents 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 resident or residents resulted from the condition or occurrence and the extent of harm.

 

B)        Whether available statistics and records from similar facilities indicate that direct and imminent danger to the resident or residents has resulted from similar conditions or occurrences and the frequency of danger.

 

C)        Whether professional opinions and findings indicate that direct and imminent danger to the resident or residents 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 resident or residents who are subject to the danger would facilitate or hinder harm actually resulting from the condition or occurrence.

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.276  Notice of Violation

 

a)         Each notice of violation shall be prepared in writing and shall contain the following information:

 

1)         A description of the nature of the violation.

 

2)         A citation of the specific statutory provision or rule alleged by the Department to have been violated.  (Section 3-301 of the Act)

 

3)         A statement of the Type of the violation as determined pursuant to Section 350.274.

 

4)         One of the following requirements for corrective action:

 

A)        The situation, condition or practice constituting a Type "AA" violation or a Type "A" violation shall be abated or eliminated immediately unless a fixed period of time, not exceeding 15 days, as determined by the Department and specified in the notice of violation, is required for correction.  In setting this period, the Department will consider whether harm to residents of the facility is imminent, whether necessary precautions can be taken to protect residents before the corrective action is completed, and whether delay would pose additional risks to the residents.

 

B)        At the time of issuance of a notice of a Type "B" violation, the Department shall request a plan of correction which is subject to the Department's approval. The facility shall have 10 days after receipt of notice of violation in which to prepare and submit a plan of correction.  (Section 3-303 of the Act)

 

5)         A statement that the Department may take additional action under the Act, including assessment of penalties or licensure action.

 

6)         A description of the licensee's right to appeal the notice and its right to a hearing.

 

b)         For each notice of violation, the Director shall serve a notice of violation upon the licensee within 10 days after the Director determines that issuance of a notice of violation is warranted under Section 350.272.  (Section 3-301 of the Act)

 

c)         Residents and their guardians or other resident representatives, if any, shall be notified of any violation of the Act or this Part pursuant to Section 2-217 of the Act, or of violations of the requirements of Titles XVIII or XIX of the Social Security Act or federal regulations, with respect to the health, safety, or welfare of the resident. (Section 2-115 of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.277  Administrative Warning

 

a)         If the Department finds a situation, condition or practice which violates the Act or this Part which does not constitute a Type "AA", Type "A", Type "B", or Type "C" violation, the Department shall issue an administrative warning. (Section 3-303.2(a) of the Act)

 

b)         Each administrative warning shall be in writing and shall include the following information:

 

1)         A description of the nature of the violation.

 

2)         A citation of the specific statutory provision or rule that the Department alleges has been violated.

 

3)         A statement that the facility shall be responsible for correcting the situation, condition, or practice. (Section 3-303.2(a) of the Act)

 

c)         Each administrative warning shall be sent to the facility and the licensee or served personally at the facility within 10 days after the Director determines that issuance of an administrative warning is warranted under Section 350.272.

 

d)         The facility is not required to submit a plan of correction in response to an administrative warning, except for violations of Sections 3-401 through 3-413 of the Act.  (Section 3-303.2(a) of the Act)

 

e)         If the Department finds, during the next on-site inspection by the Department that occurs no earlier than 90 days from the issuance of the administrative warning, that the facility has not corrected the situation, condition, or practice that resulted in the issuance of the administrative warning, the Department shall notify the facility of the finding.  The facility shall then submit a written plan of correction as provided in Section 350.278.  The Department will consider the plan of correction and take any necessary action in accordance with Section 350.278.  (Section 3-303.2(b) of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.278  Plans of Correction

 

a)         The situation, condition or practice constituting a Type "AA" violation or a Type "A" violation shall be abated or eliminated immediately unless a fixed period of time, not exceeding 15 days, as determined by the Department and specified in the notice of violation, is required for correction. (Section 3-303(a) of the Act)

 

b)         The facility shall have 10 days after receipt of notice of violation for a Type "B" violation, or after receipt of a notice under Section 350.277(e) of failure to correct a situation, condition, or practice that resulted in the issuance of an administrative warning, to prepare and submit a plan of correction to the Department.  (Section 3-303(b) of the Act)

 

c)         Within the 10-day period, a facility may request additional time for submission of the plan of correction.  The Department will extend the period for submission of the plan of correction for an additional 30 days, when it finds that corrective action by a facility to abate or eliminate the violation will require substantial capital improvement.  The Department will consider the extent and complexity of necessary physical plant repairs and improvements and any impact on the health, safety, or welfare of the residents of the facility in determining whether to grant a requested extension. (Section 3-303(b) of the Act)

 

d)         No person shall intentionally fail to correct or interfere with the correction of a Type "AA", Type "A", or Type "B" violation within the time specified on the notice or approved plan of correction under the Act as the maximum period given for correction, unless an extension is granted pursuant to subsection (c) and the corrections are made before expiration of extension.  A violation of this subsection is a business offense, punishable by a fine not to exceed $10,000, except as otherwise provided in subsection (2) of Section 3-103 of the Act and Section 350.120(c) as to submission of false or misleading information in a license application.  (Section 3-318 (a)(1) and (b) of the Act)

 

e)         Each plan of correction shall be based on an assessment by the facility of the conditions or occurrences that are the basis of the violation and an evaluation of the practices, policies, and procedures that have caused or contributed to the conditions or occurrences.  The facility shall maintain evidence of the assessment and evaluation.  Each plan of correction shall include:

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

h)         When the Department rejects a submitted plan of correction, it will notify the facility.  The notice of rejection shall be in writing and shall specify the reason for the rejection.  The facility shall have 10 days after receipt of the notice of rejection in which to submit a modified plan. (Section 3-303(b) of the Act)

 

i)          If a facility fails to submit a plan or modified plan meeting the criteria in subsection (e) within the prescribed time periods in subsection (b) or (c), or anytime the Department issues a Type "AA," a Type "A," or Repeat "B" violation, the Department will impose an approved plan of correction.

 

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

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.280  Reports of Correction

 

a)         In lieu of submission of a plan of correction, a facility may submit a report of correction if the corrective action has been completed.  The report of correction must be submitted within the time periods required in Section 350.278 for submission of a plan of correction.

 

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

 

1)         A description of the specific corrective action the facility has taken to abate, eliminate, or correct the violation cited in the notice.

 

2)         A description of the steps which have been taken to avoid future occurrences of the same and similar violations.

 

3)         The specific date on which the corrective action was completed.

 

4)         A signed statement by the administrator of the facility that the report of correction is true and accurate, which shall be considered an oath for the purposes of any legal proceedings.

 

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

 

d)         The Department shall review and approve or disapprove the report of correction based on the criteria outlined in Section 350.278(d) for review of plans of correction.  If a report of correction is disapproved, the facility shall be subject to a plan of correction imposed by the Department as provided in Section 350.278.

 

e)         The Department shall verify the completion of the corrective action outlined in the report of correction during subsequent investigations, surveys and evaluations of the facility.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.282  Conditions for Assessment of Penalties

 

The Department will consider the assessment of a monetary penalty against a facility under the following conditions:

 

a)         A licensee who commits a Type "AA" violation as defined in Section 1-128.5 of the Act is automatically issued a conditional license for a period of 6 months to coincide with an acceptable plan of correction and assessed a fine of up to $25,000 per violation. For a facility licensed to provide care to fewer than 100 residents, but no less than 17 residents, the fine shall be up to $18,500 per violation. For a facility licensed to provide care to fewer than 17 residents, the fine shall be up to $12,500 per violation. (Section 3-305(1) of the Act)

 

b)         A licensee who commits a Type "A" violation as defined in Section 1-129 of the Act is automatically issued a conditional license for a period of 6 months to coincide with an acceptable plan of correction and assessed a fine of up to $12,500 per violation. For a facility licensed to provide care to fewer than 100 residents, but no less than 17 residents, the fine shall be up to $10,000 per violation. For a facility licensed to provide care to fewer than 17 residents, the fine shall be up to $6,250 per violation. (Section 3-305(1.5) of the Act)

 

c)         A licensee who commits a Type "AA" or Type "A" violation as defined in Section 1-128.5 or 1-129 of the Act which continues beyond the time specified in Section 3-303(a), which is cited as a repeat violation shall have its license revoked and shall be assessed a fine of 3 times the fine computed under subsection (a) or (b). (Section 3-305(3) of the Act)

 

d)         A licensee who commits a Type "B" violation as defined in Section 1-130 of the Act shall be assessed a fine of up to $1,100 per violation. For a facility licensed to provide care to fewer than 100 residents, but no less than 17 residents, the fine shall be up to $750 per violation. For a facility licensed to provide care to fewer than 17 residents, the fine shall be up to $550 per violation. (Section 3-305(2) of the Act)

 

e)         A licensee who fails to satisfactorily comply with an accepted plan of correction for a Type "B" violation or an administrative warning issued pursuant to Sections 3-401 through 3-413 of the Act or this Part shall be automatically issued a conditional license for a period of not less than 6 months. A second or subsequent acceptable plan of correction shall be filed. A fine shall be assessed in accordance with subsection (d) when cited for the repeat violation. This fine shall be computed for all days of the violation, including the duration of the first plan of correction compliance time. (Section 3-305(4) of the Act)

 

f)         A licensee who commits 8 or more Type "C" violations as defined in Section 1-132 of the Act in a single survey shall be assessed a fine of up to $250 per violation. A facility licensed to provide care to fewer than 100 residents, but no less than 17 residents, that commits 8 or more Type "C" violations in a single survey, shall be assessed a fine of up to $200 per violation. A facility licensed to provide care to fewer than 17 residents, that commits 8 or more Type "C" violations in a single survey, shall be assessed a fine of up to $175 per violation. (Section 3-305(2.5) of the Act)

 

g)         If an occurrence results in more than one type of violation as defined in the Act (that is, a Type "AA", Type "A", Type "B", or Type "C" violation), then the maximum fine that may be assessed for that occurrence is the maximum fine that may be assessed for the most serious type of violation charged. For purposes of the preceding sentence, a Type "AA" violation is the most serious type of violation that may be charged, followed by a Type "A", Type "B", or Type "C" violation, in that order. (Section 3-305(8) of the Act)

 

h)         If any facility willfully makes a misstatement of fact to the Department or willfully fails to make a required notification to the Department and that misstatement or failure delays the start of a survey or impedes a survey, then it will constitute a Type "B" violation. The minimum and maximum fines that may be assessed pursuant to Section 3-305 of the Act and this Part shall be 3 times those otherwise specified for any facility. (Section 3-305(9) of the Act

 

i)          High risk designation. If the Department finds that a facility has violated a provision of this Part that has a high risk designation, or that a facility has violated the same provision of this Part 3 or more times in the previous 12 months, the Department may assess a fine of up to 2 times the maximum fine otherwise allowed. (Section 3-305(10) of the Act)

 

j)          For the purposes of calculating certain penalties pursuant to this Section, violations of the following requirements shall have the status of "high risk designation":

 

1)         Section 350.625(e)

 

2)         Section 350.625(f)

 

3)         Section 350.625(g)

 

4)         Section 350.635(c)

 

5)         Section 350.635(f)

 

6)         Section 350.635(j)

 

7)         Section 350.635(k)

 

8)         Section 350.635(l)

 

9)         Section 350.635(n)

 

10)        Section 350.635(o)

 

11)        Section 350.637(c)

 

12)        Section 350.637(d)

 

13)        Section 350.637(e)

 

14)        Section 350.681

 

15)        Section 350.700

 

16)        Section 350.750(b)

 

17)        Section 350.760

 

18)        Section 350.1080

 

19)        Section 350.1086

 

20)        Section 350.1210

 

21)        Section 350.1230

 

22)        Section 350.2700(d)(2)

 

23)        Section 350.3000(d)(2)

 

24)        Section 350.3240(a)

 

25)        Section 350.3240(d)

 

26)        Section 350.3240(e)

 

k)         When the Department finds that a provision of Article II of the Act has been violated with regard to a particular resident, the Department shall issue an order requiring the facility to reimburse the resident for injuries incurred, or $100, whichever is greater. In the case of a violation involving any action other than theft of money belonging to a resident, reimbursement shall be ordered only if a provision of Article II of the Act has been violated with regard to that or any other resident of the facility within the 2 years immediately preceding the violation in question. (Section 3-305(6) of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.284  Calculation of Penalties (Repealed)

 

(Source:  Repealed at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.286  Notice of Penalty Assessment: Response by Facility

 

a)         If the Director determines that a penalty is to be assessed, a written notice of penalty assessment shall be sent to the facility.  Each notice of penalty assessment shall include:

 

1)         The amount of the penalty assessed as provided in Section 350.282.

 

2)         The amount of any reduction or whether the penalty has been waived pursuant to Section 350.288.

 

3)         A description of the violation, including a reference to the notices of violation and plans of correction that are the basis of the assessment.

 

4)         A citation to the provision of the statute or rule alleged to have been violated.

 

5)         A description of the right of the facility to appeal the assessment and of the right to a hearing under Section 3-703 of the Act (Section 3-307 of the Act).

 

6)         For violations which are continuing at the time the notice of assessment, the amount of additional penalties per day which will be assessed.  (Section 3-307 of the Act)

 

b)         A facility may contest an assessment of a penalty by sending a written request to the Department for hearing under Section 3-703 of the Act. Upon receipt of the request the Department shall hold a hearing as provided under Section 3-703 of the Act. Instead of requesting a hearing pursuant to Section 3-703 of the Act, a facility may, within 10 business days after receipt of the notice of violation and fine assessment, transmit to the Department 65% of the amount assessed for each violation specified in the penalty assessment. (Section 3-309 of the Act)

 

c)         The facility shall pay the penalties to the Department within the time periods provided in Section 3-310 of the Act.

 

d)         The submission of 65% of the amount assessed for each violation specified in the penalty assessment, pursuant to subsection (b) shall constitute a waiver by the facility of a right to hearing pursuant to Section 3-703 of the Act.

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.287  Consideration of Factors for Assessing Penalties

 

a)         In determining whether a penalty is to be imposed and in determining the amount of the penalty to be imposed, if any, for a violation, the Director shall consider the following factors:

 

1)         The gravity of the violation, including the probability that death or serious physical or mental harm to a resident will result or has resulted; the severity of the actual or potential harm, and the extent to which the provisions of the Act or this Part were violated.  A penalty will be assessed when the Director finds that death or serious physical or mental harm to a resident has occurred or that the facility subjected residents to potential serious harm.

 

2)         The reasonable diligence exercised by the licensee and efforts to correct violations.  The Director will assess a monetary penalty upon finding that the violation recurred or continued, is widespread throughout the facility or evidences flagrant violation of the Act or this Part.

 

3)         Any previous violations committed by the licensee.  The Director will assess a penalty upon finding that the facility has been cited for similar violations and has failed to correct those violations as promptly as practicable or has failed to exercise diligence in taking necessary corrective action.  The Director will also consider the compliance history of the facility for previous violations.  Any change in the ownership and management of the facility will be considered in relation to the seriousness of previous violations.

 

4)         The financial benefit to the facility of committing or continuing the violation.  These benefits include, but are not limited to, diversion of costs associated with physical plant repairs, staff salaries, consultant fees or direct patient care services. (Section 3-306 of the Act)

 

b)         At a hearing requested by a facility that challenges the appropriateness of any penalty imposed by the Department under this Section, the facility may present evidence as to any or all of the factors in subsections (a)(1) through (4).  The Director will consider the evidence presented by the facility, or any evidence otherwise available to the Department, in determining whether a penalty is to be imposed and in determining the amount of the penalty to be imposed, if any, for a violation.

 

(Source:  Added at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.288  Reduction or Waiver of Penalties

 

a)         Reductions for all types of violations subject to penalties.

 

1)         The Director shall consider the factors contained in Section 350.287 in determining whether to reduce the amount of the penalty to be assessed from the amount calculated pursuant to Section 350.282 and in determining the amount of the reduction.

 

2)         When the Director finds that correction of a violation required capital improvements or repairs in the physical plant of the facility and the facility has a history of compliance with physical plant requirements, the penalty will be reduced by the amount of the cost of the improvements or repairs.  This reduction, however, shall not reduce the penalty for a Type "A" violation to an amount less than $1000.

 

b)         Penalties resulting from Type "B" violations may be reduced or waived only under one of the following conditions:

 

1)         The facility submits a true report of correction within 10 days after the notice of violation is received, and the report is subsequently verified by the Department.

 

2)         The facility submits a plan of correction within 10 days after the notice of violation is received, the plan is approved by the Department, the facility submits a true report of correction within 15 days after submission of the plan of correction, and the report is subsequently verified by the Department.

 

3)         The facility submits a plan of correction within 10 days after the notice of violation is received, the plan provides for a correction time that is less than or equal to 30 days after submission of the plan of correction, and the Department approves the plan.

 

4)         Correction of the violation requires substantial capital improvements or repairs in the physical plant of the facility, the facility submits a plan of correction for violations involving substantial capital improvements which provides for correction within the initial 90 day limit Department approves the plan.  (Section 3-308 of the Act)

 

c)         Under the conditions set forth in this Section, the Director shall consider the factors outlined in Section 350.286(a) in determining whether to reduce or waive the penalty and in setting the amount of any reduction.

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.290  Quarterly List of Violators (Repealed)

 

(Source:  Repealed at 24 Ill. Reg. 17254, effective November 1, 2000)

 

Section 350.300  Alcoholism Treatment Programs in Long-Term Care Facilities

 

a)         A facility that desires to provide an alcoholism treatment program shall first receive written approval from the Department.  Approval will be granted only if the facility can demonstrate that the program will not interfere in any way with the residents in the other parts of the facility.

 

b)         Any alcoholism treatment program in a facility shall meet the requirements of the Alcoholism and Substance Abuse Treatment and Intervention Licenses Code and the Substance Use Disorder Act.

 

c)         The alcoholism treatment program shall be in a separate distinct part of the facility, and shall include all beds in that distinct part.  It shall be separated from the rest of the facility, and have separate entrances.

 

d)         Beds designated for alcoholism treatment shall not be used for long-term care residents, nor shall beds designated for long-term care residents be used for residents undergoing treatment for alcoholism.

 

e)         The alcoholism treatment program staff shall not perform services in the long-term care distinct part of the facility, nor shall long-term care program staff provide any services in the alcoholism treatment designated area.

 

f)         Joint use of laundry, food service, housekeeping and administrative services is permitted, provided prior written approval is obtained from the Department.  Approval will be granted only if the facility can demonstrate that joint usage will not interfere in any way with the residents in other distinct of the facility.

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.310  Department May Survey Facilities Formerly Licensed

 

The Department may survey any former facility that once held a license to ensure that the facility is not again operating without a license. (Section 3-107 of the Act)

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.315  Supported Congregate Living Arrangement Demonstration (Repealed)

 

(Source:  Repealed at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.320  Waivers

 

a)         Upon application by a facility, the Director may grant or renew the waiver of the facility's compliance with a rule or standard for a period not to exceed the duration of the current license or, in the case of an application for license renewal, the duration of the renewal period. (Section 3-303.1 of the Act)

 

b)         The waiver may be conditioned upon the facility taking action prescribed by the Director as a measure equivalent to compliance. (Section 3-303.1 of the Act)

 

c)         In determining whether to grant or renew a waiver, the Director shall consider:

 

1)         The duration and basis for any current waiver with respect to the same rule or standard and the validity and effect upon patient health and safety of extending it on the same basis;

 

2)         The effect upon the health and safety of residents;

 

3)         The quality of resident care (whether the waiver would reduce the overall quality of the resident care below that required by the Act or this Part);

 

4)         The facility's history of compliance with the Act and this Part the Act and this Part (the existence of a consistent pattern of violation of the Act or this Part); and

 

5)         The facility's attempts to comply with the particular rule or standard in question.  (Section 3-303.1 of the Act)

 

d)         The Department shall renew waivers relating to physical plant standards issued pursuant to the Act and this Section at the time of the indicated reviews, unless it can show why the waivers should not be extended for the following reasons:

 

1)         The condition of the physical plant has deteriorated or its use substantially changed so that the basis upon which the waiver was issued is materially different; or

 

2)         The facility is renovated or substantially remodeled in such a way as to permit compliance with the applicable rules and standards without substantial increase in cost.  (Section 3-303.1 of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.330  Definitions

 

Abuse − any physical or mental injury or sexual assault inflicted on a resident other than by accidental means in a facility. (Section 1-103 of the Act)

 

Abuse means:

 

Physical abuse means any physical motion or action (e.g., hitting, slapping, punching, kicking, pinching, etc.) that is not accidental. Physical abuse includes, but is not limited to, the use of corporal punishment as well as the use of any restrictive intrusive procedure to control inappropriate behavior for purposes of punishment.

 

Mental injury arises from the following types of conduct:

 

Verbal abuse means the use of oral, written or gestured language that includes disparaging and derogatory terms to a resident or within the resident's hearing or seeing distance, regardless of the resident's age, ability to comprehend or disability.

 

Mental abuse includes, but is not limited to, offensive physical contact, or humiliation, harassment, or threats of punishment or deprivation to a resident or within the resident's hearing or seeing distance, regardless of the resident's age, ability to comprehend, or disability.

 

Sexual harassment or sexual coercion perpetrated on a resident.

 

Sexual assault – an act of nonconsensual sexual conduct or sexual penetration, as defined in Section 11-0.1 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. Sexual assault also includes sexual harassment or sexual coercion.

 

Access − the right to:

 

Enter any facility;

 

Communicate privately and without restriction with any resident who consents to the communication;

 

Seek consent to communicate privately and without restriction with any resident;

 

Inspect the clinical and other records of a resident with the express written consent of the resident;

 

Observe all areas of the facility except the living area of any resident who protests the observation. (Section 1-104 of the Act)

 

Act − the ID/DD Community Care Act [210 ILCS 47].

 

Active Treatment – the aggressive, consistent implementation of a program of specialized or generic training, treatment, health services and related services. This program is directed toward the acquisition of the behaviors necessary for the individual to function with as much self-determination and independence as possible, while preventing or decelerating the regression or loss of current optimal functional status.

 

Adaptive Behavior − the effectiveness or degree with which the individual meets the standards of personal independence and social responsibility expected of the individual's age and cultural group.

 

Adaptive Equipment − a physical or mechanical device, material or equipment attached or adjacent to the resident's body, the purpose of which is to permit or encourage movement, or to provide opportunities for increased functioning, or to prevent contractures or deformities.  Adaptive equipment is not a physical restraint.  No matter the purpose, adaptive equipment does not include any device, material or method described in Section 350.1080 as a physical restraint.

 

Addition − any construction attached to the original building that increases the area or cubic content of the building.

 

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

 

Administrative Warning − a notice to a facility issued by the Department under Section 350.277 and Section 3-303.2 of the Act, which indicates that a situation, condition, or practice in the facility violates the Act or the Department's rules, but is not a Type "AA," Type "A," Type "B," or Type "C" violation.

 

Administrator − a person who is charged with the general administration and supervision of a facility and licensed, if required, under the Nursing Home Administrators Licensing and Disciplinary Act.  (Section 1-105 of the Act).

 

Advocate − a person who represents the rights and interests of an individual as though they were the person's own, to realize the rights to which the individual is entitled, obtain needed services, and remove barriers to meeting the individual's needs.

 

Affiliate − means:

 

With respect to a partnership, each partner thereof.

 

With respect to a corporation, each officer, director and stockholder thereof.

 

With respect to a natural person: any person related in the first degree of kinship to that person; each partnership and each partner thereof of which that person or any affiliate of that person is a partner; and each corporation in which that person or any affiliate of that person is an officer, director or stockholder. (Section 1-106 of the Act)

 

Alteration − any construction change or modification of an existing building that does not increase the area or cubic content of the building.

 

Ambulatory Resident − a person who is physically and mentally capable of walking without assistance, or is physically able with guidance to do so, including the ascent and descent of stairs.

 

Applicant − any person making application for a license. (Section 1-107 of the Act)

 

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

 

Approved – acceptable to the authority having jurisdiction.

 

Assessment − the use of an objective tool with which to evaluate the physical, social, affective, developmental, vocational, motor, nutritional, speech and language, cognitive, behavioral, and psychosocial aspects of an individual.

 

Audiologist − a person who is licensed as an audiologist under the Speech-Language Pathology and Audiology Practice Act.

 

Autism or autism spectrum disorder − a disorder that is characterized by persistent deficits in social communication and social interaction across multiple contexts, including deficits in social reciprocity, nonverbal communicative behaviors used for social interaction, and skills in developing maintaining, and understanding relationships. In addition to the social communication deficits, the diagnosis of autism spectrum disorder requires the presence of restricted, repetitive patterns of behavior, interests, or activities.

 

Basement − any story or floor level below the main or street floor.  Where, due to grade difference, two levels qualify as a street floor, a basement is any floor below the level of the two street floors.  Basements shall not be counted in determining the height of a building in stories.

 

Behavior Management Plan – a comprehensive plan, developed by a qualified member of the interdisciplinary team, based upon assessments that include analysis of the potential causes, which identifies specific developmental and behavioral management needs.  The Behavioral Management Plan shall include specific methods and techniques, with goals to meet the identified behavioral outcome.

 

Behavior Modification − a group of teaching techniques, strategies and supports to reduce or eliminate unwanted or maladaptive behavior.

 

Cerebral Palsy − a disorder dating from birth or early infancy, nonprogressive, characterized by examples of aberrations of motor function (paralysis, weakness, incoordination) and often other manifestations of organic brain damage such as sensory disorders, seizures, developmental disability, learning difficulty and behavior disorders.

 

Certification for Title XVIII and XIX − documentation issued by the Department to the Department of Health and Human Services or the Department of Healthcare and Family Services verifying compliance with applicable statutory or regulatory requirements for participation as a provider of care and service in a specific federal or State health program.

 

Certified Nursing Assistant – any person who meets the requirements of 77 Ill. Adm. Code 395 and who provides nursing care or personal care to residents of facilities, regardless of title, and who is not otherwise licensed, certified, or registered by the Department of Financial and Professional Regulation to render medical care.  Nursing assistants shall function under the supervision of a licensed nurse.

 

Charge Nurse − a registered professional nurse or a licensed practical nurse in charge of the nursing activities for a specific unit or floor during a shift.

 

Chemical Restraint − any drug that is used for discipline or convenience and is not required to treat medical symptoms or behavior manifestations of mental illness.  (Section 2-106(a)(ii) of the Act)

 

Community Alternatives − service programs in the community provided as an alternative to institutionalization.

 

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

 

Convenience − the use of any restraint by the facility to control resident behavior or maintain a resident, which is not in the resident's best interest, and with less use of the facility's effort and resources than would otherwise be required by the facility.  This definition is limited to the definition of chemical restraint and Section 350.1080.

 

Corporal Punishment − painful stimuli inflicted directly upon the body.

 

Dentist − any person licensed to practice dentistry, including persons holding a Temporary Certificate of Registration, as provided in the Illinois Dental Practice Act.

 

Department – the Department of Public Health.  (Section 1-109 of the Act)

 

Developmental Disability − means a severe, chronic disability of a person which:

 

is attributable to a mental or physical impairment or combination of mental and physical impairments, such as intellectual functioning, cerebral palsy, epilepsy, or autism;

 

is manifested before the person attains age 22;

 

is likely to continue indefinitely;

 

results in substantial functional limitations in 3 or more of the following areas of major life activity:

 

self-care,

 

receptive and expressive language,

 

learning,

 

mobility,

 

self-direction,

 

capacity for independent living, and

 

economic self-sufficiency; and

 

reflects the person's need for combination and sequence of special, interdisciplinary or generic care, active treatment or other services which are of lifelong or extended duration and are individually planned and coordinated. (Section 3-801.1 of the Act)

 

Dietetic Service Supervisor − a person who:

 

is a dietitian; or

 

is a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Clinical Board of Nutrition;

 

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, which included consultation from a dietitian;

 

has successfully completed an Association of Nutrition & Foodservice Professionals-approved Certified Dietary Manager or Certified Food Protection Professional course;

 

is certified as a Certified Dietary Manager or Certified Food Protection Professional by the Association of Nutrition & Foodservice Professionals; 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 who is a licensed dietitian nutritionist as defined in the Dietitian Nutritionist Practice Act.

 

Direct Supervision − under the guidance and direction of a supervisor who is responsible for the work, who plans work and methods, who is available on short notice to answer questions and deal with problems that are not strictly routine, who regularly reviews the work performed, and who is accountable for the results.

 

Direct Support Person or DSP – any person who provides habilitative care, services, or support to individuals with developmental disabilities.  DSPs shall function under the supervision of a Qualified Intellectual Disabilities Professional (QIDP) or a Licensed/Registered Nurse.  Other titles often used to refer to Direct Support Persons include, but are not limited to, Intellectual/Developmental Disabilities (ID/DD) Aide, Mental Health Technician, Habilitation Aide, Program Aide or Program Technician.  These individuals shall meet the training requirements set forth in the Department's Long-Term Care Assistants and Aides Training Programs Code and by the Department of Human Services.

 

Director − the Director of Public Health or his or her designee. (Section 1-110 of the Act)

 

Director of Nursing Service − the full-time Registered Professional Nurse who is directly responsible for the immediate supervision of the nursing services.

 

Discharge − the full release of any resident from a facility. (Section 1-111 of the Act)

 

Discipline − any action taken by the facility for the purpose of punishing or penalizing residents.

 

Distinct Part − an entire, physically identifiable unit consisting of all of the beds within that unit and meeting the standards applicable to the levels of service to be provided.  Staff and services for a distinct part are established in the respective administrative rules governing the services approved for the distinct part.

 

Distressed facility – a facility determined by the Department to be a distressed facility pursuant to Section 3-304.2 of the Act and Section 350.185. (Section 1-111.05 of the Act)

 

Emergency − a situation, physical condition or one or more practices, methods or operations which present imminent danger of death or serious physical or mental harm to residents of a facility.  (Section 1-112 of the Act)

 

Epilepsy − a chronic symptom of cerebral dysfunction, characterized by recurrent attacks, involving changes in the state of consciousness, sudden in onset, and of brief duration.  Many attacks are accompanied by a seizure in which the person falls involuntarily.

 

Existing Facility − any facility initially licensed as a health care facility or approved for construction by the Department, or any facility initially licensed or operated by any other agency of the State of Illinois, prior to March 1, 1980.  Existing facilities shall meet the design and construction standards for existing facilities for the level of care for which the license (new or renewal) is to be granted.

 

Facility or ID/DD facility − an intermediate care facility for the developmentally disabled, whether operated for profit or not, which provides, through its ownership or management, personal care or nursing for 3 or more persons not related to the applicant or owner by blood or marriage. It includes intermediate care facilities for the intellectually disabled as the term is defined in Title XVIII and Title XIX of the federal Social Security Act.  A "facility" may consist of more than one building as long as the buildings are on the same tract, or adjacent tracts of land.  "Facility" does not include the following:

 

A home, institution, or other place operated by the federal government or agency thereof, or by the State of Illinois, other than homes, institutions or other places operated by or under the authority of the Illinois Department of Veterans' Affairs;

 

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 therefor, which is required to be licensed under the Hospital Licensing Act;

 

Any "facility for child care" as defined in the Child Care Act of 1969;

 

Any "community living facility" as defined in the Community Living Facilities Licensing Act;

 

Any "community residential alternative" as defined in the Community Residential Alternatives Licensing Act;

 

Any 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, such nursing home or sanatorium shall comply with all local laws and rules relating to sanitation and safety;

 

Any facility licensed by the Department of Human Services as a community-integrated living arrangement as defined in the Community-Integrated Living Arrangement Licensure and Certification Act;

 

Any supportive residence licensed under the Supportive Residences Licensing Act;

 

Any 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 Act;

 

Any 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 Act;

 

An Alzheimer's disease management center alternative health care model licensed under the Alternative Health Care Delivery Act; or

 

A home, institution, or other place operated by or under the authority of the Illinois Department of Veterans' Affairs; or

 

Any MC/DD facility licensed under the MC/DD Act.  (Section 1-113 of the Act)

 

Financial Responsibility − having sufficient assets to provide adequate services, such as: staff, heat, laundry, foods, supplies, and utilities, for at least a two-month period of time.

 

Full-time − on duty a minimum of 36 hours, four days per week.

 

Goal − an expected result or outcome condition that involves an attainable, appropriate amount of time to achieve, that is stated in specific behavioral terms and that provides guidance in establishing specific, short-term objectives directed toward its attainment.

 

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

 

Guardian − a person appointed as a guardian of the person or guardian of the estate, or both, of a resident under the Probate Act of 1975. (Section 1-114 of the Act)

 

Habilitation – an effort directed toward increasing a person's level of physical, mental, social, or economic functioning. Habilitation may include, but is not limited to, diagnosis, evaluation, medical services, residential care, day care, special living arrangements, training, education, employment services, protective services, and counseling. (Section 1-114.001 of the Act)

 

Health Information Management Consultant − a person who is certified as a Registered Health Information Administrator (RHIA) or a Registered Health Information Technician (RHIT) by the American Health Information Management Association; or is a graduate of a school of health information management that is accredited jointly by the American Medical Association and the American Health Information Management Association.

 

Health Services Supervisor (Director of Nursing Service) − the full-time Registered Professional Nurse who is directly responsible for the immediate supervision of the health services in an Intermediate Care Facility.

 

High-risk designation – a violation, as described in Section 350.282(i), of a provision of the Illinois Administrative Code that has been identified by the Department through rulemaking to be inherently necessary to protect the health, safety, and welfare of a resident. (Section 1-114.005 of the Act)

 

Hospitalization − the care and treatment of a person in a hospital as an inpatient.

 

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 4, 5, 6, 8, or 17.02 of the Illinois Credit Card and Debit Card 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 subsection (c) of Section 10 of the Sex Offender Management Board Act;

 

Is any other resident as determined by the Department of State Police.  (Section 1-114.01 of the Act)

 

Immediate family – the spouse, an adult child, a parent, an adult brother or sister, or an adult grandchild of a person.  (Section 1-114.1 of the Act)

 

Individual Education Program (IEP) − a written education plan for each resident currently within the public school system, with the identified goals and objectives to be incorporated into the Individual Habilitation Plan (IHP) or Individual Program Plan (IPP).

 

Individual Habilitation Plan (IHP) or Individual Program Plan (IPP) − a total plan of care that is developed by the interdisciplinary team for each resident, and that is developed on the basis of all assessment results to provide a specific program plan that is consistent with the identified goals and objectives of the resident.

 

Institutional Review Board or IRB – a body established in accordance with applicable federal regulations for human research protections as set forth in 45 CFR 46.  The IRB chairperson may act on behalf of the IRB as specified in 45 CFR 46.

 

Intellectual Disability or Intellectually Disabled – a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains.  The essential features of intellectual disability are deficits in general mental abilities and impairment in everyday adaptive functioning, in comparison to an individual's age-, gender-, and socioculturally matched peers.

 

Interdisciplinary Team − a group of persons that represents those professions, disciplines, or service areas that are relevant to identifying an individual's strengths and needs, and designs a program to meet those needs as identified by the comprehensive functions and assessments.  This team shall include at least a physician, a social worker and other professionals.  In ID/DD facilities, at least one member of the team shall be a Qualified Intellectual Disability Professional.  The Interdisciplinary Team includes the resident, the resident's guardian, the resident's primary service providers, including staff most familiar with the resident; and other appropriate professionals and caregivers as determined by the resident's needs.  The resident or the resident's guardian may also invite other individuals to meet with the Interdisciplinary Team and participate in the process of identifying the resident's strengths and needs.

 

Licensed Practical Nurse − a person with a valid Illinois license under the Nurse Practice Act to practice as a practical nurse.

 

Licensee − the individual or entity licensed by the Department to operate the facility. (Section 1-115 of the Act)

 

Life-Care Contract – a contract through which a facility agrees to provide maintenance and care for a resident throughout the remainder of the resident's life.  (Section 2-202(i) of the Act)

 

Maintenance − food, shelter, and laundry services. (Section 1-116 of the Act)

 

Maladaptive Behavior − impairment in adaptive behavior as determined by the interdisciplinary team.  Impaired adaptive behavior may be reflected in delayed maturation, reduced learning ability or inadequate social adjustment.

 

 

Misappropriation of a Resident's Property − the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.  (Section 1-116.5 of the Act)  Misappropriation of a resident's property includes failure to return valuables after a resident's discharge; or failure to refund money after death or discharge when there is an unused balance in the resident's personal account.

 

Monitor − a qualified person placed in a facility by the Department to observe operations of the facility and assist the facility by advising it on how to comply with the State regulations, and who reports periodically to the Department on the operations of the facility.

 

Neglect − a failure in a facility to provide adequate medical or personal care or maintenance, which failure results in physical or mental injury to a resident or in the deterioration of a resident's physical or mental condition. (Section 1-117 of the Act)  This shall include any allegation in which:

 

the alleged failure causing injury or deterioration is ongoing or repetitious; or

 

a resident required medical treatment as a result of the alleged failure; or

 

the failure is alleged to have caused a noticeable negative impact on a resident's health, behavior or activities for more than 24 hours.

 

New Facility − any facility initially licensed as a health care facility by the Department, or any facility initially licensed or operated by any other agency of the State of Illinois, on or after March 1, 1980.  New facilities shall meet the design and construction standards for new facilities for the level of care for which the license (new or renewal) is to be granted.

 

Nurse − a registered nurse or a licensed practical nurse as defined in the Nurse Practice Act.  (Section 1-118 of the Act)

 

Nursing Care − a complex of activities that carries out the diagnostic, therapeutic, and rehabilitative plan as prescribed by the physician; care for the resident's environment; observing symptoms and reactions and taking necessary measures to carry out nursing activities or nursing-related tasks involving understanding of cause and effect in order to safeguard life and health.

 

Objective − an expected result or condition that involves a relatively short period of time to achieve, that is specified in behavioral terms, and that is related to the achievement of a goal.

 

Occupational Therapist (OT) − a person who is registered as an occupational therapist under the Illinois Occupational Therapy Practice Act.

 

Occupational Therapy Assistant − a person who is registered as a certified occupational therapy assistant under the Illinois Occupational Therapy Practice Act.

 

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

 

Oversight − general watchfulness and appropriate reaction to meet the total needs of the residents, exclusive of nursing or personal care.  Oversight shall include, but is not limited to, social, recreational and employment opportunities for residents who, by reason of mental disability, or in the opinion of a licensed physician, are in need of residential care.

 

Owner − the individual, partnership, corporation, association or other person who owns a facility.  In the event a facility is operated by a person who leases the physical plant, which is owned by another person, "owner" means the person who operates the facility, except that if the person who owns the physical plant is an affiliate of the person who operates the facility and has significant control over the day-to-day operations of the facility, the person who owns the physical plant shall incur jointly and severally with the owner all liabilities imposed on an owner under the Act. (Section 1-119 of the Act)

 

Person − with regard to the term owner, a person is any individual, partnership, corporation, association, municipality, political subdivision, trust, estate or other legal entity whatsoever.

 

Personal Care − assistance with meals, dressing, movement, bathing or other personal needs or 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 such individual. (Section 1-120 of the Act)

 

Pharmacist − a person who holds a license as a pharmacist under the Pharmacy Practice Act.

 

Physical Restraint − any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the resident cannot remove easily and restricts freedom of movement or normal access to one's body. (Section 2-106 of the Act)

 

Physical Therapist − a person who is licensed as a physical therapist under the Illinois Physical Therapy Act.

 

Physical Therapist Assistant − a person who is licensed as a physical therapist assistant under the Illinois Physical Therapy Act.

 

Physician − any person licensed to practice medicine in all its branches as provided in the Medical Practice Act of 1987.

 

Probationary License − an initial license issued for a period of 120 days, during which time the Department will determine the qualifications of the applicant.

 

Provisional admission period – the time between the admission of an identified offender as defined in Section 1-114.01 of the Act and this Section, and 3 working days following the admitting facility's receipt of an Identified Offender Report and Recommendation in accordance with Section 2-201.6 of the Act. (Section 1-120.3 of the Act)

 

Psychiatrist − a physician who is board eligible or board certified in psychiatry by the American Board of Psychiatry and Neurology.

 

Psychologist − a person who is licensed to practice clinical psychology under the Clinical Psychologist Licensing Act.

 

Qualified Intellectual Disability Professional − a person who has at least one year of experience working directly with individuals with developmental disabilities, who is directly responsible for coordinating and monitoring the residents' overall plans of care in an intermediate care facility, and who meets at least one of the following additional qualifications:

 

Be a physician as defined in this Section;

 

Be a registered nurse as defined in this Section; or

 

Hold at least a bachelor's degree in one of the following fields:  occupational therapy, physical therapy, psychology, social work, speech or language pathology, recreation (or a recreational specialty area such as art, dance, music, or physical education), dietary services or dietetics, or a human services field (such as sociology, special education, or rehabilitation counseling).

 

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

 

Reasonable hour − any time between the hours of 10 a.m. and 8 p.m. daily. (Section 1-121 of the Act)

 

Registered Nurse − a person with a valid license to practice as a registered professional nurse under the Nurse Practice Act.

 

Repeat Violation − for purposes of assessing fines under Section 3-305 of the Act, a violation that has been cited during one inspection of the facility for which a subsequent inspection indicates that an accepted plan of correction was not complied with, within a period of not more than 12 months from the issuance of the initial violation or a new citation of the same rule if the licensee is not substantially addressing the issue routinely throughout the facility. (Section 3-305(7) of the Act)

 

Resident − a person receiving personal or medical care, including, but not limited to, habilitation, psychiatric services, therapeutic services, and assistance with activities of daily living from a facility. (Section 1-122 of the Act)

 

Resident Services Director − the full-time manager, or an individual on the professional staff in the facility.

 

Resident's Representative − a person other than the owner, or an agent or employee of a facility not related to the resident, designated in writing by a resident to be his or her representative, or the resident's guardian, or the parent of a minor resident for whom no guardian has been appointed. (Section 1-123 of the Act)

 

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

 

Sanitization − the reduction of pathogenic organisms on a utensil surface to a safe level, which is accomplished through the use of steam, hot water, or chemicals.

 

Seclusion − the retention of a resident alone in a room with a door that the resident cannot open.

 

Self-Preservation − the ability to follow directions and recognize impending danger or emergency situations and react by avoiding or leaving the unsafe area.

 

Social Worker − a person who is a licensed social worker or a licensed clinical social worker under the Clinical Social Work and Social Work Practice Act.

 

State Fire Marshal − the Illinois State Fire Marshal, who serves as the executive director of the Office of the State Fire Marshal.  (Section 1 of the State Fire Marshal Act)

 

Stockholder of a Corporation − any person who, directly or indirectly, beneficially owns, holds or has the power to vote, at least five percent of any class of securities issued by the corporation. (Section 1-125 of the Act)

 

Story − that portion of a building between the upper surface of any floor and the upper surface of the floor above, except that the topmost story shall be the portion of a building between the upper surface of the topmost floor and the upper surface of the roof above.

 

Student Intern − any person whose total term of employment in any facility during any 12-month period is equal to or less than 90 continuous days, and whose term of employment is either:

 

an academic credit requirement in a high school or undergraduate institution; or

 

immediately succeeds a full quarter, semester or trimester of academic enrollment in either a high school or undergraduate institution, provided that such person is registered for another full quarter, semester or trimester of academic enrollment in either a high school or undergraduate institution which quarter, semester or trimester will commence immediately following the term of employment. (Section 1-125.1 of the Act)

 

Substantial Compliance − meeting the requirements of the Act and this Part, except for variance from the strict and literal performance requirements of the Act or this Part that results in unimportant omissions or defects given the particular circumstances involved.  This definition is limited to the phrase as used in Sections 350.140 and 350.150.

 

Substantial Failure − the failure to meet the requirements of the Act or this Part, other than a variance from the strict and literal performance requirements of the Act or this Part that results in unimportant omissions or defects given the particular circumstances involved.  This definition is limited to the phrase as used in Section 350.165.

 

Supervision − authoritative guidance by a qualified person for the accomplishment of a function or activity within the person's sphere of competence.

 

Therapeutic Recreation Specialist − a person who is certified by the National Council for Therapeutic Recreation Certification and who meets the minimum standards it has established for classification as a Therapeutic Recreation Specialist.

 

Time Out − removing an individual from a situation that results in undesirable behavior.  It is a behavior modification procedure that is developed and implemented under the supervision of a qualified professional, and only as a technique that has been identified in the individual's behavior management plan.

 

Title XVIII − Title XVIII of the federal Social Security Act. (Section 1-126 of the Act)

 

Title XIX − Title XIX of the federal Social Security Act. (Section 1-127 of the Act)

 

Transfer − a change in status of a resident's living arrangements from one facility to another facility. (Section 1-128 of the Act)

 

Type "AA" violation – a violation of the Act or this Part that creates a condition or occurrence relating to the operation and maintenance of a facility that proximately caused a resident's death. (Section 1-128.5 of the Act)

 

Type "A" Violation − a violation of the Act or this Part that creates 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 resident will result therefrom or has resulted in actual physical or mental harm to a resident. (Section 1-129 of the Act)

 

Type "B" Violation − a violation of the Act or this Part that creates 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 resident or is specifically designated as a Type B violation in the Act or this Part. (Section 1-130 of the Act)

 

Type "C" violation – a violation of the Act or this Part that creates 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 resident will result therefrom. (Section 1-132 of the Act)

 

Unit − an entire physically identifiable residence area consisting of not less than five nor more than 20 beds, and having facilities meeting the standards applicable to the levels of service to be provided.  Staff and services for each distinct resident area are established as set forth in the respective rules governing the approved levels of service.

 

Universal Progress Notes − a common record with periodic narrative documentation by all persons involved in resident care.

 

Valid License − a license that is unsuspended, unrevoked, and unexpired, however, a license shall not be deemed to have expired if the Department fails to timely respond to a timely request for renewal under the Act or for a hearing to contest nonrenewal under Section 3-119(c) of the Act.

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.340  Incorporated and Referenced Materials

 

a)         The following regulations and standards are incorporated in this Part:

 

1)         Private and professional association standards:

 

A)        ANSI/ASME Standard A17.1 – 2007, Safety Code for Elevators and Escalators, which may be obtained from the American Society of Mechanical Engineers (ASME) International, 22 Law Drive, Box 2900, Fairfield, NJ  07007-2900.

 

B)        ANSI/ASHRAE/ASHE Standard 170-2008, Ventilation of Health Care Facilities, which may be accessed at:  https://www.ashrae.org/File%20Library/Technical%20Resources/Standards%20and%20Guidelines/Standards%20Addenda/170-2008/ad170_2008_d.pdf.

 

C)        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.

 

D)        American Society for Testing and Materials (ASTM), Standard E90-09 (2009):  Standard Test Method for Laboratory Measurement of Airborne Sound Transmission Loss of Building Partitions and Elements, and Standard No. E84-08a, Standard Test Method for Surface Burning Characteristics of Building Materials (2010), which may be obtained from ASTM International, 100 Barr Harbor Drive, P.O. Box C700, West Conshohocken, PA  19428-2959.

 

E)        International Building Code (IBC) (2012), which may be obtained from the International Code Council (ICC), 4051 W. Flossmoor Road, Country Club Hills, IL  60478-5795.

 

F)         For existing facilities (see Subpart N), National Fire Protection Association (NFPA) 101:  Life Safety Code (2012), and the following standards, which may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA  02169:

 

i)          NFPA 10 (2010):  Standard for Portable Fire Extinguishers

 

ii)         NFPA 13 (2010):  Standards for the Installation of Sprinkler Systems

 

iii)        NFPA 54 (2012):  National Fuel Gas Code

 

iv)        NFPA 70 (2011):  National Electrical Code

 

v)         NFPA 90A (2012):  Standards for the Installation of Air Conditioning and Ventilating Systems

 

vi)        NFPA 96 (2011):  Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations

 

vii)       NFPA 99 (2012):  Health Care Facilities Code

 

viii)      NFPA 101A (2013):  Guide on Alternative Approaches to Life Safety

 

ix)        NFPA 220 (2012):  Standard on Types of Building Construction

 

x)         NFPA 253 (2011):  Standard Method of Test for Critical Radiant Flux of Floor Covering Systems using a Radiant Heat Energy Source

 

G)        For new facilities (see Subpart M), the following standards of the NFPA 101 (2012) and the following additional standards, which may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA  02169:

 

i)          NFPA 10 (2010):  Standard for Portable Fire Extinguishers

 

ii)         NFPA 13 (2010):  Standard for the Installation of Sprinkler Systems

 

iii)        NFPA 54 (2010):  National Fuel Gas Code

 

iv)        NFPA 70 (2011):  National Electrical Code

 

v)         NFPA 90A (2012):  Standard for the Installation of Air Conditioning and Ventilating Systems

 

vi)        NFPA 96 (2011):  Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations

 

vii)       NFPA 99 (2011):  Health Care Facilities Code

 

viii)      NFPA 220 (2012):  Standard on Types of Building Construction

 

ix)        NFPA 253 (2011):  Standard Method of Test for Critical Radiant Flux of Floor Covering Systems Using a Radiant Heat Energy Source

 

H)        Underwriters Laboratories, Inc. (UL), which may be obtained from Underwriters Laboratories, Inc., 333 Pfingsten Rd., Northbrook, IL  60062:

 

i)          Fire Resistance Directory (2014 Edition)

 

ii)         Building Material Directory (2014 Edition)

 

I)         American College of Obstetricians and Gynecologists, Guidelines for Women's Health Care, 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). (See Section 350.3220.)

 

2)         Federal regulations and guidelines:

 

A)        21 CFR 1306, Prescriptions (April 1, 2022)

 

B)        42 CFR 483.440(c), Conditions of Participation: Active Treatment Services (October 1, 2022)

 

C)        45 CFR 46, Protection of Human Subjects (October 1, 2022)

 

D)        The following guidelines and toolkits of the Centers for Disease Control and Prevention, United States Public Health Service, and Department of Health and Human Services:

 

i)          Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 2009 (June 6, 2019), available at:  https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf

 

ii)         Guideline for Hand Hygiene in Health-Care Settings (October 25, 2002), available at:  https://www.cdc.gov/infectioncontrol/guidelines/hand-hygiene/index.html

 

iii)        Guidelines for Prevention of Intravascular Catheter-Related Infections, 2011 (October 2017), available at:  https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf

 

iv)        Guideline for Prevention of Surgical Site Infection (August 2017), available at:  https://www.cdc.gov/infectioncontrol/guidelines/ssi/index.html

 

v)         Guidelines for Prevention of Healthcare Associated Pneumonia, 2003 (March 26, 2004), available at:  https://www.cdc.gov/infectioncontrol/pdf/guidelines/healthcare-associated-pneumonia-H.pdf

 

vi)        2007 Guideline for Isolation Precautions:  Preventing Transmission of Infectious Agents in Healthcare Settings (July 2023), available at:  https://www.cdc.gov/infectioncontrol/pdf/guidelines/

isolation-guidelines-H.pdf

 

vii)       Infection Control in Healthcare Personnel, available in two parts:  Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services (October 25, 2019) and Epidemiology and Control of Selected Infections Transmitted Among Healthcare Personnel and Patients (October 3, 2022), both available at:  https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/index.html

 

b)         All incorporations by reference of federal regulations and guidelines and the standards of nationally recognized organizations refer to the regulations and standards on the date specified and do not include any amendments or editions subsequent to the date specified.

 

c)         The following statutes and State regulations are referenced in this Part:

 

1)         Federal statutes:

 

A)        Civil Rights Act of 1964 (42 U.S.C. 2000e et seq.)

 

B)        Social Security Act (42 U.S.C. 301 et seq., 1935 et seq. and 1936 et seq.)

 

C)        Controlled Substances Act (21 U.S.C. 802)

 

2)         State of Illinois statutes:  

 

A)        Substance Use Disorder Act [20 ILCS 301]

 

B)        Boiler and Pressure Vessel Safety Act [430 ILCS 75]

 

C)        Child Care Act of 1969 [225 ILCS 10]

 

D)        Court of Claims Act [705 ILCS 505]

 

E)        Illinois Dental Practice Act [225 ILCS 25]

 

F)         Election Code [10 ILCS 5]

 

G)        Freedom of Information Act [5 ILCS 140]

 

H)        General Not For Profit Corporation Act of 1986 [805 ILCS 105]

 

I)         Illinois Health Facilities Planning Act [20 ILCS 3960]

 

J)         Hospital Licensing Act [210 ILCS 85]

 

K)        Illinois Municipal Code [65 ILCS 5]

 

L)        Illinois Controlled Substances Act [720 ILCS 570]

 

M)       Life Care Facilities Act [210 ILCS 40]

 

N)        Local Governmental and Governmental Employees Tort Immunity Act [745 ILCS 10]

 

O)        Medical Practice Act of 1987 [225 ILCS 60]

 

P)         Mental Health and Developmental Disabilities Code [405 ILCS 5]

 

Q)        Nurse Practice Act [225 ILCS 65]

 

R)        Nursing Home Administrators Licensing and Disciplinary Act [225 ILCS 70]

 

S)         ID/DD Community Care Act [210 ILCS 47]

 

T)         Illinois Occupational Therapy Practice Act [225 ILCS 75]

 

U)        Pharmacy Practice Act [225 ILCS 85]

 

V)        Illinois Physical Therapy Act [225 ILCS 90]

 

W)       Private Sewage Disposal Licensing Act [225 ILCS 225]

 

X)        Probate Act of 1975 [755 ILCS 5]

 

Y)        Illinois Public Aid Code [305 ILCS 5]

 

Z)        Safety Glazing Materials Act [430 ILCS 60]

 

AA)     Illinois Administrative Procedure Act [5 ILCS 100]

 

BB)     Clinical Psychologist Licensing Act [225 ILCS 15]

 

CC)     Dietitian Nutritionist Practice Act [225 ILCS 30]

 

DD)     Health Care Worker Background Check Act [225 ILCS 46]

 

EE)      Clinical Social Work and Social Work Practice Act [225 ILCS 20]

 

FF)      Illinois Living Will Act [755 ILCS 35]

 

GG)     Powers of Attorney for Health Care Law [755 ILCS 45/Art. IV]

 

HH)     Health Care Surrogate Act [755 ILCS 40]

 

II)        Health Care Right of Conscience Act [745 ILCS 70]

 

JJ)        Abused and Neglected Long-Term Care Facility Residents Reporting Act [210 ILCS 30]

 

KK)     Supportive Residences Licensing Act [210 ILCS 65]

 

LL)      Community Living Facilities Licensing Act [210 ILCS 35]

 

MM)    Community-Integrated Living Arrangements Licensure and Certification Act [210 ILCS 135]

 

NN)     Counties Code [55 ILCS 5]

 

OO)     Illinois Act on the Aging [20 ILCS 105]

 

PP)      Speech-Language Pathology and Audiology Practice Act [225 ILCS 110]

 

QQ)     Assisted Living and Shared Housing Act [210 ILCS 9]

 

RR)     Alternative Health Care Delivery Act [210 ILCS 3]

 

SS)      Podiatric Medical Practice Act of 1987 [225 ILCS 100]

 

TT)      Physician Assistant Practice Act of 1987 [225 ILCS 95]

 

UU)     Language Assistance Services Act [210 ILCS 87]

 

VV)     MC/DD Act [210 ILCS 46]

 

WW)   Authorized Electronic Monitoring in Long-Term Care Facilities Act [210 ILCS 32]

 

3)         State of Illinois rules:

 

A)        Office of the State Fire Marshal, Boiler and Pressure Vessel Safety (41 Ill. Adm. Code 120)

 

B)        Capital Development Board, Illinois Accessibility Code (71 Ill. Adm. Code 400)

 

C)        Department of Public Health:

 

i)          Control of Communicable Diseases Code (77 Ill. Adm. Code 690)

 

ii)         Control of Sexually Transmissible Infections Code (77 Ill. Adm. Code 693)

 

iii)        Food Code (77 Ill. Adm. Code 750)

 

iv)        Illinois Plumbing Code (77 Ill. Adm. Code 890)

 

v)         Private Sewage Disposal Code (77 Ill. Adm. Code 905)

 

vi)        Drinking Water Systems Code (77 Ill. Adm. Code 900)

 

vii)       Water Well Construction Code (77 Ill. Adm. Code 920)

 

viii)      Illinois Water Well Pump Installation Code (77 Ill. Adm. Code 925)

 

ix)        Access to Records of the Department of Public Health (2 Ill. Adm. Code 1127)

 

x)         Practice and Procedure in Administrative Hearings (77 Ill. Adm. Code 100)

 

xi)        Medically Complex for the Developmentally Disabled Facilities Code (77 Ill. Adm. Code 390)

 

xii)       Long-Term Care Assistants and Aides Training Programs Code (77 Ill. Adm. Code 395)

 

xiii)      Control of Tuberculosis Code (77 Ill. Adm. Code 696)

 

xiv)      Health Care Worker Background Check Code (77 Ill. Adm. Code 955)

 

xv)       Language Assistance Services Code (77 Ill. Adm. Code 940)

 

xvi)      Collection, Disclosure and Confidentiality of Health Statistics; Institutional Review Board (77 Ill. Adm. Code 1005

 

xvii)     Authorized Electronic Monitoring in Long Term Care Facilities Code (77 Ill. Adm. Code 389)

 

D)        Department of Financial and Professional Regulation:

 

i)          Illinois Controlled Substances Act (77 Ill. Adm. Code 3100)

 

ii)         Pharmacy Practice Act (68 Ill. Adm. Code 1330)

 

E)        Department of Human Services, Alcoholism and Substance Abuse Treatment and Intervention Licenses (77 Ill. Adm. Code 2060)

 

F)         Department of Natural Resources, Regulation of Construction within Flood Plains (17 Ill. Adm. Code 3706)

 

G)        Department of Healthcare and Family Services:

 

i)          Medical Payment (89 Ill. Adm. Code 140)

 

ii)         Crisis Assistance (89 Ill. Adm. Code 116)

 

iii)        Developmental Disabilities Services (89 Ill. Adm. Code 144)

 

(Source:  Amended at 47 Ill. Reg. 14492, effective September 26, 2023)

SUBPART B: ADMINISTRATION

 

Section 350.510  Administrator

 

a)         An administrator licensed under the Nursing Home Administrators Licensing and Disciplinary Act shall be employed full-time for each facility.  The licensee shall report any change in administrator to the Department within five days after any change.

 

b)         The Department will consider the administrator, or the licensed or certified person designated in writing by the administrator to be in charge of the facility in the administrator's absence.

 

c)         The administrator shall arrange for facility supervisory personnel to annually attend appropriate educational programs on supervision, nutrition, and other pertinent subjects.

 

d)         The administrator shall appoint in writing a member of the facility staff to coordinate the establishment of, and render assistance to, the residents' advisory council.

 

e)         The licensee and the administrator shall be familiar with this Part. They shall be responsible for seeing that the requirements of this Part are met in the facility and that employees are familiar with those requirements according to the level of their responsibilities.

 

f)         If the facility has an assistant administrator, the facility shall inform the Department of the name and dates of employment and termination of this person. This will provide documentation of service to qualify for a license under the Nursing Home Administrators Licensing and Disciplinary Act.

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

SUBPART C: POLICIES

 

Section 350.610  Management Policies

 

a)         The facility's governing body shall exercise general direction of the facility, and shall establish the broad policies and procedures for the facility related to its purpose, objectives, operation, and the welfare of the residents served.

 

b)         There shall be established a table of organization showing the major operating programs of the facility, with staff divisions, the administrative personnel in charge of programs and divisions, and their lines of authority, responsibilities and communication.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.620  Resident Care Policies

 

a)         The facility shall have written policies and procedures governing all services provided by the facility which shall be formulated with the involvement of the administrator. The policies shall be available to the staff, residents and the public.  These written policies shall be followed in operating the facility and shall be reviewed at least annually.  (B)

 

b)         These policies shall include:

 

1)         A written statement of the philosophy, objectives and goals the facility is striving to achieve,

 

2)         A written statement linking the facility's role to the "State Plan for the Developmentally Disabled," as prepared by and available from the Governor's Planning Council for Developmental Disabilities,

 

3)         A written statement of the facility's goals for its residents,

 

4)         A written statement of the facility's concept of its relationship to the parents of its residents or to the surrogates,

 

5)         A written statement concerning admission, transfer, and discharge of residents including categories of residents accepted and not accepted, residents that will be transferred or discharged, and other policies of the facility.

 

6)         A written statement for resident care services including physician services, emergency services, personal care and nursing services, restorative services, activity services, pharmaceutical services, dietary services, social services, resident records, dental services, and diagnostic service (including laboratory and x-ray), (B)

 

7)         All the information contained in the policies shall be  available to consumer representatives, the public, staff, residents, and for review by Department personnel.

 

c)         The facility shall have a written agreement with one or more hospitals which indicates the hospital or hospitals will provide the following services:

 

1)         Emergency admissions.

 

2)         Admission to a hospital of residents from the facility who are in need of hospital care.

 

3)         Needed diagnostic services.

 

4)         Any other hospital based services needed by the resident.

 

d)         There shall be no blood transfusions performed in the facility.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.625  Determination of Need Screening and Request for Resident Criminal History Record Information

 

a)         For the purpose of this Section only, a facility is any location certified to participate in the Medicare program under Title XVIII of the Social Security Act or Medicaid program under Title XIX of the Social Security Act.

 

b)         All persons seeking admission to a facility must be screened to determine the need for facility services prior to being admitted, regardless of income, assets, or funding source. (Section 2-201.5(a) of the Act)  A screening assessment is not required provided one of the conditions in Section 140.642(c) of the rules of the Department of Healthcare and Family Services titled Medical Payment is met.

 

c)         Any person who seeks to become eligible for medical assistance from the Medical Assistance program under the Illinois Public Aid Code to pay for active treatment services while residing in a facility shall be screened in accordance with 89 Ill. Adm. Code 140.642(b)(4). (Section 2-201.5(a) of the Act)

 

d)         Screening for facility services shall be administered through procedures established by administrative rule by the agency responsible for screening. (Section 2-201.5(a) of the Act)  The Illinois Department of Human Services is responsible for the screening required in subsection (b) for all individuals 18 through 59 years of age and for individuals 60 years of age or older who are developmentally disabled or have a severe mental illness.  The Illinois Department of Healthcare and Family Services or its designee is responsible for the screening required in subsection (c).

 

e)         In addition to the screening required by Section 2-201.5(a) of the Act and this Section, a facility shall, within 24 hours after admission of a resident, request a criminal history background check pursuant to the Uniform Conviction Information Act for all persons seeking admission to the facility.  Background checks shall be based on the resident's name, date of birth, and other identifiers as required by the Department of State Police.  (Section 2-201.5(b) of the Act)

 

f)         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.illinois.gov/idoc/Pages/default.aspx to determine if the individual is listed as a registered sex offender.

 

g)         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 resident is completely immobile or that the resident meets other criteria related to the resident's health or lack of potential risk, such as the existence of a severe, debilitating physical, medical, or mental condition that nullifies any potential risk presented by the resident.  (Section 2-201.5(b) of the Act) The facility shall arrange for a fingerprint-based check or request a waiver from the Department within 5 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.

 

h)         A waiver issued pursuant to Section 2-201.5(b) of the Act shall be valid only while the resident is immobile or while the criteria supporting the waiver exist. (Section 2-201.5(b) of the Act)

 

i)          The facility shall provide for or arrange for any required fingerprint-based checks.  If a fingerprint-based check is required, the facility shall arrange for it to be conducted in a manner that is respectful of the resident's dignity and that minimizes any emotional or physical hardship to the resident.  (Section 2-201.5(b) of the Act) If a facility is unable to 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 2-201.5(b) of the Act.

 

j)          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 is pending.

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.630  Admission, Retention and Discharge Policies

 

a)         All involuntary discharges and transfers shall be in accordance with Sections 3-401 through 3-423 of the Act.

 

b)         Only residents who have had a comprehensive evaluation covering physical, emotional, social and cognitive factors, conducted by an appropriately constituted interdisciplinary team shall be admitted.

 

c)         No resident determined by professional evaluation to be in need of skilled level of nursing care shall be admitted to, or kept in, an Intermediate Care Facility, or Intermediate Care Facility for the Developmentally Disabled, or any distinct part of the facility designated and classified for intermediate care for the developmentally disabled.

 

d)         Each facility shall have a policy concerning the admission of persons needing prenatal or maternity care, and a policy concerning the keeping of these persons who become pregnant while they are residents of the facility.  If these policies permit these persons to be admitted to or kept in the facility, then the facility shall have a policy concerning the provision of adequate and appropriate prenatal and maternity care to these individuals from in-house or outside resources.

 

e)         A facility for infants and children under 18 years of age shall be used exclusively for children.  Persons under 18 years of age may not be cared for in a facility for adults without prior approval from the Department.  This approval will be granted only when it is the best possible placement for the person under the particular set of circumstances.

 

f)         A facility shall not refuse to discharge or transfer a resident when requested to do so by the resident or, if the resident is incompetent, by the resident's guardian.

 

g)         If a resident insists on being discharged and is discharged against the advice of a physician or a Qualified Intellectual Disability Professional, the facts involved in the situation shall be fully documented in the resident's clinical record.

 

h)         No resident shall be discharged without the concurrence of the attending physician. 

 

i)          No resident shall be admitted with a communicable, contagious or infectious disease except as set forth in Section 350.1223 of this Part.

 

j)          A facility shall not admit more residents than the number authorized by the license issued to it.

 

k)         No identified offender shall be admitted to or kept in a facility, unless the requirements of Section 350.625 for new admissions and the requirements of Section 350.635 are met.

 

l)          Upon a finding by the Department that there has been a substantial failure to comply with the Act and Section 350.165, including, without limitation, the circumstances set forth in subsection (a) of Section 3-119 of the Act, or if the Department otherwise finds that it would be in the public interest or the interest of the health, safety, and welfare of facility residents, the Department may impose a ban on new admissions to any facility licensed under the Act.  The ban shall continue until the Department determines that the circumstances giving rise to the ban no longer exist. (Section 3-119.1(a) of the Act)

 

m)        The Department shall provide notice to the facility and licensee of any ban imposed pursuant to subsection (l) and Section 350.165.  The notice shall provide a clear and concise statement of the circumstances on which the ban on new admissions is based and notice of the opportunity for a hearing. (Section 3-119.1(b) of the Act)

 

n)         If the Department finds that the public interest or the health, safety, or welfare of facility residents imperatively requires immediate action and if the Department incorporates a finding to that effect in its notice per subsection (m), then the ban on new admissions may be ordered pending any hearing requested by the facility. (Section 3-119.1(b) of the Act)

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.634  Criminal History Background Checks for Persons Who Were Residents on May 10, 2006 (Repealed)

 

(Source:  Repealed at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.635  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 residents while the results of a name-based background check or a fingerprint-based check are pending; while the results of a request for a waiver of a fingerprint-based check are pending; and/or while the Identified Offender Report and Recommendation is pending.

 

c)         If the results of a resident's criminal history background check reveal that the resident is an identified offender as defined in Section 1-114.01 of the Act, the facility shall do the following:

 

1)         Immediately notify the Department of State Police, in the form and manner required by the Department of State Police, in collaboration with the Department of Public Health, that the resident is an identified offender.

 

2)         Within 72 hours, arrange for a fingerprint-based criminal history record inquiry to be requested on the identified offender resident. The inquiry shall be based on the subject's name, sex, race, date of birth, fingerprint images, and other identifiers required by the Department of State Police. The inquiry shall be processed through the files of the Department of State Police 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 the Department of State Police, pursuant to an inquiry under this subsection (c)(2), any criminal history record information contained in its files.

 

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 the Department of State Police electronically in the form and manner prescribed by the Department of State Police. The Department of State Police 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. (Section 2-201.5(c) of the Act)

 

f)         If identified offenders are residents 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 residents of the facility.  If a resident 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 resident to verify compliance with the requirements of the Sex Offender Registration Act or to verify compliance with applicable terms of probation, parole, or mandatory supervised release. (Section 2-110(a-5) of the Act)  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 residents 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 350.750.

 

3)         If identified offenders are residents of the licensed facility, the licensed facility shall notify every resident or resident's guardian in writing that such offenders are residents of the licensed facility. The licensed facility shall also provide notice to its employees and to visitors to the facility that identified offenders are residents. (Section 2-216 of the Act) 

 

4)         If the identified offender is on probation, parole, or mandatory supervised release, the facility shall contact the resident'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 resident's record.  The record must also include the resident's criminal history record.

 

g)         Facilities shall maintain written documentation of compliance with Section 350.625.

 

h)         Facilities shall annually complete all of the steps required in subsection (f) for identified offenders.  This requirement does not apply to residents who have not been discharged from the facility during the previous 12 months.

 

i)          For current residents who are identified offenders, the facility shall review the security measures listed in the Identified Offender Report and Recommendation provided by the Department of the State Police.

 

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 medical director and law enforcement, shall specifically address the resident's needs in an individualized plan of care.

 

k)         The facility shall incorporate the Identified Offender Report and Recommendation into the identified offender's individual program plan created pursuant to 42 CFR 483.440(c).  (Section 2-201.6(g) 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 2-201.6(a) 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 subject to the rights of married residents under Section 2-108(e) of the Act.  (Section 2-201.6(d) of the Act)  

 

m)       The facility's reliance on the Identified Offender Report and Recommendation prepared pursuant to Section 2-201.6(a) of the Act shall not relieve or indemnify in any manner the facility's liability or responsibility with regard to the identified offender or other facility residents.

 

n)         The facility shall evaluate individual program plans at least quarterly for identified offenders for appropriateness and effectiveness of the portions specific to the identified offense and shall document the review.  The facility shall modify the individual program plan if necessary in response to this evaluation.  The facility remains responsible for continuously evaluating the identified offender and for making any changes in the individual program plan that are necessary to ensure the safety of residents.

 

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 350.700.  The facility shall review its 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 residents from misconduct by the identified offender, then the facility shall transfer or discharge the identified offender in accordance with Section 350.3300.

 

p)         The facility shall notify the 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 resident.

 

q)         The facility shall develop procedures for implementing changes in resident care and facility policies when the resident no longer meets the definition of identified offender.

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.636  Discharge Planning for Identified Offenders

 

a)         If, based on the security measures listed in the Identified Offender Report and Recommendation, a facility determines that it cannot manage the identified offender resident safely within the facility, it shall commence involuntary transfer or discharge proceedings pursuant to Section 3-402 of the Act and Section 350.3300(d).  (Section 2-201.6(h) of the Act)  The facility may initiate involuntary transfer or discharge proceedings if it determines, during the provisional admission period described in Section 350.625 (a) through (e), that it cannot manage the identified offender safely within the facility.

 

b)         All discharges and transfers shall be in accordance with Section 350.3300.

 

c)         When a resident who is an identified offender is discharged, the discharging facility shall notify the Department.

 

d)         A facility that admits or retains an identified offender shall have policies and procedures in place for discharging an identified offender for reasons related to the individual's status as an identified offender, including, but not limited to:

 

1)         The facility's inability to meet the needs of the resident, based on Section 350.635 and subsection (a);

 

2)         The facility's inability to provide the security measures necessary to protect facility residents, staff and visitors; or

 

3)         The physical safety of the resident, other residents, the facility staff, or facility visitors.

 

e)         Discharge planning shall be included as part of the individual program plan developed in accordance with Section 350.635(k).

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.637  Transfer of an Identified Offender

 

a)         If, based on the security measures listed in the Identified Offender Report and Recommendation, a facility determines that it cannot manage the identified offender resident safely within the facility, it shall commence involuntary transfer or discharge proceedings pursuant to Section 3-402 of the Act and Section 350.3300(d).  (Section 2-201.6(h) of the Act)  The facility also may initiate involuntary transfer or discharge proceedings if it determines, during the provisional admission period described in Section 350.625 (a) through (e), that it cannot manage the identified offender safely within the facility.

 

b)         All discharges and transfers shall be in accordance with Section 350.3300.

 

c)         When a resident who is an identified offender is transferred to another facility regulated by the Department, the Department of Healthcare and Family Services, or the Department of Human Services, the transferring facility shall notify the Department and the receiving facility that the individual is an identified offender before making the transfer.

 

d)         Notification shall include all of the documentation required under Section 350.635 and subsection (a), and the transferring facility shall provide this documentation to the receiving facility to complete the discharge planning.

 

e)         If the following information has been provided to the transferring facility from the Department of Corrections, the transferring facility shall provide copies to the receiving facility before making the transfer:

 

1)         The mittimus and any pre-sentence investigation reports;

 

2)         The social evaluation prepared pursuant to Section 3-8-2 of the Unified Code of Corrections;

 

3)         Any pre-release evaluation conducted pursuant to subsection (j) of Section 3-6-2 of the Unified Code of Corrections;

 

4)         Reports of disciplinary infractions and dispositions;

 

5)         Any parole plan, including orders issued by the Illinois Prisoner Review Board and any violation reports and dispositions; and

 

6)         The name and contact information for the assigned parole agent and parole supervisor. (Section 3-14-1 of the Unified Code of Corrections)

 

f)         The information required by this Section shall be provided upon transfer.  Information compiled concerning an identified offender shall not be further disseminated except to the resident; the resident's legal representative; law enforcement agencies; the resident's parole or probation officer; the Division of Long Term Care Field Operations in the Department's Office of Health Care Regulation; other facilities licensed by the Department, the Illinois Department of Healthcare and Family Services, the State ombudsman, or the Illinois Department of Human Services that are or will be providing care to the resident, or are considering whether to do so; health care and social service providers licensed by the Illinois Department of Financial and Professional Regulation who are or will be providing care to the resident, or are considering whether to do so; health care facilities and providers in other states that are licensed or regulated in their home state and would be authorized to receive this information if they were in Illinois.

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.640  Contract Between Resident and Facility

 

a)         Contract Execution

 

1)         Before a person is admitted to a facility, or at the expiration of the period of previous contract, or when the source of payment for the resident's care changes from private to public funds or from public to private funds, a written contract shall be executed between a licensee and the following in order of priority:

 

A)        The person, or if the person is a minor, his parent or guardian; or

 

B)        The person's guardian, if any, or agent, if any, as defined in Section 2-3 of the Illinois Power of Attorney Act; or

 

C)        A member of the person's immediate family. (Section 2-202(a) of the Act)

 

2)         An adult person shall be presumed to have the capacity to contract for admission to a long-term care facility unless he or she has been adjudicated a "disabled person" within the meaning of Section 11a-2 of the Probate Act of 1975, or unless a petition for such an adjudication is pending in a circuit court of Illinois. (Section 2-202(a) of the Act)

 

3)         If there is no guardian, agent or member of the person's immediate family available, able or willing to execute the contract required by Section 2-202 of the Act and a physician determines that a person is so disabled as to be unable to consent to placement in a facility, or if a person has already been found to be a "disabled person," but no order has been entered allowing residential placement of the person, that person may be admitted to a facility before the execution of a contract required by Section 2-202 of the Act; provided that a petition for guardianship or for modification of guardianship is filed within 15 days after the person's admission to a facility, and provided further that such a contract is executed within ten days after the disposition of the petition. (Section 2-202(a) of the Act)

 

4)         No adult shall be admitted to a facility if he or she objects, orally or in writing, to the admission, except as otherwise provided in Chapters III and IV of the Mental Health and Developmental Disabilities Code, or Section 11a-14.1 of the Probate Act of 1975. (Section 2-202(a) of the Act)

 

b)         The contract shall be clearly and unambiguously titled, "Contract between Resident and (name of facility)."

 

c)         Before a licensee enters a contract under Section 2-202 of the Act, it shall provide the prospective resident and his or her guardian, if any, with written notice of the licensee's policy regarding discharge of a resident whose private funds for payment of care are exhausted. (Section 2-202(a) of the Act)

 

d)         A resident shall not be discharged or transferred at the expiration of the term of a contract, except as provided in Sections 3-401 through 3-423 of the Act. (Section 2-202(b) of the Act)

 

e)         At the time of the resident's admission to the facility, a copy of the contract shall be given to the resident, his or her guardian, if any, and any other person who executed the contract. (Section 2-202(c) of the Act)

 

f)         The contract shall be signed by the licensee or the licensee's agent.  The title of each person signing the contract for the facility shall be clearly indicated next to each signature.  The facility administrator may sign as the agent of the licensee.

 

g)         The contract shall be signed by, or for, the resident, as described in subsection (a). If any person other than the principal signatory is to be held individually responsible for payments due under the contract, that person shall also sign the contract on a separate signature line labeled "signature of responsible party" or "signature of guarantor."

 

h)         The contract shall include a definition of "responsible party" or "guarantor" that describes in full the liability incurred by that person.

 

i)          A copy of the contract for a resident who is supported by nonpublic funds other than the resident's own funds shall be made available to the person providing the funds for the resident's support.  (Section 2-202(d) of the Act)

 

j)          The original or a copy of the contract shall be maintained in the facility and be made available upon request to representatives of the Department and the Department of Healthcare and Family Services. (Section 2-202(e) of the Act)

 

k)         The contract shall be written in clear and unambiguous language and shall be printed in not less than 12-point type. (Section 2-202(f) of the Act)

 

l)          The contract shall specify the term of the contract. (Section 2-202(g)(1) of the Act) The term can be until a certain date or event.  If a certain date is specified in the contract, an addendum can extend the term of the contract to another date certain or on a month-to-month basis.

 

m)        The contract shall specify the services to be provided under the contract and the charges for the services. (Section 2-202(g)(2) of the Act) A paragraph shall itemize the services and products to be provided by the facility and express the costs of the itemized services and products to be provided either in terms of a daily, weekly, monthly or yearly rate, or in terms of a single fee. The contract may provide that the charges for services may be changed with 30 days advance written notice to the resident or the person executing the contract on behalf of the resident.  The resident or the person executing the contract on behalf of the resident may either assent to the change or choose to terminate the contract at any time within 30 days after receiving the written notice of the change.  The written notice shall become an addendum to the contract.

 

n)         The contract shall specify the services that may be provided to supplement the contract and the charges for the services. (Section 2-202(g)(3) of the Act)

 

1)         A paragraph shall itemize all services and products offered by the facility or related institutions that are not covered by the rate or fee established in subsection (m).  If a separate rate or fee for any supplemental service or product can be calculated with definiteness at the time the contract is executed, then the additional cost shall be specified in the contract.

 

2)         If the cost of any itemized service or product to be provided to the resident by the facility or related institutions cannot be established or predicted with definiteness at the time of the resident's admission to the facility or at the time of the execution of the contract, then no cost for that service or product need be stated in the contract.  However, the contract shall include a statement explaining the resident's liability for the itemized service or product and explaining that the resident will be receiving a bill for the itemized service or product beyond and in addition to any rate or fee set forth in the contract.

 

3)         The contract may provide that the charges for services and products not covered by the rate or fee established in subsection (m) may be changed with 30 days advance written notice to the resident or the person executing the contract on behalf of the resident.  The resident or the person executing the contract on behalf of the resident may either assent to the change or choose to terminate the contract at any time within 30 days after receiving the written notice of the change.  The written notice shall become an addendum to the contract.

 

o)         The contract shall specify the sources liable for payments due under the contract. (Section 2-202(g)(4) of the Act)

 

p)         Deposit Provisions

 

1)         The contract shall specify the amount of deposit paid. (Section 2-202(g)(5) of the Act)

 

2)         The amount of the deposit shall be expressed in terms of a precise number of dollars and be clearly designated as a deposit.  The contract shall specify when the resident shall pay the deposit, and when the facility shall return the deposit.  The contract shall specify the conditions (if any) that the resident shall satisfy before the facility shall return the deposit.  When all of the specified conditions are satisfied, the facility shall return the deposit to the resident.  If the deposit is nonrefundable, the contract shall provide express notice of nonrefundability.

 

q)         The contract shall specify the rights, duties and obligations of the resident, except that the specification of a resident's rights may be furnished on a separate document that complies with the requirements of Section 2-211 of the Act. (Section 2-202(g)(6) of the Act)

 

r)          The contract shall designate the name of the resident's representative, if any.  The resident shall provide the facility with a copy of the written agreement between the resident and the resident's representative that authorizes the resident's representative to inspect and copy the resident's records and authorizes the resident's representative to execute the contract on behalf of the resident required by Section 2-202 of the Act.  (Section 2-202(h) of the Act)

 

s)         The contract shall provide that if the resident is compelled by a change in physical or mental health to leave the facility, the contract and all obligations under it shall terminate on seven days notice.  No prior notice of termination of the contract shall be required, however, in the case of a resident's death.  The contract shall also provide that in all other situations, a resident may terminate the contract and all obligations under it with 30 days notice.  All charges shall be prorated as of the date on which the contract terminates, and, if any payments have been made in advance, the excess shall be refunded to the resident. This provision shall not apply to life-care contracts through which a facility agrees to provide maintenance and care for a resident throughout the remainder of his or her life nor to continuing-care contracts through which a facility agrees to supplement all available forms of financial support in providing maintenance and care for a resident throughout the remainder of his or her life. (Section 2-202(i) of the Act)

 

t)          All facilities that offer to provide a resident with nursing services, medical services or personal care services, in addition to maintenance services, conditioned upon the transfer of an entrance fee to the provider of such services in addition to or in lieu of the payment of regular periodic charges for the care and services involved, for a term in excess of one year or for life pursuant to a life care contract, shall meet all of the provisions of the Life Care Facilities Act, including obtaining a permit from the Department, before they may enter into life care contracts. (Section 2(c) of the Life Care Facilities Act)

 

u)         In addition to all other contract specifications contained in this Section, admission contracts shall also specify:

 

1)         whether the facility accepts Medicaid clients;

 

2)         whether the facility requires a deposit of the resident or his family prior to the establishment of Medicaid eligibility;

 

3)         in the event that a deposit is required, a clear and concise statement of the procedure to be followed for the return of such deposit to the resident or the appropriate family member or guardian of the person;

 

4)         that all deposits made to a facility by a resident, or on behalf of a resident, shall be returned by the facility within 30 days of the establishment of Medicaid eligibility, unless such deposits must be drawn upon or encumbered in accordance with Medicaid eligibility requirements established by the Illinois Department of Healthcare and Family Services.  (Section 2-202(j) of the Act)

 

v)         It shall be a business offense for a facility to knowingly and intentionally both retain a resident's deposit and accept Medicaid payments on behalf of the resident.  (Section 2-202(k) of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.650  Residents' Advisory Council

 

a)         Each facility shall establish a residents' advisory council consisting of at least five resident members.  If there are not five residents capable of functioning on the residents' advisory council, as determined by the Interdisciplinary Team and based upon evaluations of the comprehensive functional assessments, residents' representatives shall take the place of the required number of residents.  The administrator shall designate a member of the facility staff (other than the administrator) to coordinate the establishment of, and render assistance to, the council. (Section 2-203 of the Act)

 

b)         Each facility shall develop and implement a plan for assuring a liaison with concerned individuals and groups in the local community.  Ways in which this requirement can be met include, but are not limited to, the following:

 

1)         Including community members such as volunteers, family members, residents' friends, residents' advocates, or community representatives on the council;

 

2)         Establishing a separate community advisory group with persons of the residents' choosing; or

 

3)         Finding a church or civic group to "adopt" the facility.

 

c)         The resident members shall be elected to the council by vote of their fellow residents, and the non-resident members shall be elected to the council by vote of the resident members of the council.

 

d)         In facilities of 50 or fewer beds, the council may consist of all of the residents of the facility, if the residents choose to operate in this way.

 

e)         All residents' advisory councils shall elect at least a chairperson or president and a vice chairperson or vice president from among the members of the council.  These persons shall preside at the meetings of the council, assisted by the facility staff person designated by the administrator to provide assistance.

 

f)         Some facilities may wish to establish mini-residents' advisory councils for various smaller units within the facility.  If this is done, each unit shall be represented on an overall facility residents' advisory council with the composition described in subsection (a).

 

g)         All residents' advisory council meetings shall be open to participation by all residents and by their representatives.

 

h)         No employee or affiliate of any facility shall be a member of any council.  Employees or affiliates persons may attend to discuss interests or functions of the non-members when invited by a majority of the officers of the council.  (Section 2-203(a) of the Act)

 

i)          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 residents, the administrator, and the staff. (Section 2-203(b) of the Act)

 

j)          Records of the council meetings shall be maintained in the office of the administrator.  (Section 2-203(c) of the Act)

 

k)         The residents' advisory council may communicate to the administrator the opinions and concerns of the residents.  The council shall review procedures for implementing resident rights and facility responsibilities and make recommendations for changes or additions that will strengthen the facility's policies and procedures as they affect residents' rights and facility responsibilities.  (Section 2-203(d) of the Act)

 

l)          The council shall be a forum for:

 

1)         Obtaining and disseminating information;

 

2)         Soliciting and adopting recommendations for facility programming and improvements; and

 

3)         Early identification and for recommending orderly resolution of problems.  (Section 2-203(e) of the Act)

 

m)        The council may present complaints on behalf of a resident to the Department, the DD Facility Advisory Board or to any other person it considers appropriate. (Section 2-203(f) of the Act)

 

n)         Families and friends of residents who live in the community retain the right to form family councils.

 

1)         If there is a family council in the facility, or if one is formed at the request of family members or the ombudsman, a facility shall make information about the family council available to all current and prospective residents, their families and their representatives.  The information shall be provided by the family council, prospective members or the ombudsman.

 

2)         If a family council is formed, facilities shall provide a place for the family council to meet.

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.660  General Policies

 

a)         The facility shall have policies and procedures, established in writing, that protect the financial interests of residents and when large sums of money accrue to a resident, provide for counseling the resident concerning its use, and for appropriate protection of such money.  These policies and procedures shall permit normalized and normalizing possession and use of money by residents for work payment and property administration as, for example, in performing cash and check transactions, and in buying clothes and other items.

 

b)         The facility shall allow daily visiting between 10 A.M. and 8 P.M.

 

c)         Residents occupying any bedroom shall be of the same sex except in the case of a room occupied by husband and wife.

 

d)         There shall be no resident traffic through a resident's room by residents to reach any other area of the building.

 

e)         The facility shall provide for the registration and disposition of complaints without threat of discharge or other reprisal against any employee or resident.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.670  Personnel Policies

 

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 Department personnel for review.

 

2)         Individual personnel files for each employee 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 and reasons for leaving.

 

3)         Individual personnel files for each employee shall also contain health records, including the initial health evaluation and the results of the tuberculin skin test required under Section 350.675, and any other pertinent health records.

 

4)         Individual personnel records for each employee shall also contain performance evaluation records.

 

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

 

d)         The facility shall check the status of all applicants with the Health Care Worker Registry prior to hiring.  Information on the Health Care Worker Registry will include:

 

1)         Whether the individual is active on the Registry;

 

2)         Whether the individual has findings of abuse, neglect, or misappropriation of property;

 

3)         The date of the individual’s most recent criminal history records check;

 

4)         Whether the individual has a conviction for a disqualifying offense pursuant to Section 25 of the Health Care Worker Background Check Act; and

 

5)         Whether the individual has a waiver.

 

e)         All facilities shall conduct required registry checks on employees at the time of hire and annually thereafter during employment. In addition to the Health Care Worker Registry, the facility shall check the Department of Children and Family Services' State Central Register and the Illinois Sex Offender Registry. A person may not be employed if he or she is found to have disqualifying convictions or substantiated cases of abuse or neglect. At the time of the annual registry checks, if a current employee's name has been placed on a registry with disqualifying convictions or disqualifying substantiated cases of abuse or neglect, then the employee must be terminated. Disqualifying convictions or disqualifying substantiated cases of abuse or neglect are defined for the Department of Children and Family Services Central Register by the Department of Children and Family Services' standards for background checks in 89 Ill. Adm. Code 385.  Disqualifying convictions or disqualifying substantiated cases of abuse or neglect are defined for the Health Care Worker Registry by the Health Care Worker Background Check Act and within the Act and this Part. A facility's failure to conduct the required registry checks will constitute a Type "B" violation.  (Section 3-206.04(a) of the Act)

 

f)         All personnel shall have either training or experience, or both, in the job assigned to them.

 

g)         Orientation and In-Service Training

 

1)         All new employees, including student interns, shall complete an orientation program covering, at a minimum, the following:  general facility and resident orientation; job orientation, emphasizing allowable duties of the new employee; resident safety, including fire and disaster, emergency care and basic resident safety; the importance of nutrition in general healthcare; and understanding and communicating with the type of residents being cared for in the facility.  Before being assigned to provide direct care to residents, all new direct care staff, including student interns, shall complete an orientation program covering the facility's policies and procedures for resident care services.  The employee's training and competency shall be documented.

 

2)         All employees, except student interns, shall attend in-service training programs pertaining to their assigned duties at least annually.  These in-service training programs shall include the facility's policies, skill training and ongoing education to enable all personnel to perform their duties effectively.  The in-service training sessions regarding personal care and nursing services shall include information on the prevention and treatment of decubitus ulcers.  In-service training concerning dietary services shall include information on the effects of diet in treatment of various diseases or medical conditions and the importance of laboratory test results in determining therapeutic diets.  Written records shall be kept of program content for each session and of personnel attending each session.

 

3)         All facility employees who deal directly with residents shall be trained on the individual requirements and behavioral issues of residents who may come under their care, to ensure the safety and dignity of each client.  The employees' training and competency shall be documented.

 

h)         Employees shall be assigned only duties that are directly related to their job functions, as identified in their job descriptions.  Exceptions may be made in emergencies.

 

i)          Personnel policies shall include a plan to provide personnel coverage for regular staff when they are absent.

 

j)          Every facility shall have a current, dated weekly employee time schedule posted where employees may refer to it.  This schedule shall contain the employee's name, job title, shift assignment, hours of work and days off. The schedule shall be kept on file in the facility for one year after the week for which the schedule was used.

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.671  Whistleblower Protection

 

a)         For the purposes of this Section, "retaliatory action" means the reprimand, discharge, suspension, demotion, denial of promotion or transfer, or change in the terms and conditions of employment of any employee of a facility that is taken in retaliation for the employee's involvement in a protected activity as set forth in Section 3-810 of the Act and this Section 350.671. (Section 3-810(a) of the Act)

 

b)         A facility shall not take any retaliatory action against an employee of the facility, including a nursing home administrator, because the employee does any of the following:

 

1)         Discloses or threatens to disclose to a supervisor or to a public body an activity, inaction, policy, or practice implemented by a facility that the employee reasonably believes is in violation of a law, rule, or regulation.

 

2)         Provides information to or testifies before any public body conducting an investigation, hearing, or inquiry into any violation of a law, rule, or regulation by a nursing home administrator.

 

3)         Assists or participates in a proceeding to enforce the provisions of the Act. (Section 3-810(b) of the Act)

 

c)         A violation of the Act and this Section may be established only upon a finding that the employee of the facility engaged in conduct described in subsection (b) of Section 3-810 of the Act and this Section, and this conduct was a contributing factor in the retaliatory action alleged by the employee. There is no violation of this Section, however, if the facility demonstrates by clear and convincing evidence that it would have taken the same unfavorable personnel action in the absence of that conduct. (Section 3-810(c) of the Act)

 

d)         The employee of the facility may be awarded all remedies necessary to make the employee whole and to prevent future violations of this Section. Remedies imposed by the court may include, but are not limited to, all of the following:

 

1)         Reinstatement of the employee to either the same position held before the retaliatory action or to an equivalent position;

 

2)         Two times the amount of back pay;

 

3)         Interest on the back pay;

 

4)         Reinstatement of full fringe benefits and seniority rights; and

 

5)         Payment of reasonable costs and attorney's fees. (Section 3-810(d) of the Act)

 

(Source:  Added at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.675  Initial Health Evaluation for Employees

 

a)         Each employee shall have an initial health evaluation which shall be used to insure that employees are not placed in positions which would pose undue risk of infection to themselves, other employees, residents, or visitors.

 

b)         The initial health evaluation shall be conducted not more than 30 days prior to the employee beginning employment in the facility.  The evaluation shall be completed not more than 30 days after the employee begins employment in the facility.

 

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 which 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, or chronic draining infections or open wounds.

 

d)         The initial health evaluation shall include a physical examination.  The examination shall include at a minimum any procedures needed in order to:

 

1)         Detect any unusual susceptibility to infection and any conditions which would increase the likelihood of the transmission of disease to residents, other employees, or visitors.

 

2)         Determine that the employee appears to be physically able to perform the job function which the facility intends to assign to the employee.

 

e)         The initial health evaluation shall include a tuberculin skin test which is conducted in accordance with the requirements of Section 350.1225.  The test must meet one of the following timeframes:

 

1)         The test must be completed no more than 90 days prior to the date of initial employment in the facility, or

 

2)         The test must be commenced no more than ten days after the date of initial employment in the facility.

 

(Source:  Added at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.680  Direct Support Persons (DSP)

 

a)         A facility shall not employ an individual as a nursing assistant, habilitation aide, home health aide, a developmental disabilities aide, or a direct support person, or newly hired as an individual who may have access to a resident, a resident's living quarters, or a resident's personal, financial, or medical records, unless the facility has checked the Department's Health Care Worker Registry and the individual is listed on the Health Care Worker Registry as eligible to work for a health care employer.  The facility shall not employ an individual as a nursing assistant, habilitation aide, a developmental disabilities aide, or a direct support person, if that individual is not on the registry unless the individual is enrolled in a training program under Section 3-206 (a)(5) of the Act and Section 350.683.  (Section 3-206.01 of the Act)

 

b)         Each of the facility's DSPs shall comply with one of the following conditions no later than 45 days after the date of initial employment:

 

1)         Is active on the Department's Health Care Worker Registry and has met the training or equivalency requirements of Section 350.683.

 

2)         Begin a current course of training for nursing assistants or habilitation aides, approved by the Department within 45 days after initial employment (see 77 Ill. Adm. Code 395).  The training shall be successfully completed within 120 days after initial employment.  Nursing assistants, habilitation aides, and child care aides who are enrolled in approved courses in community colleges or other educational institutions on a term, semester or trimester basis, shall be exempt from the 120-day completion time limit.  (Section 3-206(a)(5) of the Act)

 

3)         Submits documentation pursuant to Section 350.683 to be placed on the Health Care Worker Registry as a nursing assistant, habilitation aide, DSP, or developmental disabilities aide.

 

c)         Each person employed by the facility as a DSP or a habilitation aide shall meet each of the following requirements:

 

1)         Be at least 16 years of age, of temperate habits and good moral character, honest, reliable, and trustworthy. (Section 3-206(a)(1) of the Act)

 

2)         Be able to speak and understand the English language or a language understood by a substantial percentage of the facility's residents. (Section 3-206(a)(2) of the Act)

 

3)         Provide evidence of prior employment or occupation, if any, and residence for two years prior to present employment. (Section 3-206(a)(3) of the Act)

 

4)         Have completed at least eight years of grade school or provide proof of equivalent knowledge.  (Section 3-206(a)(4) of the Act)

 

5)         Comply with Section 395.150 of the Long-Term Care Assistants and Aides Training Programs Code.

 

6)         Be familiar with and have general skills related to resident care.  (Section 3-206(a)(6) of the Act)

 

7)         Perform their duties under the supervision of a licensed nurse or other appropriately trained, licensed, or certified personnel.  (Section 3-206(b) of the Act)

 

d)         Each facility shall certify to the Department that each DSP and habilitation aide subject to Section 3-206 of the Act meets all the requirements of the Act and this Section, and shall maintain proof of compliance by each employee with the requirements set out in this Section shall be maintained for each such employee by each facility in the individual personnel folder of the employee. Proof of training shall be obtained only from the Health Care Worker Registry.  Each facility shall obtain access to the Health Care Worker Registry's web application, maintain the employment and demographic information relating to each employee, and verify by the category and type of employment that each employee subject to this Section meets all the requirements of the Act and this Section.  (Section 3-206(d) and (e) of the Act)

 

e)         During inspections of the facility and pursuant to Section 3-206(a)(5) of the Act, the Department may require DSPs to demonstrate competency in the principles, techniques, and procedures covered by the DSP training program curriculum described in 77 Ill. Adm. Code 395.320, when possible problems in the care provided by DSPs or other evidences of inadequate training are observed.  If the DSP fails to demonstrate competency, the facility shall provide in-service training to the DSP.  The in-service training shall address the DSP training principles, techniques, and procedures in which the DSP is found to be deficient during inspection (see 77 Ill. Adm. Code 395).

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.681  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.

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.682  Resident Attendants

 

a)         As used in this Section, "resident attendant" means an individual who assists residents in a facility with the following activities:

 

1)         eating and drinking; and

 

2)         personal hygiene limited to washing a resident's hands and face, brushing and combing a resident's hair, oral hygiene, shaving residents with an electric razor, and applying makeup.  (Section 3-206.03(a) of the Act)

 

b)         The term "resident attendant" does not include an individual who:

 

1)         is a licensed health professional or a registered dietitian;

 

2)         volunteers without monetary compensation;

 

3)         is a nurse assistant or DSP; or

 

4)         performs any nursing or nursing-related services for residents of a facility. (Section 3-206.03(a) of the Act)

 

c)         A facility may employ resident attendants to assist the DSPs with the activities authorized under subsection (a).  The resident attendants shall not count in the minimum staffing requirements under this Part. (Section 3-206.03(b) of the Act)

 

d)         Each person employed by the facility as a resident attendant shall meet the following requirements:

 

1)         Be at least 16 years of age; and

 

2)         Be able to speak and understand the English language or a language understood by a substantial percentage of the facility's residents.

 

e)         Resident attendants shall be supervised by, and shall report to, a nurse.

 

f)         The facility shall develop and implement policies and procedures concerning the duties of resident attendants in accordance with this Section, and shall document such duties in a written job description.

 

g)         As part of the comprehensive assessment, each resident shall be evaluated to determine whether the resident may or may not be fed, hydrated or provided personal hygiene by a resident attendant.  The evaluation shall include, but not be limited to, the resident's level of care; the resident's functional status in regard to feeding, hydration, and personal hygiene; the resident's ability to cooperate and communicate with staff.

 

h)         A facility may not use on a full-time or other paid basis any individual as a resident attendant in the facility unless the individual:

 

1)         has completed a Department-approved training and competency evaluation program encompassing the tasks the individual provides; and

 

2)         is competent to provide feeding, hydration, and personal hygiene services. (Section 3-206.03(c) of the Act)  The individual shall be considered to be competent if he/she is able to perform a hands-on return demonstration of the required skills, as determined by a nurse.

 

i)          The facility shall maintain documentation of completion of the training program and determination of competency for each person employed as a resident attendant.

 

j)          A facility-based training and competency evaluation program shall be conducted by a nurse and/or dietician and shall include one or more of the following units:

 

1)         A feeding unit that is a maximum of five hours in length, that is specific to the needs of the residents, and that includes the anatomy of digestion and swallowing; feeding techniques; developing an awareness of eating limitations; potential feeding problems and complications; resident identification; necessary equipment and materials; resident privacy; hand washing; use of disposable gloves; verbal and nonverbal communication skills; behavioral issues and management techniques; signs of choking; signs and symptoms of aspiration; and Heimlich maneuver;

 

2)         A hydration unit that is a maximum of three hours in length and that includes the anatomy of digestion and swallowing; hydration technique; resident identification; necessary equipment and materials; potential hydration problems and complications; verbal and nonverbal communication skills; behavioral issues and management techniques; use of disposable gloves; signs of choking; signs and symptoms of aspiration; hand washing; and resident privacy;

 

3)         A personal hygiene unit that is a maximum of five hours in length and includes oral hygiene technique, denture care; potential oral hygiene problems and complications; resident identification; verbal and nonverbal communication skills; behavioral issues and management techniques; resident privacy; hand washing; use of disposable gloves; hair combing and brushing; face and hand washing technique; necessary equipment and materials; shaving technique.  (Section 3-206.03(d) of the Act)

 

k)         All training shall also include a unit in safety and resident rights that is at least five hours in length and that includes resident rights; fire safety, use of a fire extinguisher, evacuation procedures; emergency and disaster preparedness; infection control; and use of the call system.

 

l)          Each resident attendant shall be given instruction by a nurse or dietitian concerning the specific feeding, hydration, and/or personal hygiene care needs of the residents whom the attendant will be assigned to assist.

 

m)        These programs must be reviewed and approved by the Department every two years. (Section 3-206.03(d) of the Act)

 

n)         Training programs shall not be implemented prior to initial Department approval.

 

o)         Application for initial approval of facility-based and non-facility-based training programs shall be in writing and shall include:

 

1)         An outline containing the methodology, content, and objectives for the training program.  The outline shall address the curriculum requirements set forth in subsection (j) for each unit included in the program;

 

2)         A schedule for the training program;

 

3)         Resumes describing the education, experience, and qualifications of each program instructor, including a copy of any valid Illinois licenses, as applicable; and

 

4)         A copy or description of the tools that will be used to evaluate competency.

 

p)         The Department will evaluate the initial application and proposed program for conformance to the program requirements contained in this Section.  Based on this review, the Department will:

 

1)         Grant approval of the proposed program for a period of two years;

 

2)         Grant approval of the proposed program contingent on the receipt of additional materials, or revisions, needed to remedy any minor deficiencies in the application or proposed program, which would not prevent the program from being implemented, such as deficiencies in the number of hours assigned to cover different areas of content, which can be corrected by submitting a revised schedule or outline; or

 

3)         Deny approval of the proposed program based on major deficiencies in the application or proposed program that would prevent the program from being implemented, such as deficiencies in the qualifications of instructors or missing areas of content.

 

q)         Programs shall be resubmitted to the Department for review within 60 days prior to expiration of program approval.

 

r)          If the Department finds that an approved program does not comply with the requirements of this Section, the Department will notify the facility in writing of non-compliance of the program and the reasons for the finding.

 

s)         If the Department finds that any conditions stated in the written notice of non-compliance issued under subsection (r) have not been corrected within 30 days after the date of issuance of the notice, the Department will revoke its approval of the program.

 

t)          Any change in program content or objectives shall be submitted to the Department at least 30 days prior to program delivery.  The Department will review the proposed change based on the requirements of this Section and will either approve or disapprove the change.  The Department will notify the facility in writing of the approval or disapproval.

 

u)         A person seeking employment as a resident attendant is subject to the Health Care Worker Background Check Act (Section 3-206.03(f) of the Act) and Section 350.681, and to Section 3-206.04(a) of the Act and Section 350.670(e).

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.683  Registry of Direct Support Persons

 

a)         To be placed on the Health Care Worker Registry as a DSP, an individual shall either complete the required training or submit documentation of equivalency, as follows:

 

1)         An individual will be placed on the Health Care Worker Registry as a DSP when he/she has successfully completed a training program approved in accordance with the Long-Term Care Assistants and Aides Training Programs Code, and has met the criminal history records check requirements pursuant to the Health Care Worker Background Check Act and the Health Care Worker Background Check Code; or

 

2)         An individual will be placed on the Health Care Worker Registry as a DSP if he/she has met the criminal history records check requirements pursuant to the Health Care Worker Background Check Act and the Health Care Worker Background Check Code, and submits documentation supporting one of the following equivalencies:

 

A)        Current registration from another state as a developmental disabilities aide;

 

B)        Successful completion of a developmental disabilities aide training course approved by another state as evidenced by a diploma, certification, or other written verification from the school.  The documentation must demonstrate that the course is equivalent to, or exceeds, the requirements for DSPs in the Department's 77 Ill. Adm. Code 395; or

 

C)        Successful completion of a Mental Health Technician Training Program conducted by the Department of Human Services.

 

b)         A DSP shall meet the requirements of the Act and Section 350.670(e).

 

c)         Pursuant to Section 3-206.01 of the Act, an individual shall notify the Health Care Worker Registry of any change of address within 30 days after the change of address.  An individual also shall notify the Registry of any name change within 30 days after the change of name, and shall submit proof of any name change to the Department. (Section 3-206.01 of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.685  Student Interns

 

a)         No person who meets the definition of student intern in Section 350.330 shall be required to complete a current course of training for developmental disabilities aides.

 

b)         The facility may utilize student interns to perform basic developmental disabilities aide practices (see 77 Ill. Adm. Code 395.310), but shall not allow interns to provide rehabilitation nursing (see 77 Ill. Adm. Code 300.1210(b)), in-bed bathing, assistance with skin care, foot care, or to administer enemas, except under the direct, immediate supervision of a licensed nurse.

 

c)         No facility shall have more than fifteen percent of its developmental disabilities aide staff positions held by student interns.

 

(Source:  Amended at 17 Ill. Reg. 19210, effective October 26, 1993)

 

Section 350.690  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 residents, personnel, and others present in the facility.

 

b)         Each facility shall have policies covering disaster preparedness, including a written plan for staff, residents and others to follow.  The plan shall include, but not be limited to, the following:

 

1)         Proper instruction in 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 residents 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, 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)         Fire drills shall be held at least quarterly for each shift of facility personnel.  Disaster drills for other than fire shall be held twice annually for each shift of facility personnel.  Drills shall be held under varied conditions to:

 

1)         Ensure that all personnel on all shifts are trained to perform assigned tasks;

 

2)         Ensure that all personnel on all shifts are familiar with the use of the fire-fighting equipment in the facility; and

 

3)         Evaluate the effectiveness of disaster plans and procedures.

 

d)         Fire drills shall include simulation of the evacuation of residents to safe areas during at least one drill each year on each shift.

 

e)         The facility shall provide for the evacuation of physically handicapped persons, including those who are hearing or sight impaired.

 

f)         If the welfare of the residents precludes an actual evacuation of an entire building, the facility shall conduct drills involving the evacuation of successive portions of the building under conditions that assure the capability of evacuating the entire building with the personnel usually available, should the need arise.

 

g)         A written evaluation of each drill shall be submitted to the facility administrator and shall be maintained for one year.

 

h)         A written plan shall be developed for temporarily relocating the residents for any disaster requiring relocation and at any time that the temperature in residents' bedrooms falls below 55°F. for 12 hours or more.

 

i)          Reporting of Disasters

 

1)         Upon the occurrence of any disaster requiring hospital service, police, fire department or coroner, the facility administrator or designee shall provide a preliminary report to the Department either by using the nursing home hotline or by directly contacting the appropriate Department Regional 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 residents;

 

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 Departmental assistance, the facility shall provide a preliminary report within 24 hours after the occurrence.  Additionally, the facility shall submit a full written account to the Department within seven days after the occurrence, which includes the information specified in subsection (i)(1) of this Section and a statement of action taken by the facility after the preliminary report.

 

j)          Each facility shall establish and implement policies and procedures in a written plan to provide for the health, safety, welfare, and comfort of all residents when the heat index/apparent temperature, as established by the National Oceanic and Atmospheric Administration (see Section 350.Table F), inside the facility exceeds 80°F.

 

k)         Coordination with Local Authorities

 

1)         Annually, each facility shall 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)         Annually, each facility shall forward copies of its emergency water supply agreements, required under Section 350.2410(b), 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 local emergency management agency, the facility shall participate in emergency planning activities.

 

(Source:  Amended at 34 Ill. Reg. 19224, effective November 23, 2010)

 

Section 350.691  Electronic Monitoring

 

A facility shall comply with Section 2-116 and subsections 3-318(a)(8) and (9) of the Act, with the Authorized Electronic Monitoring in Long-Term Care Facilities Act, and with the Authorized Electronic Monitoring in Long-Term Care Facilities Code.

 

(Source:  Added at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.700  Incidents and Accidents

 

a)         The facility shall maintain a file of all written reports of each incident and accident affecting a resident that is not the expected outcome of a resident's condition or disease process.  A descriptive summary of each incident or accident affecting a resident shall also be recorded in the progress notes or nurse's notes of that resident

 

b)         The facility shall notify the Department of any serious incident or accident.  For purposes of this Section, "serious" means any incident or accident that causes physical harm or injury to a resident.

 

c)         The facility shall, by fax or phone, notify the Regional Office within 24 hours after each reportable incident or accident.  If the facility is unable to contact the Regional Office, it shall notify the Department's toll-free complaint registry hotline.  The facility shall send a narrative summary of each reportable accident or incident to the Department within seven days after the occurrence.

 

(Source:  Amended at 33 Ill. Reg. 9393, effective June 17, 2009)

 

Section 350.750  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)         Physical abuse − see Section 350.330.

 

3)         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 resident by a staff member or visitor;

 

2)         Physical abuse involving physical injury inflicted on a resident by another resident, except in situations where the behavior is associated with dementia or developmental disability;

 

3)         Sexual abuse of a resident by a staff member, another resident, or a visitor;

 

4)         When a crime has been committed in a facility by a person other than a resident; or

 

5)         When a resident death has occurred other than by disease processes.

 

c)         The facility shall develop and implement a policy concerning local law enforcement notification, including:

 

1)         Ensuring the safety of residents in situations requiring local law enforcement notification;

 

2)         Contacting local law enforcement in situations involving physical abuse of a resident by another resident;

 

3)         Contacting police, fire, ambulance and rescue services in accordance with recommended procedure;

 

4)         Seeking advice concerning preservation of a potential crime scene;

 

5)         Facility investigation of the situation.

 

d)         Facility staff shall be trained in implementing the policy developed pursuant to subsection (c).

 

e)         The facility shall also comply with other reporting requirements of this Part.

 

(Source:  Added at 26 Ill. Reg. 4878, effective April 1, 2002)

 

Section 350.760  Infection Control

 

a)         Policies and procedures for investigating, controlling, and preventing infections in the facility shall be established and followed.  The policies and procedures shall be consistent with and include the requirements of the Control of Communicable Diseases Code (77 Ill. Adm. Code 690) and Control of Sexually Transmissible Diseases Code (77 Ill. Adm. Code 693).  Activities shall be monitored to ensure that these policies and procedures are followed.

 

b)         A group, i.e., an infection control committee, quality assurance committee, or other facility entity, shall periodically review the results of investigations and activities to control infections. 

 

c)         Depending on the services provided by the facility, each facility shall adhere to the following guidelines of the Center for Infectious Diseases, Centers for Disease Control and Prevention, United States Public Health Service, Department of Health and Human Services, as applicable (see Section 350.340):

 

1)         Guideline for Prevention of Catheter-Associated Urinary Tract Infections

 

2)         Guideline for Hand Hygiene in Health-Care Settings

 

3)         Guidelines for Prevention of Intravascular Catheter-Related Infections

 

4)         Guideline for Prevention of Surgical Site Infection

 

5)         Guideline for Prevention of Nosocomial Pneumonia

 

6)         Guideline for Isolation Precautions in Hospitals

 

7)         Guidelines for Infection Control in Health Care Personnel

 

(Source:  Added at 29 Ill. Reg. 12954, effective August 2, 2005)

SUBPART D: PERSONNEL

 

Section 350.810  Personnel

 

a)         The facility shall have staff sufficient in number and qualifications on duty 24 hours each day to provide services that meet the total needs of the residents.  At a minimum, there shall be at least one staff member awake dressed and on duty at the facility at all times.

 

b)         Regardless of the organization or design of resident living units, the minimum direct care staff to resident ratios are as follows:

 

1)         For units that include any of the following types of residents, the staff-to-resident ratio shall be two and one-half hours of care per day per resident:

 

A)        children under the age of six years,

 

B)        severely and profoundly intellectually disabled,

 

C)        severely physically handicapped, and

 

D)        residents who are aggressive, assaultive, or security risks, or who manifest severely hyperactive or psychotic behavior.

 

2)         For units serving moderately intellectually disabled residents requiring habit training, the ratio shall be two hours of care per day per resident.

 

3)         For units serving residents in vocational training programs and adults who work in sheltered employment situations the staff to resident ratio shall be one hour of care per resident per day.

 

4)         Direct care staff includes licensed nurses, auxiliary personnel, qualified intellectual disability professionals, and DSPs.  The health services supervisor is not included in determining the ratio.

 

c)         The number and categories of personnel to be provided shall be based on the following:

 

1)         Number of residents.

 

2)         Amount and type of program content, supervision, and personal care needed to meet the particular needs of the residents at all times.

 

3)         Size, physical condition, and the layout of the building including proximity of service areas to the resident's rooms.

 

4)         Medical orders

 

d)         The facility shall provide an administrator as set forth in Subpart B.

 

e)         The facility shall provide a Resident Services Director who is a Qualified Intellectual Disability Professional as defined in Section 350.330, who is assigned responsibility for the coordination and monitoring of the residents' overall plan of care.  The administrator or an individual on the professional staff of the facility may fulfil this assignment to ensure that residents' plans of care are individualized, written in terms of short- and long-range goals, understandable and utilized; meet the resident's needs through appropriate staff interventions and community resources.  Residents shall be involved in the preparation of their plan of care, whenever possible.

 

f)         The facility shall provide activity personnel as set forth in Section 350.1050(c).

 

g)         The facility shall provide dietary personnel as set forth in Sections 350.1810 and 350.1820.

 

h)         The facility shall designate a staff member suited by training, or experience, or both, to be responsible for social services and for the integration of social services with other elements of the plan of care.

 

i)          The facility shall provide nursing personnel as set forth in Subpart F

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.820  Consultation Services

 

a)         The facility shall have all arrangements for each consultant's services in a written agreement setting forth the services to be provided.  These agreements shall be updated annually.

 

b)         The facility shall designate a staff member to provide social services to residents.  If the staff member designated to provide social services is not a social worker, the facility shall have an effective arrangement with a social worker to provide social services consultation.

 

(Source:  Amended at 26 Ill. Reg. 10611, effective July 1, 2002)

 

Section 350.830  Personnel Policies (Repealed)

 

(Source:  Repealed at 26 Ill. Reg. 10611, effective July 1, 2002)

 

Section 350.840  Employee Assistance Program

 

a)         For the purposes of this Section, an "employee assistance program" is a program that supports individual physical and mental well-being and that is provided by the facility or through an insurance or employee benefits program offered by the facility.  Employee assistance programs may include but are not limited to programs that offer professional counseling, stress management, mental wellness support, smoking cessation, and other support services.

 

b)         A facility shall ensure that nurses employed by the facility are aware of employee assistance programs or other like programs available for the physical and mental well-being of the employee.

 

c)         The facility shall provide information on these programs, no less than at the time of employment and during any benefit open enrollment period, by an information form about the respective programs that a nurse shall sign during onboarding at the facility, and upon request of the employee.

 

d)         The signed information form shall be added to the nurse's personnel file. The facility may provide this information to nurses electronically. Section 3-613 of the Act from P.A. 102-1007)

 

(Source:  Added at 48 Ill. Reg. 2546, effective January 30, 2024)

SUBPART E: RESIDENT LIVING SERVICES

 

Section 350.1010  Service Programs

 

The facility shall provide, either directly or through arrangements with an outside resource, as needed by the individual resident, all resident living services, training and guidance necessary in the activities of daily living and in the development of self-help skills for maximum independence.  These services shall consist of at a minimum the following:  (B)

 

a)         Psychological Services (as defined in Section 350.1020) (B)

 

b)         Social Services (as defined in Section 350.1030) (B)

 

c)         Speech Pathology and Audiology Services (as defined in Section 350.1040) (B)

 

d)         Organized Recreational Activities Services (as defined in Section 350.1050) (B)

 

e)         Training and Habilitation Services (as defined in Section 350.1060) (B)

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1020  Psychological Services

 

a)         Psychological services shall be provided to residents, directly through contact with psychologists and indirectly through the psychologists' consultation with other persons involved in psychological testing of or behavior modification of residents. (B)

 

b)         Psychologists shall participate, when appropriate, in the continuing interdisciplinary evaluation of individual residents for the purpose of initiating and monitoring individual habilitation programs.

 

c)         The psychologist shall report and disseminate the evaluation results in such a manner that the information, useful to the staff working with the resident, will be promptly provided and that confidentiality will be maintained.

 

d)         Psychologists shall participate, when appropriate, in the development of written, detailed, specific and individualized habilitation program plans, that provide for periodic review, follow-up and updating and that are designed to maximize each resident's development and acquisition of:

 

1)         Perceptual skills

 

2)         Sensorimotor skills

 

3)         Self-help skills

 

4)         Communication skills

 

5)         Social skills

 

6)         Self direction

 

7)         Emotional stability

 

8)         Effective use of time (including leisure time)

 

e)         The facility shall employ sufficient, appropriately qualified staff, and necessary supporting personnel, to carry out the various psychological service activities in accordance with the needs of the following functions:  (B)

 

1)         Psychological services to residents including evaluation, consultation, therapy, and program development

 

2)         Administration and supervision of psychological services

 

3)         Staff training

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1030  Social Services

 

a)         Social services, as part of an interdisciplinary spectrum of services, shall be provided to the residents through the use of social work methods directed toward:  (B)

 

1)         Maximizing the social functioning of each resident.

 

2)         Enhancing the coping capacity of the resident or his family.

 

3)         Asserting and safeguarding the human and civil rights of the developmentally disabled and their families, and fostering the human dignity and personal worth of each resident.

 

b)         The resident and his family shall be helped by social workers during the evaluation process, which may or may not lead to admission, to consider alternative services, based on the developmentally disabled person's status and salient family and community factors, and to make a responsible choice as to whether and when residential placement is indicated.

 

c)         Social workers shall participate, when appropriate, in the continuing interdisciplinary evaluation of individual residents for the purposes of initiation, monitoring, and follow-up of individualized habilitation programs.

 

d)         As appropriate during the developmentally disabled person's admission to and while receiving services in the facility, the social worker shall provide liaison between him, the facility, the family, and the community, so as to help the staff to:

 

1)         Individualize and understand the needs of the resident and his family in relation to each other.

 

2)         Understand social factors, including staff/resident relationships, in the resident's day-to-day behavior.

 

3)         Prepare the resident for changes in his living situation.

 

e)         Social workers shall help the family to develop constructive and personally meaningful ways to support the resident's experience in the facility through:

 

1)         Collateral counseling concerned with problems associated with changes in family structure and functioning.

 

2)         Referral to specific services, as appropriate.

 

3)         Help the family to participate in planning for the resident's return to home or other community placement.

 

f)         The facility shall employ sufficient, appropriately qualified staff, and necessary supporting personnel to carry out the various social service activities to meet the program needs of the residents.  (B)

 

1)         Social worker services to the residents shall be provided or supervised by a qualified social worker who meets the definition in Section 350.330.  (B)

 

2)         Social work assistants or aides employed by the facility shall work under the supervision of a qualified social worker who meets the definition in Section 350.330. (B)

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1040  Speech Pathology and Audiology Services

 

a)         Speech pathology and audiology services shall be provided to meet the needs of the residents through the following:  (B)

 

1)         Direct contact between speech pathologists, audiologists and residents.

 

2)         Working with other personnel, such as teachers and direct care staff, in implementing communication improvement programs.

 

b)         Speech pathology and audiology services available to the facility shall include the following:

 

1)         Screening and evaluation of residents with respect to speech and hearing functions.

 

2)         Comprehensive audiological assessment of residents, as indicated by screening results, to include tests of puretone air and bone conduction, speech audiometry, and other procedures, as necessary, and to include assessment of the use of visual cues.

 

3)         Assessment of the use of amplification.

 

4)         Provision for procurement, maintenance, and replacement of hearing aids, as specified by a qualified audiologist.

 

5)         Comprehensive speech and language evaluation of residents, as indicated by screening results, which include appraisal of articulation, voice, rhythm and language.

 

6)         Participation in the continuing interdisciplinary evaluation of individual residents for purposes of initiation, monitoring, and follow-up of individualized habilitation programs.

 

7)         Treatment services interpreted as an extension of the evaluation process that include:

 

A)        Direct counseling with residents.

 

B)        Consultation with appropriate staff for speech improvement and speech education activities.

 

C)        Collaboration with appropriate staff to  develop specialized programs for developing the communication skills of individuals in comprehension (for example, speech, reading, auditory training, and hearing aid utilization) as well as expression (for example, improvement in articulation, voice, rhythm, and language).

 

8)         Participation in inservice programs for direct care and other staff.

 

9)         Report evaluation and assessment results accurately and systematically, and in such manner as to, where appropriate, provide information useful to other staff working directly with the resident and to provide evaluative and summary reports for inclusion in the resident's unit record.

 

10)         Continuing observations of treatment progress shall be recorded accurately, summarized, communicated and utilized in evaluating progress.

 

c)         There shall be provided sufficient, appropriately qualified staff, and necessary supporting personnel, to carry out the various speech pathology and audiology services, in accordance with stated goals and objectives.  (B)

 

d)         Staff who assume independent responsibilities for clinical services shall meet the requirements as defined in Section 350.330.  (B)

 

e)         Adequate, direct and continuing supervision shall be provided personnel, volunteers, or supportive personnel utilized in providing clinical services.

 

f)         Space, facilities, equipment, and supplies shall be adequate for providing efficient and effective speech pathology and audiology services.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1050  Recreational and Activities Services

 

a)         The facility shall provide an ongoing program of activities to meet the interests and preferences and the physical, mental and psychosocial well-being of each resident, in accordance with the resident's comprehensive assessment.  The recreational and activity services shall be coordinated with other services and programs to make use of both community and facility resources and to benefit the residents.

 

b)         Activity Director and Consultation

 

1)         A trained staff person shall be designated as activity director, and shall be responsible for planning and directing the activities program.  This person shall be regularly scheduled to be in the facility at least four days per week.  In a facility of 16 or fewer residents, the Qualified Intellectual Disability Professional (QIDP) may serve as the activity director.  Additional activity personnel shall be provided as necessary to meet the needs of the residents and the program.

 

2)         If the activity director is not a Certified Therapeutic Recreation Specialist (CTRS), Occupational Therapist (OT), or a Licensed Social Worker (LSW) or Licensed Clinical Social Worker (LCSW) who has specialized course work in social group work, the facility shall have a written agreement with a person from one of those disciplines to provide consultation to the activity director and/or activity department at least monthly, to ensure that the activity programming meets the needs of the residents of the facility.

 

3)         Any person designated as activity director hired after November 1, 2000 shall have a high school diploma or equivalent.

 

4)         Except for individuals qualified as a CTRS, OTR/L, LSW or LCSW as listed in subsection (b)(2), any person hired as an activity director shall have completed a 36-hour basic orientation course or shall register to take a 36-hour basic orientation course within 90 days after employment and shall complete the course within 180 days after employment.  This course shall be recognized by an accredited college or university or a nationally recognized continuing education sponsor following the guidelines of the International Association for Continuing Education and Training and include at least the following: resident rights; activity care planning for quality of life, human wellness and self-esteem; etiology and symptomatology of persons who are aged, developmentally disabled or mentally ill; therapeutic approaches; philosophy and design of activity programs; activity program resources; program evaluation; practitioner behavior and ethics; resident assessments and supportive documentation; standards and regulations concerning activity programs; management and administration.  Individuals who have previously taken a 36-hour basic orientation course, a 42-hour basic activity course or a 90-hour basic education course shall be considered to have met this requirement.

 

5)         The activity director shall have a minimum of ten hours of continuing education per year pertaining to activities programming.

 

6)         Consultation shall be required only quarterly when the activity director meets or exceeds the following criteria:

 

A)        High school diploma or equivalent, five years of full-time or 10,000 hours of part-time experience in activities (three years of that experience as an activity director), and completion of a basic orientation course of at least 36 hours; or

 

B)        A two-year associate's degree, three years of experience as an activity director, and completion of a basic orientation course of at least 36 hours; or

 

C)        A four-year degree, one year of full-time experience as an activity director, and completion of a basic orientation course of at least 36 hours.

 

c)         Activity personnel shall have a minimum of 6 hours of in-service training per calendar or employment year, directly related to recreation/activities.  Habilitation aides who provide activities to residents shall also meet this requirement.  In-service training may be provided by qualified facility staff and/or consultants, or may be obtained from college or university courses, seminars and/or workshops, educational offerings through professional organizations, similar educational offerings or any combination thereof.

 

d)         Written permission, with any contraindications stated, shall be given by the resident's physician if the resident participates in the activity program. Standing orders will be acceptable with individual contraindications noted.

 

e)         An assessment of each resident shall be conducted, which shall include the following:

 

1)         Background information, including education level, cultural/social issues, and spiritual needs;

 

2)         Current functional status, including communication status, physical functioning, cognitive abilities, and behavioral issues; and

 

3)         Leisure functioning, including attitude toward leisure, awareness of leisure resources, knowledge of activity skills, and social interaction skills and activity interests, both current and past.

 

f)         The activity staff shall participate in the development of an individualized habilitation plan that addresses the needs and interests of the residents including activity/recreational goals and interventions.

 

g)         The facility shall provide a specific, planned program of individual (including self-initiated) and group activities that are aimed at improving, maintaining, or minimizing decline in the resident's functional status, and at promoting well-being.  The program shall be designated in accordance with the individual resident's needs, based on past and present lifestyle, cultural/ethnic background interests, capabilities, and tolerance.  Activities shall be held daily and shall reflect the schedules, choices, and rights of the residents (e.g., morning, afternoon, evenings and weekends).  The residents shall be given opportunities to contribute to planning, preparing, conducting, concluding and evaluating the activity program.

 

h)         The activity program shall be multifaceted and shall reflect each individual resident's needs and be adapted to the resident's capabilities.  The activity program philosophy shall encompass programs that provide stimulation or solace; promote physical, cognitive, and emotional health; enhance, to the extent practicable, each resident's physical and mental status; and promote each resident's self-respect by providing, for example, activities that support self-expression and choice.  Specific types of activities may include:

 

1)         Physical activity (e.g., exercise, fitness, adapted sports);

 

2)         Cognitive stimulation/intellectual/educational activity (e.g., discussion groups, guest speakers, films, trivia, quizzes, table games, puzzles, writing, spelling, newsletter);

 

3)         Spiritual/religious activity (e.g., religious services, spiritual study groups, visits from spiritual support groups);

 

4)         Service activity (e.g., volunteer work for the facility, other individuals or the community);

 

5)         Sensory stimulation (e.g., tactile, olfactory, auditory, visual and gustatory);

 

6)         Community involvement (e.g., community groups coming into the facility for intergenerational programs, special entertainment and volunteer visits; excursions outside the facility to museums, sporting events, entertainment, parks);

 

7)         Expressive and creative arts/crafts (adapted to the resident's capabilities), music, movement/dance, horticulture, pet-facilitated therapy, drama, literary programs, art, cooking;

 

8)         Family involvement (e.g., correspondence, family parties, holiday celebrations, family volunteers); and

 

9)         Social activity (e.g., parties and seasonal activities).

 

i)          If residents participate in regularly scheduled therapeutic programs outside the facility (e.g., school, employment, or sheltered workshop), the residents' needs for activities while they are in the facility shall be met.

 

j)          Residents' participation in and response to the activity program shall be documented at least quarterly and included in the clinical record.  The facility shall maintain current records of resident participation in the activity program.

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.1055  Volunteer Program

 

a)         If the facility has a volunteer or auxiliary program, a facility staff person shall direct the program.  Community groups such as Boy and Girl Scouts, church groups and civic organizations that may occasionally present programs, activities, or entertainment in the facility shall not be considered volunteers for the purposes of this Section.

 

b)         Volunteers shall complete a standard orientation program, in accordance with their facility responsibilities and with the facility's policies and procedures governing the volunteer program.  The orientation shall include, but not be limited to:

 

1)         Residents' rights;

 

2)         Confidentiality;

 

3)         Disaster preparedness (i.e., fire, tornado);

 

4)         Emergency response procedures;

 

5)         Safety procedures/precautions;

 

6)         Infection control; and

 

7)         Body mechanics.

 

c)         Volunteers shall respect all aspects of confidentiality.

 

d)         Volunteers shall be informed of and shall implement medical and physical precautions related to the residents with whom they work.

 

e)         Volunteers shall not take the place of qualified staff (e.g., activity professionals, nursing assistants, or case workers).

 

(Source:  Added at 24 Ill. Reg. 17254, effective November 1, 2000)

 

Section 350.1060  Training and Habilitation Services

 

a)         The facility shall provide training and habilitation services to facilitate the intellectual, sensorimotor, and effective development of each resident in the facility.

 

b)         Each resident shall have individual evaluations that shall:

 

1)         Be based upon the use of empirically reliable and valid instruments whenever the tools are available.

 

2)         Provide the basis for prescribing an appropriate program of training experiences for the resident.

 

c)         Written training and habilitation objectives for each resident shall be:

 

1)         Based upon complete and relevant diagnostic and prognostic data.

 

2)         Stated in specific behavioral terms that permit the progress of the individual to be assessed.

 

d)         There shall be evidence of training and habilitation services activities designed to meet the training and habilitation objectives set for every resident.

 

e)         An appropriate, effective and individualized program that manages residents' behaviors shall be developed and implemented for residents with aggressive or self-abusive behavior.  Adequate, properly trained and supervised staff shall be available to administer these programs.

 

f)         There shall be a functional training and habilitation record for each resident, maintained by and available to the training and habilitation staff.

 

g)         Appropriate training and habilitation programs shall be provided residents with hearing, vision, perceptual, or motor impairments, in cooperation with appropriate staff.

 

h)         There shall be available sufficient, appropriately qualified training and habilitation personnel, and necessary supporting staff, to carry out the training and habilitation program.  Supervision of delivery of training and habilitation services shall be the responsibility of a person who is a Qualified Intellectual Disability Professional.

 

i)          When appropriate, providers shall cooperate with the Department of Mental Health and Developmental Disabilities and community agencies to assist individual residents to take advantage of specialized work activity programs, prevocational and work adjustment training, or sheltered workshop programs.

 

j)          Appropriate records shall be maintained for each resident functioning in these programs.  Records shall include documentation of the appropriateness of the program for the individual, the resident's response to the program and any other pertinent observations.  These records shall be included in the resident's record.

 

k)         Residents shall not be used to replace employed staff.

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.1070  Training and Habilitation Staff

 

Appropriately qualified staff shall be provided in sufficient numbers to meet the training and habilitation needs of the residents.  At a minimum, staffing shall be provided as described in Section 350.810(b) of this Part.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1080  Restraints

 

a)         The facility shall have written policies controlling the use of physical restraints including, but not limited to, leg restraints, arm restraints, hand mitts, soft ties or vests, wheelchair safety bars and lap trays, and all facility practices that meet the definition of a restraint, such as tucking in a sheet so tightly that a bed-bound resident cannot move; bed rails used to keep a resident from getting out of bed; chairs that prevent rising; or placing a resident who uses a wheelchair so close to a wall that the wall prevents the resident from rising.  Adaptive equipment is not considered a physical restraint.  Wrist bands or devices on clothing that trigger electronic alarms to warn staff that a resident is leaving a room do not, in and of themselves, restrict freedom of movement and should not be considered as physical restraints. The policies shall be followed in the operation of the facility and shall comply with the Act and this Part.

 

b)         No physical restraints with locks shall be used.

 

c)         Physical restraints shall not be used on a resident for the purpose of discipline or convenience.

 

d)         The use of chemical restraints is prohibited.

 

(Source:  Added at 20 Ill. Reg. 12049, effective September 10, 1996)

 

Section 350.1082  Nonemergency Use of Physical Restraints

 

a)         Physical restraints shall only be used when required to treat the resident's medical symptoms or as a therapeutic intervention, as ordered by a physician, and based on:

 

1)         the assessment of the resident's capabilities and an evaluation and trial of less restrictive alternatives that could prove effective;

 

2)         the assessment of a specific physical condition or medical treatment that requires the use of physical restraints, and how the use of physical restraints will assist the resident in reaching his or her highest practicable physical, mental or psychosocial well being;

 

3)         consultation with appropriate health professionals, such as rehabilitative nurses and occupational or physical therapists, which indicates that the use of less restrictive measures or therapeutic interventions has proven ineffective; and

 

4)         demonstration by the care planning process that using a physical restraint as a therapeutic intervention will promote the care and services necessary for the resident to attain or maintain the highest practicable physical, mental or psychosocial well being.  (Section 2-106(c) of the Act)

 

b)         A physical restraint may be used only with the informed consent of the resident, the resident's guardian, or other authorized representative.  (Section 2-106(c) of the Act) Informed consent includes information about potential negative outcomes of physical restraint use, including incontinence, decreased range of motion, decreased ability to ambulate, symptoms of withdrawal or depression, or reduced social contact.

 

c)         The informed consent may authorize the use of a physical restraint only for a specified period of time.  The effectiveness of the physical restraint in treating medical symptoms or as a therapeutic intervention and any negative impact on the resident shall be assessed by the facility throughout the period of time the restraint is used.

 

d)         After 50 percent of the period of physical restraint use authorized by the informed consent has expired, but not less than five days before it has expired, information about the actual effectiveness of the physical restraint in treating the resident's medical symptoms or as a therapeutic intervention and about any actual negative impact on the resident shall be given to the resident, resident's guardian, or other authorized representative before the facility secures an informed consent for an additional period of time.  Information about the effectiveness of the physical restraint program and about any negative impact on the resident shall be provided in writing.

 

e)         A physical restraint may be applied only by staff trained in the application of the particular type of restraint.  (Section 2-106(d) of the Act)

 

f)         Whenever a period of use of a physical restraint is initiated, the resident 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 resident 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.  If the resident so chooses, the facility shall make the notification within 24 hours, including any information about the period of time that the physical restraint is to be used.  Whenever the Guardianship and Advocacy Commission is notified that a resident has been restrained, it shall contact the resident to determine the circumstances of the restraint and whether further action is warranted.  (Section 2-106(e) of the Act) If the resident requests that the Guardianship and Advocacy Commission be contacted, the facility shall provide the following information, in writing, to the Guardianship and Advocacy Commission:

 

1)         the reason the physical restraint was needed;

 

2)         the type of physical restraint that was used;

 

3)         the interventions utilized or considered prior to physical restraint and the impact of these interventions;

 

4)         the length of time the physical restraint was to be applied; and

 

5)         the name and title of the facility person who should be contacted for further information.

 

g)         Whenever a physical restraint is used on a resident whose primary mode of communication is sign language, the resident 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 resident or others.  (Section 2-106(f) of the Act)

 

h)         The plan of care shall contain a schedule or plan of rehabilitative/habilitative training to enable the most feasible progressive removal of physical restraints or the most practicable progressive use of less restrictive means to enable the resident to attain or maintain the highest practicable physical, mental or psychosocial well-being.

 

i)          A resident wearing a physical restraint shall have it released for a few minutes at least once every two hours, or more often if necessary.  During these times, residents shall be assisted with ambulation, as their condition permits, and provided a change in position, skin care and nursing care, as appropriate.

 

j)          No form of seclusion shall be permitted.

 

(Source:  Added at 20 Ill. Reg. 12049, effective September 10, 1996)

 

Section 350.1084  Emergency Use of Physical Restraints  

 

a)         If a resident needs emergency care, physical restraints may be used for brief periods to permit treatment to proceed unless the facility has notice that the resident has previously made a valid refusal of the treatment in question.  (Section 2-106(c) of the Act)

 

b)         For this Section only, "emergency care" means the unforeseen need for immediate treatment inside or outside the facility that is necessary to:

 

1)         save the resident's life;

 

2)         prevent the resident from doing serious mental or physical harm to himself/herself; or

 

3)         prevent the resident from injuring another individual.

 

c)         If a resident needs emergency care and other less restrictive interventions have proven ineffective, a physical restraint may be used briefly to permit treatment to proceed.  The attending physician shall be contacted immediately for orders.  If the attending physician is not available, the facility's advisory physician or Medical Director shall be contacted.  If a physician is not immediately available, a nurse or QMRP with supervisory responsibility may approve, in writing, the use of physical restraints.  A confirming order, which may be obtained by telephone, shall be obtained from the physician as soon as possible, but no later than within eight hours.  The effectiveness of the physical restraint in treating medical symptoms or as a therapeutic intervention and any negative impact on the resident shall be assessed by the facility throughout the period of time the physical restraint is used.  The resident must be in view of a staff person at all times until either the resident has been examined by a physician or the physical restraint has been removed.  The resident's needs for toileting, ambulation, hydration, nutrition, repositioning, and skin care must be met while the physical restraint is being used.

 

d)         The emergency use of a physical restraint must be documented in the resident's record, including:

 

1)         the behavior incident that prompted the use of the physical restraint;

 

2)         the date and times the physical restraint was applied and released;

 

3)         the name and title of the person responsible for the application and supervision of the physical restraint;

 

4)         the action by the resident's physician upon notification of the physical restraint use;

 

5)         the new or revised orders issued by the physician;

 

6)         the effectiveness of the physical restraint in treating medical symptoms or as a therapeutic intervention and any negative impact on the resident; and

 

7)         the date of the scheduled care planning conference or the reason a care planning conference is not needed, in light of the resident's emergency need for physical restraint.

 

e)         The facility's emergency use of physical restraints shall comply with Sections 350.1082(e), (f), (g), and (j).

 

(Source:  Added at 20 Ill. Reg. 12049, effective September 10, 1996)

 

Section 350.1086  Unnecessary, Psychotropic, and Antipsychotic Drugs

 

a)         A resident shall not be given unnecessary drugs in accordance with Section 350.Appendix E.  In addition, an unnecessary drug is any drug used:

 

1)         in an excessive dose, including in duplicative therapy;

 

2)         for excessive duration;

 

3)         without adequate monitoring;

 

4)         without adequate indications for its use; or

 

5)         in the presence of adverse consequences that indicate the drugs should be reduced or discontinued.  (Section 2-106.1(a) of the Act)

 

b)         Psychotropic medication shall not be prescribed without the informed consent of the resident, the resident's guardian, or other authorized representative.  (Section 2-106.1(b) of the Act)  Additional informed consent is not required for reductions in dosage level or deletion of a specific medication.  The informed consent may provide for a medication administration program of sequentially increased doses or a combination of medications to establish the lowest effective dose that will achieve the desired therapeutic outcome.  Side effects of the medications shall be described.

 

c)         Residents shall not be given antipsychotic drugs unless antipsychotic drug therapy is necessary, as documented in the resident's comprehensive assessment, to treat a specific or suspected condition as diagnosed and documented in the clinical record or to rule out the possibility of one of the conditions in accordance with Section 350.Appendix E.

 

d)         Residents who use antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue these drugs in accordance with Section 350.Appendix E.

 

e)         For the purposes of this Section:

 

1)         "Duplicative drug therapy" means any drug therapy that duplicates a particular drug effect on the resident without any demonstrative therapeutic benefit.  For example, any two or more drugs, whether from the same drug category or not, which have a sedative effect.

 

2)         "Psychotropic medication" means medication that is used for or listed as used for antipsychotic, antidepressant, antimanic or antianxiety behavior modification or behavior management purposes in the latest editions of the AMA Drug Evaluations (Drug Evaluation Subscription, American Medical Association, Vols. I-III, Summer 1993), United States Pharmacopoeia Dispensing Information Volume I (USP DI) (United States Pharmacopoeial Convention, Inc., 15th Edition, 1995), American Hospital Formulary Service Drug Information 1995 (American Society of Health Systems Pharmacists, 1995), or the Physician's Desk Reference (Medical Economics Data Production Company, 49th Edition, 1995) or the United States Food and Drug Administration approved package insert for the psychotropic medication.  (Section 2-106.1(b) of the Act)

 

3)         "Antipsychotic drug" means a neuroleptic drug that is helpful in the treatment of psychosis and has a capacity to ameliorate thought disorders.

 

(Source:  Added at 20 Ill. Reg. 12049, effective September 10, 1996)

 

Section 350.1088  Language Assistance Services

 

A facility shall provide language assistance services in accordance with the Language Assistance Services Act [210 ILCS 87] and the Language Assistance Services Code (77 Ill. Adm. Code 940).

 

(Source:  Added at 29 Ill. Reg. 12954, effective August 2, 2005)

SUBPART F: HEALTH SERVICES

 

Section 350.1210  Health Services

 

a)         Comprehensive resident care plan. A facility, with the participation of the resident and the resident's guardian or resident's representative, as applicable, must develop and implement a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental health, psychosocial, and habilitation needs that are identified in the resident's comprehensive assessment that allows the resident to attain or maintain the highest practicable level of independent functioning and provide for discharge planning to the least restrictive setting based on the resident's care needs. The assessment shall be developed with the active participation of the resident and the resident's guardian or resident's representative, as applicable. (Section 3-202.2a of the Act)

 

b)         The facility shall provide all services necessary to maintain each resident in good physical health.  These services include, but are not limited to, the following: 

 

1)         Physician services, including a complete physical examination at least annually and formal arrangements to provide for medical emergencies on a 24-hour, seven-day-a-week basis. 

 

2)         Nursing services to provide immediate supervision of the health needs of each resident by a registered professional nurse or a licensed practical nurse. 

 

3)         Dental services to provide evaluation, diagnosis, treatment, and annual review, including care for dental emergencies, administered by or under the supervision of a dentist. 

 

4)         Physical and occupational therapy services for purposes of initiating, monitoring and follow-up of individualized treatment programs rendered by or under the supervision of a physician with special training or experience in the specialty or a physical therapist or an occupational therapist. 

 

5)         Other professional consulting services as identified in the comprehensive functional assessment including, but not limited to, psychiatry, gynecology, and other services as specified in the individual program plan.

 

c)         The facility may not refer a resident or the family of a resident to a home health agency, home services agency, or home nursing agency unless the agency is licensed under the Home Health, Home Services and Home Nursing Agency Licensing Act.  A facility shall request a copy of an agency's license prior to making a referral to that agency.  (Section 3.8 of the Home Health, Home Services, and Home Nursing Agency Licensing Act)

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.1220  Physician Services

 

a)         The facility shall have a written program of medical services that reflects the philosophy of care provided, the policies relating to this, and the procedures for implementation of the services.  The program shall include the health services provided by the facility and the arrangements to effect a transfer to other facilities as promptly as needed.  The written program of medical services shall be followed in the operation of the facility.

 

b)         The facility shall have a formal arrangement for qualified medical care, including care for medical emergencies on a 24 hour, seven days-a-week basis.  An advisory physician shall provide advice on general health conditions and practices of the facility.

 

c)         The services of a physician shall be available to every resident in the facility.

 

d)         The resident or his guardian shall be permitted his choice of physicians.

 

e)         All residents shall be seen by their physician as often as necessary to assure adequate health care.

 

f)         Physicians shall participate in the continuing interdisciplinary evaluation of individual residents, for the purposes of initiation, monitoring, and follow-up of individualized habilitation programs for treatment.

 

g)         The statement of treatment goals and management plans shall be reviewed and updated at least semiannually to insure that the goals are appropriate and that management methods are consistent with the goals; and to determine whether progress toward the goals is being achieved or the goals should be reevaluated.

 

h)         The facility shall maintain effective arrangements through which medical and remedial services required by the resident but not regularly provided within the facility can be obtained promptly when needed.

 

i)          Each resident admitted shall have a complete physical examination, within five days prior to admission, or within 72 hours after admission to the facility. This examination report shall include an evaluation of the resident's condition, including height and weight, diagnosis, plan of treatment and recommendations, treatment orders, personal care needs, and permission for participation in facility programs as determined appropriate by the attending physician.  The report shall document the presence or absence of tuberculosis infection by tuberculin skin test in accordance with Section 350.1225.  The report shall also document the presence or absence of incipient or manifest decubitus ulcers (commonly known as bed sores) with grade, size and location specified, and orders for treatment if present.   The report shall also include orders from the physician regarding weighing of the resident and the frequency of such weighing, if ordered.

 

j)          The facility shall notify the resident's physician of any accident, injury, or change in a resident's condition that threatens the health, safety or welfare of a resident, including, but not limited to, the presence of incipient or manifest decubitus ulcers or a weight loss or gain of five percent or more within a period of 30 days.

 

k)         At the time of an accident, immediate first aid treatment shall be provided by personnel trained in medically approved first aid procedures.

 

l)          The admission information for a resident shall include diagnoses, summary of present medical findings, psychological findings, medical history, mental and physical functioning capacity, prognosis and an explicit recommendation by the physician with respect to admission to or continued care in the facility; it shall also include orders for medications, treatments, restorative services, diet, specific procedures recorded for the health and safety of the resident activities and plans for continuing care and discharge.  If this information is not received with the resident at the time of admission, it must be received within 48 hours.

 

m)        A resident who becomes unmanageable shall promptly be examined by a physician or a psychiatrist. A psychologist and members of other appropriate professional disciplines should be consulted, as necessary.

 

n)         No resident shall be discharged without the concurrence of the attending physician.  All involuntary discharges and transfers shall be in accordance with Sections 3-401 to 3-423 of the Act.

 

(Source:  Amended at 23 Ill. Reg. 7970, effective July 15, 1999)

 

Section 350.1223  Communicable Disease Policies

 

a)         The facility shall comply with the Control of Communicable Diseases Code (77 Ill. Adm. Code 690).

 

b)         The facility shall not knowingly admit a person with a communicable, contagious or infectious disease, as defined in the Control of Communicable Diseases Code, except as allowed in subsection (d) of this Section.  A resident who is suspected of or diagnosed as having any such disease shall be placed in isolation, if required, in accordance with the Control of Communicable Diseases Code.  If the facility believes that it cannot provide the necessary infection control measures, it must initiate an involuntary transfer and discharge pursuant to Article III, Part 4 of the Act and Section 350.630 of this Part.  In determining whether a transfer or discharge is necessary, the burden of proof rests on the facility.

 

c)         All illnesses required to be reported under the Control of Communicable Diseases Code and Control of Sexually Transmissible Diseases Code (77 Ill. Adm. Code 693) shall be reported immediately to the local health department and to the Department.  The facility shall furnish all pertinent information relating to such occurrences.  In addition, the facility shall also inform the Department of all incidents of scabies and other skin infestations.

 

d)         Persons with communicable, contagious, or infectious diseases may be admitted under the following conditions:

 

1)        When a person's infectious condition is directly related to one or more chronic pressure sores, from which laboratory tests have proven the presence of a pathogenic organism.  Such a person may be admitted if the facility is capable of implementing appropriate treatment and isolation techniques to avoid secondary spread of infection.

 

2)        When a person's condition is communicable, contagious, or infectious only through blood or other body fluid contact, such as hepatitis, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV) infection.

 

e)         The facility shall notify the Department no later than five working days after the date of the admission of any person with a communicable, contagious, or infectious disease under subsection of this Section.  The notice to the Department shall include at least the date of the admission and the nature of the condition.

 

f)          Written approval to admit or keep a person with other communicable, contagious, or infectious diseases may be granted by the Department on an individual case basis.  Such approval will depend upon the nature of the infectious condition or disease and the capability of the facility to provide proper care to the person and to safeguard the staff and other residents of the facility from the spread of primary and secondary infections

           

(Source:  Amended at 29 Ill. Reg. 12954, effective August 2, 2005)

 

Section 350.1225  Tuberculin Skin Test Procedures

 

Tuberculin skin tests for employees and residents shall be conducted in accordance with the Control of Tuberculosis Code (77 Ill. Adm. Code 696).

 

(Source:  Amended at 23 Ill. Reg. 7970, effective July 15, 1999)

 

Section 350.1230  Nursing Services

 

a)         Each facility shall have a full-time director of nursing services (DON) who is a registered nurse (RN) and whose only responsibility is the immediate supervision of the facility's health services.  This person shall be on duty a minimum of 36 hours, four days per week.  At least 50 percent of this person's hours shall be regularly scheduled between 7 A.M. and 7 P.M.

 

1)         A registered nurse or licensed practical nurse shall be on duty 24 hours per day and seven days per week in charge of health services at all times when the director of nursing services is not on duty.  The nurse shall be a registered nurse when required by the medical and/or nursing needs of the residents.

 

2)         A facility may, with written approval from the Department, have two registered nurses share the duties of this position if the facility is unable to obtain a full-time person.  Such an arrangement will be granted approval only through written documentation that the facility was unable to obtain the full-time services of a qualified individual to fill this position. Such documentation shall include, but not be limited to:  an advertisement that has appeared in a newspaper of general circulation in the area for at least three weeks; the names, addresses and phone numbers of all persons who applied for the position and the reasons why they were not acceptable or would not work full time; and information about the number and availability of registered nurses in the area.  The Department will grant approval only when such documentation indicates that there were no qualified applicants who were willing to accept the job on a full-time basis, and the pool of registered nurses available in the area cannot be expected to produce, in the near future, a qualified person who is willing to work full time.

 

3)         In facilities with a capacity of fewer than 50 beds, this person (or these persons) may also provide direct patient care, and this person's time may be included in meeting the staff to resident ratio requirements.

 

b)         Residents shall be provided with nursing services, in accordance with their needs, which shall include, but are not limited to, the following: The DON shall participate in:

 

1)         Pre-admission evaluation study and plan.

 

2)         Evaluation study, program design, and placement of the resident at the time of admission to the facility.

 

3)         Periodic reevaluation of the type, extent, and quality of services and programming.

 

4)         Development of discharge plans, and the referral to appropriate community resources.

 

5)         Training in habits in personal hygiene and activities of daily living.

 

6)         Development of a written plan for each resident to provide for nursing services as part of the total habilitation program.

 

7)         Modification of the resident care plan, in terms of the resident's daily needs, as needed.

 

c)         A registered nurse shall participate, as appropriate, in planning and implementing the training of facility personnel.

 

d)         Direct care personnel shall be trained in, but are not limited to, the following:

 

1)         Detecting signs of illness, dysfunction or maladaptive behavior that warrant medical, nursing or psychosocial intervention.

 

2)         Basic skills required to meet the health needs and problems of the residents.

 

3)         First aid in the presence of accident or illness.

 

e)         Sufficient, appropriately qualified nursing staff shall be available, which may include licensed practical nurses and other supporting personnel, to carry out the various nursing service activities.

 

f)         The individual responsible for providing nursing services shall have knowledge and experience in the field of developmental disabilities.

 

g)         Nursing service personnel at all levels of competence and experience shall be assigned responsibilities in accordance with their qualifications.

 

(Source:  Amended at 28 Ill. Reg. 7653, effective May 24, 2004)

 

Section 350.1235  Life-Sustaining Treatments

 

a)         Every facility shall respect the residents' right to make decisions relating to their own medical treatment, including the right to accept, reject, or limit life-sustaining treatment.  Every facility shall establish a policy concerning the implementation of those rights.  This policy shall include:

 

1)         Implementation of Living Wills or Powers of Attorney for Health Care in accordance with the Living Will Act and the Powers of Attorney for Health Care Law;

 

2)         The implementation of physician orders limiting resuscitation such as those commonly referred to as "Do Not Resuscitate" orders.  This policy may only prescribe the format, method of documentation and duration of any physician orders limiting resuscitation.  Any orders under this policy shall be honored by the facility. (Section 2-104.2 of the Act);

 

3)         Procedures for providing life-sustaining treatments available to residents at the facility;

 

4)         Procedures detailing staff's responsibility with respect to the provision of life-sustaining treatment when a resident has chosen to accept, reject, or limit life-sustaining treatment, or when a resident has not made or has not yet been given the opportunity to make these choices; and

 

5)         Procedures for educating both direct and indirect care staff in the application of those specific provisions of the policy for which they are responsible.

 

b)         For the purposes of this Section:

 

1)         "Agent" means a person acting under a Health Care Power of Attorney in accordance with the Powers of Attorney for Health Care Law.

 

2)         "Life-sustaining treatment" means any medical treatment, procedure, or intervention that, in the judgment of the attending physician, when applied to a resident, would serve only to prolong the dying process.  Those procedures can include, but are not limited to, cardiopulmonary resuscitation (CPR), assisted ventilation, renal dialysis, surgical procedures, blood transfusions, and the administration of drugs, antibiotics, and artificial nutrition and hydration. Those procedures do not include performing the Heimlich maneuver or clearing the airway, as indicated.

 

3)         "Surrogate" means a surrogate decision maker acting in accordance with the Health Care Surrogate Act.

 

c)         Within 30 days after admission, residents, agents, or surrogates shall be given written information describing the facility's policies required by this Section and shall be given the opportunity to:

 

1)         Execute a Living Will or Power of Attorney for Health Care in accordance with State law, if they have not already done so; and

 

2)         Decline consent to any or all of the life-sustaining treatments available at the facility.

 

d)         Any decision made by a resident, an agent, or a surrogate pursuant to subsection (c) shall be recorded in the resident's medical record.  Any subsequent changes or modifications shall also be recorded in the medical record.

 

e)         The facility shall honor all decisions made by a resident, an agent, or a surrogate pursuant to subsection (c) and shall not discriminate in providing health care on the basis of the decision, or will transfer care in accordance with the Living Will Act, the Powers of Attorney for Health Care Law, the Health Care Surrogate Act or the Right of Conscience Act.

 

f)         The resident, agent, or surrogate may change his or her decision regarding life-sustaining treatments by notifying the treating facility of this decision change orally or in writing in accordance with State law.

 

g)         The physician shall confirm the resident's choice by writing appropriate orders in the patient record or will transfer care in accordance with the Living Will Act, the Powers of Attorney for Health Care Law, the Health Care Surrogate Act or the Right of Conscience Act.

 

h)         If no choice is made pursuant to subsection (c), and in the absence of any physician's order to the contrary, then the facility's policy with respect to the provision of life-sustaining treatment shall control until and if a decision is made by the resident, agent, or surrogate in accordance with the requirements of the Health Care Surrogate Act.

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.1236  Care and Treatment of Sexual Assault Survivors

 

a)         For the purposes of this Section, the following definitions shall apply:

 

1)         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.

 

2)         Sexual Assault – an act of nonconsensual sexual conduct or sexual penetration, as defined in Section 11-0.1 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.

 

b)         When a sexual assault is alleged to have occurred, the facility shall adhere to the following protocol for the care and treatment of residents who are suspected of having been sexually assaulted in an ID/DD facility or elsewhere (Section 3-808 of the Act):

 

1)         Notify local law enforcement pursuant to the requirements of Section 350.750;

 

2)         Call an ambulance provider if medical care is needed;

 

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)         Immediately notify the resident's guardian or other authorized representative, and inform the guardian or other authorized representative, and the resident, that the facility will call another friend or family member and a sexual assault crisis advocate, when available, to accompany the survivor, if the guardian or other representative, or the resident, wishes.

 

c)         The facility shall preserve evidence of the alleged sexual assault, and shall not launder or dispose of the resident's clothing or bed linens until local law enforcement can determine whether they have evidentiary value. The facility shall encourage the survivor not to change clothes or bathe, if the survivor has not done so since the sexual assault.

 

d)         The facility shall notify the Department and draft a descriptive summary of the alleged sexual assault pursuant to the requirements of Section 350.700.

 

(Source:  Added at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.1240  Dental Services

 

a)         There shall be comprehensive diagnostic services for all residents which include a complete extra and intra oral examination utilizing all diagnostic aides necessary to properly evaluate the resident's oral condition, within a period of one month following admission unless such an examination was done within six months of admission, and the results are received and reviewed by the facility and are entered in the resident's record.  (B)

 

b)         There shall be comprehensive treatment services for all residents which include, but are not limited to, the following:  (B)

 

1)         Provision for dental treatment.

 

2)         Provision for emergency treatment on a 24 hour, seven days a week basis, by a qualified dentist.

 

3)         A recall system that will assure that each resident is reexamined at specified intervals in accordance with his needs, but at least annually.

 

c)         There is education and training in the maintenance of oral health and a dental hygiene program that includes:  (B) Imparting information regarding nutrition and diet control measures to residents and staff; instruction of residents and staff in living units in proper oral hygiene methods; and instruction of parents or surrogates in the maintenance of proper oral hygiene, where appropriate (as in the case of residents leaving the facility).

 

d)         A permanent dental record shall be maintained for each resident.  A summary dental progress report shall be entered in the resident's unit record at stated intervals.  A copy of the permanent dental record shall be provided a facility to which a resident is transferred.  (B)

 

e)         There shall be a formal arrangement for providing qualified and adequate dental services to the facility, including care in dental emergencies on a 24 hour, seven days-a-week basis.  (B)

 

f)         There shall be available sufficient, appropriately qualified dental personnel, and necessary supporting staff, to carry out the dental services program.  All dentists providing services to the facility shall be fully licensed to practice in the State of Illinois.  All dental hygienists providing services to the facility shall be licensed to practice in the State of Illinois.(B)

 

g)         Each facility shall have a denture and dental prosthesis marking system which takes into account the identification marking system contained in Section 49 of the Illinois Dental Practice Act (Ill. Rev. Stat. 1987, ch. 111, par. 2349). Policies and Procedures shall be written and contained in the facilities Policies and Procedure Manual.  It shall include, at a minimum, provisions for:  (B)

 

1)         Marking individual dentures or dental protheses, if not marked prior to admission to the facility, within ten days of admittance; and

 

2)         individually marked denture cups for denture storage at night.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1250  Physical and Occupational Therapy Services

 

a)         Physical and occupational therapy services shall be provided as needed by the residents through personal contact of the therapists directly with the residents or indirectly with persons involved with the residents.

 

b)         Physical therapy and occupational therapy by the facility or by arrangements with an outside resource shall provide treatment training programs that are designed to preserve and improve abilities for independent function, such as range of motion, strength, tolerance, coordination, and activities of daily living; and to prevent, insofar as possible, irreducible or progressive disabilities, through means such as the use of orthotic and prosthetic appliances, assistive and adaptive devices, positioning, behavior, adaptation, and sensory stimulation.

 

c)         The therapist shall function closely with the resident's primary physician and with other medical specialists and treatment training progress shall be recorded regularly, evaluated periodically, and used as the basis for continuation or change of the resident's program.

 

d)         Evaluation results, treatment objectives, plans, procedures, and continuing observations of treatment progress shall be recorded accurately, summarized, communicated, and included in the resident's record.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1260  Vaccinations

 

a)         A facility shall annually administer or arrange for a vaccination against influenza to each resident, in accordance with the 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 resident has refused the vaccine.  Influenza vaccinations for all residents age 65 and over shall be completed by November 30 of each year or as soon as practicable if vaccine supplies are not available before November 1.  Residents admitted after November 30, during the flu season, and until February 1 shall, as medically appropriate, receive an influenza vaccination prior to or upon admission or as soon as practicable if vaccine supplies are not available at the time of the admission, unless the vaccine is medically contraindicated or the resident has refused the vaccine.  (Section 2-213 of the Act)

 

b)         A facility shall document in the resident's medical record that an annual vaccination against influenza was administered, refused or medically contraindicated.  (Section 2-213 of the Act)

 

c)         A facility shall provide or arrange for administration of a pneumococcal vaccination to each resident in accordance with the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, who has not received this immunization prior to or upon admission to the facility unless the resident refuses the offer for vaccination or the vaccination is medically contraindicated.  (Section 2-213 of the Act)

 

d)         A facility shall document in each resident's medical record that a vaccination against pneumococcal pneumonia was offered and administered, refused, or medically contraindicated.  (Section 2-213 of the Act)

 

(Source:  Amended at 39 Ill. Reg. 5490, effective March 25, 2015)

SUBPART G: MEDICATIONS

 

Section 350.1410  Medication Policies and Procedures

 

a)         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 be followed by the facility.  These policies and procedures shall be in compliance with all applicable federal, State and local laws.  Medication policies and procedures shall be developed with the advice of a pharmaceutical advisory committee that includes at least one licensed pharmacist, one physician, the administrator and the director of nursing. This committee shall meet at least quarterly. 

 

b)         For the purpose of this Subpart, "licensed prescriber" means a physician; a dentist; a podiatrist; an optometrist certified to use therapeutic ocular pharmaceutical agents; a physician assistant to whom prescriptive authority has been delegated by a supervising physician; or an advanced practice nurse practicing under a valid collaborative agreement.

 

c)         All legend medications maintained in the facility shall be on individual prescription or from the licensed prescriber's personal office supply, and shall be labeled as set forth in Section 350.1440.  A licensed prescriber who supplies medication from his or her personal office supply shall comply with Sections 33 and 54.5 of the Medical Practice Act of 1987 [225 ILCS 60/33 and 54.5]; or Section 51 of the Illinois Dental Practice Act [225 ILCS 25/51]; or the Podiatric Medical Practice Act of 1987 [225 ILCS 100]; or Section 15.1 of the Illinois Optometric Practice Act of 1987 [225 ILCS 80/15.1]; or Section 15-20 of the Nursing and Advanced Practice Nursing Act [225 ILCS 65/15-20]; or Section 7.5 of the Physician Assistant Practice Act of 1987 [225 ILCS 95/7.5]. 

 

d)         All medications administered shall be recorded as set forth in Section 350.1620.  Medications shall not be recorded as having been administered prior to their actual administration to the resident.

 

e)         The staff pharmacist or consultant pharmacist shall participate in the planned in-service education program of the facility on topics related to pharmaceutical services.

 

f)         A pharmacist shall obtain a Division III license to operate an on-premises pharmacy in accordance with the Pharmacy Practice Act of 1987 [225 ILCS 85] and the rules of the Illinois Department of Professional Regulation (68 Ill. Adm. Code 1330).

 

g)         No facility shall maintain a stock supply of controlled drugs or legend drugs, except for those in emergency medication kits or convenience boxes, as described in this Section.

 

h)         A facility may stock drugs that are regularly available without prescription.  These shall be administered to a resident only upon written order of a licensed prescriber.  Administration shall be from the original containers, and shall be recorded in the resident's clinical record. 

 

i)          A facility may keep convenience boxes containing medications to be used for initial doses.

 

1)         The contents and number of convenience boxes shall be determined by the pharmaceutical advisory committee.  The contents shall be listed on the outside of each box.

 

2)         Each convenience box 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. 

 

3)         No Schedule II controlled substances shall be kept in convenience boxes.

 

j)          Emergency medication kits shall be approved by the facility's pharmaceutical advisory committee, and shall be available for immediate use at all times in locations determined by the pharmaceutical advisory committee. 

 

1)         Each emergency medication kit shall be sealed after it has been checked and refilled. 

 

2)         Emergency medication kits shall contain all of the equipment needed to administer the medications.

 

3)         The contents of emergency medication kits shall be labeled on the outside of each 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.  Written documentation of this review shall be maintained. 

 

k)         The following requirements shall be met when controlled substances are kept as part of the emergency medication kits: 

 

1)         If an emergency medication kit is not stored in a locked room or cabinet, or if the kit contains controlled substances that require refrigeration, then the controlled substances portion of the kit shall be stored separately in a locked cabinet or room (or locked refrigerator or locked cabinet within a refrigerator, as appropriate) and labeled with a list of the substances and a statement they they are part of the emergency medication kit.  The label of the emergency medication kit shall list the substance and the specific location where it is stored. 

 

2)         Controlled substances for emergency medication kits shall be obtained from a federal Drug Enforcement Administration registered hospital, pharmacy, or licensed prescriber. 

 

3)         Only the director of nursing, registered nurse on duty, licensed practical nurse on duty, consultant pharmacist or licensed prescriber shall have access to controlled substances stored in emergency medication kits. 

 

4)         No more than ten 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. 

 

5)         Controlled substances in emergency medication kits may be administered only by persons licensed to administer medications, in compliance with 21 CFR 1306.11 and the Illinois Controlled Substances Act [720 ILCS 570]. 

 

6)         A proof-of-use sheet shall be stored with each controlled substance.  Entries shall be made on the proof-of-use sheet by the nursing staff or licensed prescriber when any controlled substance from the kit is used. The consultant pharmacist shall receive and file for two years a copy of all completed proof-of-use sheets. 

 

7)         Whenever the controlled substance portion of an emergency medication kit is opened, the consultant pharmacist shall be notified within 24 hours.  During any period when this kit is opened, a shift count shall be done on all controlled substances until the kit is closed or 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. 

 

8)         The consultant pharmacist shall check the controlled substances portions of emergency medication kits at least monthly and so document on the outside of each kit. 

 

9)         Failure to comply with any provision of this Section, or with any applicable provision of State or federal statutes or State regulations pertaining to controlled substances shall result in loss of the privilege of having or placing controlled substances in emergency medication kits until the facility can demonstrate that it is in compliance with such regulations.  This is in addition to the usual methods of corrective action available to the Department, such as fines or other penalties.

 

l)          Oxygen may be administered in a facility. The oxygen supply shall be stored and handled in accordance with the  National Fire Protection Association (NFPA) Standard No. 99: Standard for Health Care Facilities (2002, no later amendments or editions included) for nonflammable medical gas systems.  The facility shall comply with directions for use of oxygen systems as established by the manufacturer and the applicable provisions of NFPA 99 and the NFPA Life Safety Code (see Section 350.340). 

 

1)         Facilities shall store medical grade products separately from industrial grade products.  The storage area for medical grade products shall be well defined with one area for receiving full medical gas vessels and another for storing empty vessels.

 

2)         All personnel who will be handling medical gases shall be trained to recognize the various medical gas labels.  Personnel shall be trained to examine all labels carefully.

 

3)         If the facility's supplier uses 360-degree wrap-around labels to designate medical oxygen, personnel shall be specifically trained to make sure each vessel they connect to the oxygen system bears such a label.

 

4)         All facility personnel responsible for changing or installing medical gas vessels shall be trained to connect medical gas vessels properly.  Personnel shall understand how vessels are connected to the oxygen supply system and shall be alerted to the serious consequences of changing connections.

 

5)         If a medical gas vessel fitting does not seem to connect to the oxygen system fitting, the supplier shall be contacted immediately.  The vessel shall be returned to the supplier to determine the fitting or connection problem.

 

6)         Once a medical gas vessel has been connected to the oxygen supply system, but prior to introducing the product into the system, a trained facility staff member shall ensure that the correct vessel has been connected properly.

 

(Source:  Amended at 27 Ill. Reg. 5924, effective April 01, 2003)

 

Section 350.1420  Compliance with Licensed Prescriber's Orders

 

a)         All medications shall be given only upon the written, facsimile or electronic order of a licensed prescriber.  The facsimile or electronic order of a licensed prescriber shall be authenticated by the licensed prescriber within 10 calendar days, in accordance with Section 350.1610.  All such orders shall have the handwritten signature (or unique identifier) of the licensed prescriber.  (Rubber stamp signatures are not acceptable.)  These medications shall be administered as ordered by the licensed prescriber and at the designated time.

 

b)         Telephone orders may be taken by a registered nurse, licensed practical nurse or licensed pharmacist.  All such orders shall be immediately written on the resident's clinical record or a telephone order form and signed by the nurse or pharmacist taking the order. These orders shall be countersigned by the licensed prescriber within ten calender days.

 

c)         The staff pharmacist or consultant pharmacist shall review the medical record, including licensed prescriber's orders and laboratory test results, at least monthly and, based on their clinical experience and judgment, and Section 350.Appendix E, determine if there are irregularities that would cause adverse reactions, allergies, contraindications, medication errors or ineffectiveness.  This review shall be done at the facility and shall be documented in the clinical record.  Any irregularities noted shall be reported to the attending physician, the advisory physician, the director of nursing and the administrator and shall be acted upon.

 

d)         A medication order not specifically limiting the time or number of doses shall be automatically stopped in accordance with written policy approved by the pharmaceutical advisory committee.

 

e)         The resident's licensed prescriber shall be notified of medications about to be stopped so that the licensed prescriber may promptly renew such orders to avoid interruption of the resident's therapeutic regimen.

 

f)         The licensed prescriber shall approve the release of any medications to the resident, or person responsible for the resident's care, at the time of discharge or when the resident is going to be temporarily out of the facility at medication time.  Disposition of the medications shall be noted in the resident's clinical record.

 

(Source:  Amended at 27 Ill. Reg. 5924, effective April 01, 2003)

 

Section 350.1430  Administration of Medication

 

a)         All medications shall be administered only by personnel who are licensed to administer medications, in accordance with their respective licensing requirements. Licensed practical nurses shall have successfully completed a course in pharmacology or have at least one year's full-time supervised experience in administering medications in a health care setting if their duties include administering medications to residents.

 

1)         Medications shall be administered as soon as possible after doses are prepared at the facility and shall be administered by the same person who prepared the doses for administration, except under single unit dose packaged distribution systems.

 

2)         Each dose administered shall be properly recorded in the clinical record by the person who administered the dose.  (See Section 350.1620.)

 

3)         Self-administration of medication shall be permitted only upon the written order of the licensed prescriber. 

 

b)         The facility shall have medication records that shall be used and checked against the licensed prescriber's  orders to assure proper administration of medicine to each resident.  Medication records shall include or be accompanied by recent photographs or other means of easy, accurate resident identification.  Medication records shall contain the resident's name, diagnoses, known allergies, current medications, dosages, directions for use, and, if available, a history of prescription and non-prescription medications taken by the resident during the 30 days prior to admission to the facility. 

 

c)         Medications prescribed for one resident shall not be administered to another resident. 

 

d)         If, for any reason, a licensed prescriber's medication order cannot be followed, the licensed prescriber shall be notified as soon as is reasonable, depending upon the situation, and a notation made in the resident's record.

 

e)         Medication errors and drug reactions shall be immediately reported to the resident's physician, licensed prescriber if other than a physician, the consulting pharmacist and the dispensing pharmacist (if the consulting pharmacist and dispensing pharmacist are not associated with the same pharmacy).  An entry shall be made in the resident's clinical record, and the error or reaction shall also be described in an incident report. 

 

f)         Nurses' stations shall be equipped in accordance with Sections 350.2660 or 350.2960 and shall have all necessary items readily available for the proper administration of medications.

 

g)         Current medication references shall be available, such as the current edition of "Drug Facts and Comparisons", "Hospital Formulary", "USP-DI (United States Pharmacopeia-Drug Information)", "Physician's Desk Reference" or other suitable references.

 

(Source:  Amended at 27 Ill. Reg. 5924, effective April 01, 2003)

 

Section 350.1440  Labeling and Storage of Medications

 

a)         All medications for all residents shall be properly labeled and stored at or near the nurses' station in a locked cabinet, in a locked medication room, or in one or more locked mobile medication carts of satisfactory design for such storage.  (See subsections (f) and (g) of this Section.)

 

1)         These cabinets, rooms, or carts shall be well lighted and of sufficient size to permit storage without crowding. 

 

2)         All mobile medication carts shall be under the visual control of the responsible nurse at all times when not stored safely and securely. 

 

b)         All medications for external use shall be kept in a separate area in the cabinet, medicine room, or locked mobile medication cart. 

 

c)         All poisonous substances and other hazardous compounds shall be kept in a separate locked container away from medications.

 

d)         Biologicals or medications requiring refrigeration shall be kept in a separate, securely fastened locked box within a refrigerator or a locked refrigerator, at or near the nurses' station or in a refrigerator within a locked medication room. 

 

e)         The key or access code to the medicine cabinet, medicine room or mobile medication cart shall be the responsibility of, and in the possession of, the persons authorized to handle and administer drugs, at all times. 

 

f)         The label of each individual multi-dose medication container filled by a pharmacist shall clearly indicate the resident's full name; licensed prescriber's name; prescription number, name, strength, and quantity of drug; date this container was last filled; the initials of the pharmacist filling the prescription; the name and address of the pharmacy; and any necessary special instructions.  If the individual multi-dose medication container is filled by a licensed prescriber from his or her own supply, the label shall clearly indicate all of the preceding information and the source of supply; it shall exclude identification of the pharmacy, pharmacist and prescription number.

 

g)         Each single unit or unit dose package shall bear the proprietary or nonproprietary name of the drug, strength of dose and total contents delivered, lot or control number, and expiration date, if applicable.  The names of the resident and the physician do not have to be on the label of the package, but they must be identified with the package in such a manner as to assure that the drug is administered to the right resident.  Appropriate accessory and cautionary statements and any necessary special instruction shall be included, as applicable.  Hardware for storing and delivering the medications shall be labeled with the identity of the dispensing pharmacy.  The pharmacist shall provide written verification of the date the medications were dispensed and the initials or unique identifier of the pharmacist who reviewed and verified the medications.  The pharmacist need not store such verification at the facility but shall readily make it available to the Department upon request.  The lot or control number need not appear on unit dose packages if the dispensing pharmacy has a system for identifying those doses recalled by the manufacturer/distributor or if the dispensing pharmacy will recall and destroy all dispensed doses of a recalled medication, irrespective of a manufacturer's/distributor's specifically recalled lot. 

 

h)         Medication in containers having soiled, damaged, incomplete, illegible, or makeshift labels shall be returned to the issuing pharmacist, pharmacy, or dispensing licensed prescriber for relabeling or disposal.  Medications whose directions for use have changed since the medication was originally dispensed and labeled may be retained for use at the facility, in accordance with the licensed prescriber's current medication order.  Medications in containers having no labels shall be destroyed in accordance with federal and State laws.

 

i)          The medications of each resident shall be kept and stored in their originally received containers.  Medications shall not be transferred between containers, except that a licensed nurse, acting as the agent of the resident, may remove previously dispensed medication from original containers and place it in other containers to be sent with a resident when the resident will be out of the facility at the time of scheduled administration of medication.  When medication is sent out of the facility with the resident, it shall be labeled by the nurse with the name of the resident, name and strength of the medication, instructions for administration and any other appropriate information. 

 

(Source:  Amended at 27 Ill. Reg. 5924, effective April 01, 2003)

 

Section 350.1450  Control of Medications

 

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

 

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

 

c)         All medications having an expiration date that has passed, and all medications of residents who have been discharged or who have died, shall be disposed of in accordance with the written policies and procedures that have been established by the facility in accordance with Section 350.1410.  Medications shall be transferred with a resident, upon the order of the resident's physician, when a resident transfers to another facility.  All discontinued medications, with the exception of those products regulated and defined as controlled substances under Section 802 of the federal Controlled Substances Act (21 USC 802), shall be returned to the dispensing pharmacy. Medications for any resident who has been temporarily transferred to a hospital shall be kept in the facility. Medications may be given to a discharged resident only upon the order of the licensed prescriber.

 

d)         For all Schedule II controlled substances, a controlled substances record shall be maintained that lists on separate sheets, for each type and strength of Schedule II controlled substance, the following information:  date, time administered, name of resident, dose, licensed perscriber's name, signature of person administering dose, and number of doses remaining.  The pharmaceutical advisory committee may also require that other medications shall be subject to such inventory records.

 

(Source:  Amended at 27 Ill. Reg. 5924, effective April 01, 2003)

SUBPART H: RESIDENT AND FACILITY RECORDS

 

Section 350.1610  Resident Record Requirements

 

a)         Each facility shall have a medical record system that retrieves information regarding individual residents.

 

b)         The facility shall keep an active medical record for each resident. This resident record shall be kept current, complete, legible and available at all times to those personnel authorized by the facility's policies, and to the Department's representatives.

 

c)         Record entries shall meet the following requirements:

 

1)         Record entries shall be made by the person providing or supervising the service or observing the occurrence that is being recorded.

 

2)         All entries into the medical record shall be authenticated by the individual who made or authored the entry.  "Authentication", for purposes of this Section, means identification of the author of a medical record entry by that author and confirmation that the contents are what the author intended.

 

3)         Medical record entries shall include all notes, orders or observations made by direct resident care providers and any other individuals authorized to make such entries in the medical record, and written interpretive reports of diagnostic tests or specific treatments including, but not limited to, radiologic or laboratory reports and other similar reports.

 

4)         Authentication shall include the initials of the signer's credentials. If the electronic signature system will not allow for the credential initials, the facility shall have a means of identifying the signer's credentials.

 

5)         Electronic Medical Records Policy.  The facility shall have a written policy on electronic medical records.  The policy shall address persons authorized to make entries, confidentiality, monitoring of record entries, and preservation of information.

 

A)        Authorized Users.  The facility shall develop a policy to assure that only authorized users make entries into medical records and that users identify the date and author of every entry in the medical records.  The policy should allow written signatures, written initials supported by a signature log, or electronic signatures with assigned identifiers, as authentication by the author that the entry made is complete, accurate and final.

 

B)        Confidentiality.  The facility policy shall include adequate safeguards to ensure confidentiality of patient medical records, including procedures to limit access to authorized users.  The authorized user must certify in writing that he or she is the only person with authorized user access to the identifier and that the identifier will not be shared or used by any other person.  A surveyor or inspector in the performance of a State-required inspection may have access to electronic medical records, using the identifier and under the supervision of an authorized user from the facility.  A surveyor or inspector may have access to the same electronic information normally found in written patient records.  Additional summary reports, analyses, or cumulative statistics available through computerized records are the internal operational reports of the facility's Quality Assurance Committee.

 

C)        Monitoring.  The facility shall develop a policy to periodically monitor the use of identifiers and take corrective action as needed.  The facility shall maintain a master list of authorized users past and present and maintain a computerized log of all entries.  The logs shall include the date and time of access and the user ID under which access occurred.

 

D)        Preservation.  The facility shall develop a plan to ensure access to medical records over the entire record retention period for that particular piece of information.

 

d)         All physician's orders, plans of treatment, Medicare or Medicaid certification, recertification statements, and similar documents shall have the authentication of the physician.  The use of a physician's rubber stamp signature, with or without initials, is not acceptable.

 

e)         An ongoing resident record including progression toward and regression from established resident goals shall be maintained.

 

1)         The progress record shall indicate significant changes in the resident's condition.  Any significant change shall be recorded upon occurrence by the staff person observing the change.

 

2)         Recommendations and findings of direct service consultants, such as providers of social, dental, dietary or habilitation services, shall be included in the resident's progress record when the recommendations pertain to an individual resident.

 

f)         A medication administration record shall be maintained which contains the date and time each medication is given, name of drug, dosage, and by whom administered.

 

g)         Treatment sheets shall be maintained recording all resident care procedures ordered by each resident's attending physician.  Physician ordered procedures that shall be recorded include, but are not limited to, the prevention and treatment of decubitus ulcers, weight monitoring to determine a resident's weight loss or gain, catheter/ostomy care, blood pressure monitoring, and fluid intake and output.

 

h)         The records maintained for each resident shall be adequate for:

 

1)         Planning and continuously evaluating each resident's habilitation program,

 

2)         Furnishing evidence of each resident's progress and response to the habilitation program, and

 

3)         Protecting each resident's legal rights.

 

i)          The facility may use universal progress notes in the medical records.

 

j)          Each facility shall have a policy regarding the retirement and destruction of medical records.  This policy shall specify the time frame for retiring a resident's medical record, and the method to be used for record destruction at the end of the record retention period.  The facility's record retirement policy shall not conflict with the record retention requirements contained in Section 350.1650 of this Part.

 

k)         Discharge information shall be completed within 48 hours after the resident leaves the facility.  The resident care staff shall record the date, time, condition of the resident, to whom released, and the resident's planned destination (home, another facility, undertaker).  This information may be entered onto the admission record form.

 

l)          Each resident record is the property of the facility.  The facility shall be responsible for securing resident record information against loss, defacement, tampering or use by unauthorized persons.

 

(Source:  Amended at 23 Ill. Reg. 7970, effective July 15, 1999)

 

Section 350.1620  Content of Medical Records

 

a)         No later than the time of admission, the facility shall enter the following information onto the identification sheet or admission sheet for each resident:

 

1)         Name, sex, date of birth and Social Security Number,

 

2)         Marital status, and the name of spouse if there is one,

 

3)         Whether the resident has been previously admitted to the facility,

 

4)         Date of current admission to the facility,

 

5)         State or country of birth,

 

6)         Home address,

 

7)         Religious affiliation (if any),

 

8)         Name, address and telephone number of any referral agency, state hospital, zone center or hospital from which the resident has been transferred (if applicable),

 

9)         Name and telephone number of the resident's personal physician,

 

10)         Name and telephone number of the resident's next of kin or responsible relative,

 

11)         Race and origin,

 

12)         Most recent occupation,

 

13)         Whether the resident or the resident's spouse is a veteran,

 

14)         Father's name and mother's maiden name, Social Security numbers, mother's birthplace and parents' marital status.

 

15)         Name, address and telephone number of the resident's dentist, and

 

16)         The diagnosis applicable at the time of admission.

 

b)         The following information shall be obtained and entered in the resident's record at the time of admission to the facility:

 

1)         Heights, weight, color of hair and eyes, any identifying marks, and recent photograph,

 

2)         Reason for admission or referral, and the diagnosis applicable at the time of admission,

 

3)         Type and legal status of admission,

 

4)         Legal competency status,

 

5)         Language spoken or understood,

 

6)         Results of the preadmission evaluation conducted pursuant to Section 350.630(a) of this Part, previous histories and any other previous evaluations available, and

 

7)         At the time of admission, the facility shall obtain a history of prescription and non-prescription medications taken by the resident during the 30 days prior to admission to the facility (if available).

 

c)         Within one month after admission, the following information shall be entered into the newly admitted resident's record:

 

1)         A statement of prognosis that can be used for programming and placement, and

 

2)         A comprehensive evaluation and individual program plan, designed by an interdisciplinary team.

 

d)         In addition to the information that is specified above, each resident's medical record shall contain the following:

 

1)         Medical history and physical examination form that includes conditions for which medications have been prescribed, physician findings, all known diagnoses and restoration potential.  This shall describe those known conditions that the medical and resident care staff should be apprised of regarding the resident.  Examples of diagnoses and conditions that are to be included are allergies, epilepsy, diabetes and asthma.

 

2)         A physician's order sheet that includes orders for all medications, treatments, therapy and rehabilitation services, diet, activities and special procedures or orders required for the safety and well-being of the resident.

 

3)         Nurse's notes that describe the nursing care provided, observations and assessment of symptoms, reactions to treatments and medications, progression toward or regression from each resident's established goals, and changes in the resident's physical or emotional condition.  (B)

 

4)         An ongoing record of notations describing significant observations or developments regarding each resident's condition and response to treatments and programs.

 

A)        Physicians and other consultants who provide direct care or treatment to residents shall make notations at the time of each visit with a resident.

 

B)        Significant observations or developments regarding resident responses to dietary services and work or vocational orientation programs shall be recorded as they are noted.  If no significant observations or developments are noted for three months, an entry shall be made in the record of that fact.

 

C)        Significant observations or developments regarding resident responses to activity programs, social services, and nursing and personal care shall be recorded as they are noted.  If no significant observations or developments are noted for a month, an entry shall be made in the record of that fact.

 

5)         Any laboratory and x-ray reports ordered by the resident's physician.

 

6)         Documentation of visits to the resident by a physician and to the physician's office by the resident. The physician shall record, or dictate and sign, the results of such visits, such as changes in medication, observations and recommendations made by the physician during the visits, in the record.

 

7)         The results of the physical examination conducted pursuant to Section 350.1220(1) of this Part.

 

8)         Upon admission from a hospital or state facility, a hospital summary sheet or transfer form that includes the hospital diagnosis and treatment, a medical evaluation, physical examination, psychological workup, and a discharge summary.  This transfer information, which may be included in the transfer agreement, shall be signed by the physician who attended the resident while in the hospital.

 

9)         A record of all psychological testing and multidisciplinary evaluations regarding each resident.

 

10)         Reports of any seizures, illnesses, and immunizations,

 

11)         Reports of overall reviews and evaluations of each resident's individualized program plan.  These reports shall identify the developmental progress and status of each resident, and shall be completed at least semiannually by each professional discipline providing services to the resident.

 

12)         Records of significant behavior incidents, reactions to any family visits and contacts, attendance at programs, and leaves from the facility.

 

13)         Any correspondence pertaining to the resident's program.

 

14)         An update of the information recorded at the time of admission.  This update shall be performed at least once every 12 months, with changes in information relevant to the resident's personal physician and responsible relative to be recorded as they occur.

 

15)         Appropriate authorizations and consents.

 

16)         Results of the annual physical examination conducted pursuant to Section 350.1210(a) of this Part.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1630  Confidentiality of Resident's Records

 

a)         All information contained in a resident's record, including any information contained in an automated data bank, shall be considered confidential.  The facility shall permit the appropriate State and federal agencies (such as Illinios Departments of Public Aid, Public Health and Mental Health and Developmental Disabilities, and the U.S. Department of Health and Human Services) to have access to resident records.

 

b)         The facility shall develop and implement written policies governing access to, duplication of and dissemination of information from medical records.

 

c)         The facility shall obtain written consent of the resident, or, if a guardian, the resident's guardian, prior to any release of any resident record information to persons not authorized to receive the information.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1640  Records Pertaining to Residents' Property

 

a)         The facility shall maintain a record of any resident's belongings, including money, valuables and personal property, accepted by the facility for safekeeping.  This record shall be initiated at the time of admission and shall be updated on an ongoing basis and made part of the resident's record.

 

b)         When purchases are made for a resident from the resident's personal monies, receipts shall be obtained and retained that verify the date, amount, and items purchased.

 

c)         A separate bookkeeping system shall be maintained by the facility which accounts for all transactions affecting each resident's account. Each individual resident, or the individual resident's representative, shall have access to the record of that individual resident's account.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1650  Retention and Transfer of Resident Records

 

a)         Records of discharged residents shall be placed in an inactive file and retained as follows:

 

1)         Records for any resident who is discharge prior to being 18 years old shall be retained at least until the resident reaches the age of 23.

 

2)         Records of residents who are over 18 years old at the time of discharge shall be retained for a minimum of five years.

 

b)         After the death of a resident, the resident's record shall be retained for a minimum of five years.

 

c)         It is suggested that the administrator check with legal counsel regarding the advisability of retaining resident records for a longer period of time, and the procedures to be followed in the event the facility ceases operation.

 

d)         When a resident is transferred to another facility, the transferring facility shall send with the resident a reason for transfer, summary of treatment and results, laboratory findings, and orders for the immediate care of the resident.  This information may be presented in a transfer form or an abstract of the resident's medical record.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1660  Other Resident Record Requirements

 

This Section contains references to rules located in other Subparts that pertain to the content and maintenance of medical records.

 

a)         The resident's record shall include facts involved if the resident's discharge occurs despite medical advice to the contrary, as required by Section 350.630(g) of this Part.

 

b)         The resident's record shall contain the physician's permission, with contraindications noted, for participation in the activity program, as required by Section 350.1050(d) of this Part.

 

c)         The records of residents participating in training and habilitation programs shall document the appropriateness of the program for the resident and the resident's response to the program, as described in Section 350.1060(i) of this Part.

 

d)         The resident's record shall identify the reasons for any order and use of safety devices or restraints, as required by Section 350.1220(t) of this Part.

 

e)         The resident's record shall include information regarding the physician's notification and response regarding any serious accident or injury, or significant change in condition, as required by Section 350.1220(m) of this Part.

 

f)         Telephone orders shall be transcribed into the resident's medical record or a telephone order form and signed by the nurse taking the order, as described in Section 350.1420(a) of this Part.

 

g)         Documentation of the monthly review of the medical record shall be entered in to the resident's medical record as described in Section 350.1420(b) of this Part.

 

h)         Instances of inability to implement a physician's medication order shall be noted in the resident's medical record, as described in Section 350.1430(d) of this Part.

 

i)          The resident's medical record shall include notations indicating any release of medications to the resident or person responsible for the resident's care, as described in Section 350.1420(e) of this Part.

 

j)          Medication errors and drug reactions shall be noted in the resident's medical record as described in Section 350.1430(e) of this Part.

 

k)         The resident's record shall include the physician's diet order and observations of the resident's response to the diet, as described in Section 350.1840 of this Part.

 

l)          The resident's record shall contain any physician determinations that limit the resident's access to the resident's personal property, as described in Section 350.3210(b) of this Part.

 

m)        The facility shall comply with Section 350.3210(g) of this Part, which requires that any medical inadvisability regarding married residents residing in the same room be documented in the resident's record.

 

n)         The facility shall permit each resident, resident's parent, guardian or representative to inspect and copy the resident's medical records as provided by Section 350.3220(g) of this Part.

 

o)         Any resident transfer or discharge mandated by the physical safety of other residents shall be documented in the resident's medical record as required by Sections 350.3300(d) and (g) of this Part.

 

p)         Summaries of discussions and explanations of any planned involuntary transfers or discharges shall be included in the medical record of the resident that is to be involuntarily transferred or discharged, as described in Section 350.3300(j) of this Part.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1670  Staff Responsibility for Medical Records

 

The facility shall designate a staff member who is skilled in record maintenance and preservation to be responsible for maintaining and preserving medical records.  If the designated person is not a health information management consultant as defined in Section 350.330, then the designated person shall receive consultation from a health information management consultant in order to meet the medical record requirements of this Part.

 

(Source:  Amended at 26 Ill. Reg. 10611, effective July 1, 2002)

 

Section 350.1680  Retention of Facility Records

 

The facility shall retain the records referenced in this Section for a minimum of three years.  It is suggested that the administrator check with legal counsel regarding the advisability of retaining records for a longer period of time, and the procedures to be followed in the event the facility ceases operation.  The records for which this requirement applies are as follows:

 

a)         The annual financial statement described in Section 350.210 of this Part.

 

b)         The minutes of resident advisory council meetings required by Section 350.650(j) of this Part.

 

c)         The records of in-service training required by Section 350.670(b)(3) of this Part.

 

d)         Copies of reports of serious incidents or accidents involving residents required by Section 350.700 of this Part.

 

e)         Records of the emergency medication kit review by the pharmaceutical advisory committee required by Section 350.1410(i)(3) of this Part.

 

f)         The reports of findings and recommendations from consultants required in Section 350.1690(a) of this Part.

 

g)         Copies of the quarterly reports for all employees that are filed for Social Security and Unemployment Compensation as required by Section 350.1690(d) of this Part.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1690  Other Facility Record Requirements

 

a)         The facility shall maintain a file of reports of findings and recommendations from consultants.  Each report shall be dated and indicate each specific date and time the consultant was in the facility.

 

b)         The facility shall complete the Illinois Department of Public Health Annual Long Term Care (LTC) Facility Survey.

 

c)         The facility shall maintain a permanent chronological resident registry showing date of admission, name of resident and date of discharge or death.

 

d)         The facility shall make available to the Department upon request copies of the quarterly reports for all employees that are filed for Social Security and Unemployment Compensation.

 

e)         Rules located in other Sections of this Part that pertain to the content and maintenance of facility records are as follows:

 

1)         The facility shall file an annual financial statement as described in Section 350.210 of this Part.

 

2)         Records and daily time schedules shall be kept on each employee as set forth in Section 350.670(a) and (b) of this Part.

 

3)         The facility shall maintain a controlled substances record as described in Section 350.1450(d) of this Part.

 

4)         Menu and food purchase records shall be maintained as set forth in Section 350.1880(d) and (f) of this Part.

 

5)         The facility shall maintain a file of all reports of serious incidents or accidents involving residents as required by Section 350.700 of this Part.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

SUBPART I: FOOD SERVICE

 

Section 350.1810  Director of Food Services

 

a)         A full-time person, qualified by training and experience, shall be responsible for the total food and nutrition services of the facility.  This person shall be on duty for a minimum of 40 hours each week.

 

1)         This person shall be either a dietitian or a dietetic service supervisor.

 

2)         The person responsible for the food service may assume some cooking duties but only if these duties do not interfere with the responsibilities of management and supervision.

 

b)         A minimum of eight hours of consulting time per month shall be provided for facilities with 50 or fewer residents.  An additional  four minutes of consulting time per month shall be provided per resident over 50 residents, based on the average daily census for the previous year.

 

(Source:  Amended at 23 Ill. Reg. 7970, effective July 15, 1999)

 

Section 350.1820  Dietary Staff in Addition to Director of Food Services

 

There shall be sufficient number of food service personnel employed and on duty to meet the dietary needs of all persons eating meals in the facility.  Their working hours shall be scheduled to meet the total dietary needs of the residents.  All dietary employees' time schedules and work assignments shall be posted in the kitchen. Dietary duties and job procedures shall be available in the dietary department for employees' knowledge and use.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1830  Hygiene of Dietary Staff

 

Food service personnel shall be in good health.  Food service personnel shall practice hygienic food handling techniques and good personal grooming.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1840  Diet Orders

 

a)         Two or more copies of a current diet manual shall be available and in use.  One copy shall be located in the kitchen for use by dietary personnel. Other copies shall be located at each nurses' station for use by physicians or dietitians when writing diet orders.

 

b)         Physicians shall write a diet order for each resident indicating whether the resident is to have a general or a therapeutic diet.  The attending physician may delegate the task of writing a diet order to the dietitian.

 

1)         The resident's diet order shall be included in the medical record.

 

2)         The diet shall be served as ordered.

 

c)         A written diet order shall be sent to the food service department when each resident is admitted and each time that the resident's diet is changed.  Each change shall be ordered by the physician or dietitian.  The diet order shall include, at a minimum, the following information:  name of resident, room and bed number, type of diet, consistency if other than regular consistency, date diet order is sent to the food service department, name of physician or dietitian ordering the diet, and the signature of the person transmitting the order to the food service department.

 

d)         The resident shall be observed to determine acceptance of the diet, and these observations shall be recorded in the medical record.

 

e)         A therapeutic diet means a diet ordered by the physician or dietitian as part of a treatment for a disease or clinical condition, to eliminate or decrease certain substances in the diet (e.g., sodium) or to increase certain substances in the diet (e.g., potassium), or to provide food in a form that the resident is able to eat (e.g., mechanically altered diet).

 

f)         The kinds and variations of prescribed therapeutic diets shall be available in the kitchen.  If separate menus are not planned for each specific diet, diet information for each specific type, in a form easily understood by staff, shall be posted in a convenient location in the kitchen.

 

g)         All oral liquid diets shall be reviewed by a physician or dietitian every 48 hours.  Medical soft diets, sometimes known as transitional diets, shall be reviewed by a physician or dietitian every three weeks.  All other therapeutic and mechanically altered diets, including commercially prepared formulas that are in liquid form and blenderized liquid diets, shall be reviewed by a physician or dietitian as needed, or at least every three months.

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.1850  Meal Planning

 

Each resident shall be served food to meet the resident's needs and to meet physician's orders. The facility shall use this Section to plan  menus and purchase food in accordance with the following Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences.

 

a)         Milk and Milk Products Group:  16 ounces or more of Grade A whole or low fat pasteurized milk where milk is used for fluid consumption.  Calcium equivalents for 8 ounces of milk:

 

1)         1 ½ ounces natural cheese,

 

2)         Two ounces processed cheese,

 

3)         One cup yogurt or one cup frozen yogurt,

 

4)         One cup cottage cheese, or

 

5)         1 ½ cups ice cream or ice milk.

 

b)         Meat Group:  A total of 6 ounces (by weight) of good quality protein to provide 38 to 42 grams of protein daily.  To ensure variety, food items repeated within the same day shall not be counted as meeting a required serving. The following are examples of one serving:

 

1)         Three ounces (excluding bone, fat and breading) of any cooked meat such as whole or ground beef, veal, pork or lamb; poultry; organ meats such as liver, heart, kidney; prepared luncheon meats.

 

2)         Three ounces (excluding skin and breading) of cooked fish or shell fish or 1/2 cup canned fish.

 

3)         Three ounces of natural or processed cheese or 3/4 cup cottage cheese.

 

4)         Three eggs (minimum weight 2l ounces per dozen, considered a medium egg).

 

            NOTE:  If one egg is served at a meal, a protein food of good quality may be reduced from six to five ounces for the remaining meals. If two eggs are served at a meal, a minimum of two ounces of good quality protein shall be served at each of the remaining meals.

 

5)         1 ½ cups cooked dried peas or beans, six tablespoons of peanut butter, or one cup nuts, not more than twice a week and provided eggs, milk or lean meat are served at the same meal.

 

6)         Three ounces of soy protein containing not less than 21 grams of protein or in combination with other sources of quality protein to equal 21 grams of protein, provided that it is acceptable to the resident population.

 

7)         Combinations of all above examples are acceptable, provided that the minimum of six ounces of a good quality protein food is served daily and provided that the combinations do not conflict with eye appeal or palatability.

 

8)         The content of meat alternative products shall be listed on the menu.

 

c)         Vegetable and Fruit Group:  Five or more servings of fruits or vegetables.

 

1)         A serving consists of:

 

A)        ½ cup chopped raw, cooked, canned, or frozen fruit or vegetables;

 

B)        ¾ cup fruit or vegetable juice; or

 

C)        One cup raw leafy vegetable.

 

2)         The five or more servings shall consist of:

 

A)        Sources of vitamin C

 

i)          One serving of a good source of vitamin C (containing at least 60 mg of vitamin C); or

 

ii)         Two servings of a fair source of vitamin C. This may be more than one food item and shall contain a total of at least 65 mg of vitamin C.

 

B)        One serving of a good source of vitamin A at least three times a week supplying at least 1000 micrograms retinol equivalent (RE) of vitamin A.

 

C)        Other fruits and vegetables, including potatoes, that may be served in ⅓ cup or larger portions.

 

3)         To ensure variety, food items repeated within the same day shall not be counted as meeting a required serving.

 

d)         Bread, Cereal, Rice and Pasta Group:  Six or more servings of whole grain, enriched or restored products.  One serving equals:

 

1)         One slice of bread,

 

2)         ½ cup of cooked cereal, rice, pasta, noodles, or grain product,

 

3)         ¾ cup of dry, ready-to-eat cereal,

 

4)         ½ hamburger or hotdog bun, bagel or English muffin,

 

5)         One 4-inch diameter pancake,

 

6)         One tortilla,

 

7)         Three to four plain crackers (small),

 

8)         ½ croissant (large), doughnut or danish (medium),

 

9)         1/16 cake,

 

10)       Two cookies, or

 

11)       1/12 pie (2-crust, 8").

 

e)         Butter or Margarine:  To be used as a spread and in cooking.

 

f)         Other foods shall be served to round out meals, satisfy individual appetites, improve flavor, and meet the individual's nutritional and caloric needs.

 

g)         Meals for the day shall be planned to provide a variety of foods, variety in texture and good color balance.  The following meal patterns shall be used.

 

1)         Three meals a day plan

 

A)        Breakfast: Fruit or juice, cereal, meat (optional, but three to four times per week preferable), bread, butter or margarine, milk, and choice of additional beverage.

 

B)        Main Meal (may be served noon or evening): Soup or juice (optional), entree (quality protein), potato or potato substitute, vegetable or salad, dessert (preferably fruit unless fruit is served as a salad or will be served at another meal), bread, butter or margarine, and choice of beverage.

 

C)        Lunch or Supper: Soup or juice (optional), entree  (quality protein), potato or potato substitute (optional if served at main meal), vegetable or salad, dessert, bread, butter or margarine, milk, and choice of additional beverage.

 

2)         Other meal patterns may be used if facilities are able to meet residents' needs using such plans.

 

(Source:  Amended at 23 Ill. Reg. 7970, effective July 15, 1999)

 

Section 350.1860  Therapeutic Diets (Repealed)

 

(Source:  Repealed at 23 Ill. Reg. 7970, effective July 15, 1999)

 

Section 350.1870  Scheduling Meals

 

a)         A minimum of three meals or their equivalent shall be served daily at regular times with no more than a 14 hour span between a substantial evening meal and breakfast.  The 14 hour span shall not apply to facilities using the "four or five meals-a-day" plan, provided the evening meal is substantial and includes, but is not limited to, a good quality protein, bread or bread substitute, butter or margarine, a dessert and a nourishing beverage.

 

b)         Bedtime snacks of nourishing quality shall be offered.  Snacks of nourishing quality shall be offered between meals when there is a time span of four or more hours between the ending of one meal and the serving of the next, or as otherwise indicated in the resident's plan of care.

 

c)         If a resident refuses food served, reasonable and nutritionally appropriate substitutions shall be served.

 

(Source:  Amended at 16 Ill. Reg. 13910, effective September 1, 1992)

 

Section 350.1880  Menus and Food Records

 

a)         Menus, including menus for "sack" lunches or between meal or bedtime snacks, shall be planned at least one week in advance.  Food sufficient to meet the nutritional needs of all the residents shall be prepared for each meal.  When changes in the menu are necessary, substitutions shall provide equal nutritive value and shall be recorded on the original menu, or in a notebook marked "Substitutions", that is kept in the kitchen.  If a notebook is used to document substitutions, it shall include the date of the substitution; the meal at which the substitution was made; the menu as originally written; and the menu as actually served.

 

b)         The menu for the current week shall be dated and available in the kitchen.  Upon the request of the Department, sample menus shall be submitted for evaluation.

 

c)         Menus shall be different for the same day of consecutive weeks and adjusted for seasonal differences.

 

d)         All menus as actually served shall be kept on file at the facility for not less than 30 days.

 

e)         Supplies of staple food for a minimum of a one week period and of perishable foods for a minimum of a two day period shall be maintained on the premises.  These supplies shall be appropriate to meet the requirements of the menu.

 

f)         Records of all food purchased shall be kept on file in the facility for not less than 30 days.

 

g)         Food label information for purchased prepared food listing food composition and, when available, nutrient content shall be kept on file in the facility for the current menu cycle.

 

(Source:  Amended at 23 Ill. Reg. 7970, effective July 15, 1999)

 

Section 350.1890  Food Preparation and Service

 

a)         Food shall be prepared by appropriate methods that will conserve their nutritive value, enhance their flavor and appearance. They shall be prepared according to standardized  recipes and a file of such recipes shall be available for the cook's use.

 

b)         Foods shall be attractively served at the proper temperatures and in a form to meet individual needs.  (B)

 

c)         All residents shall be served in a dining room or a multipurpose room except for an individual with a temporary illness, who is too ill, or for other valid reasons.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1900  Food Handling Sanitation

 

Every facility shall comply with the Department's rules entitled "Food Service Sanitation" (77 Ill. Adm. Code 750).

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.1910  Kitchen Equipment, Utensils, and Supplies

 

Each facility shall provide an adequate number of dishes, glassware, and silverware of a satisfactory type to serve all the residents in the facility at each meal.

 

(Source:  Amended at 14 Ill. Reg. 14876, effective October 1, 1990)

SUBPART J: MAINTENANCE, HOUSEKEEPING AND LAUNDRY

 

Section 350.2010  Maintenance

 

a)         Every facility shall have an effective written plan for maintenance, including sufficient staff, appropriate equipment, and adequate supplies. Each facility shall: (B)

 

1)         Maintain the building in good repair safe and free of the following:  cracks in floors, walls, or ceilings; peeling wallpaper or paint; warped or loose boards; warped, broken, loose, or cracked floor covering, such as tile or linoleum; loose handrails or railings; loose or broken window panes; and any other similar hazards.  (B)

 

2)         Maintain all electrical, signaling, mechanical, water supply, heating, fire protection, and sewage disposal systems in safe, clean and functioning condition.  This shall include regular inspections of these systems.  (A, B)

 

3)         Maintain all electrical cords and appliances in a safe and functioning condition.  (B)

 

4)         Maintain the interior and exterior finishes of the building as needed to keep it attractive and clean and safe (painting and washing and other types of maintenance).

 

5)         Maintain all furniture and furnishings in a clean, attractive, and safely repaired condition.

 

6)         Maintain the grounds and other buildings on the grounds in a safe, sanitary and presentable condition.  (B)

 

7)         Maintain the grounds free from refuse, litter, insect and rodent breeding areas.

 

8)         The building and grounds shall be kept free of any possible infestations of insects and rodents by:  eliminating sites of breeding and harborage inside and outside the building; eliminating sites of entry into the building with screens of not less than 16 mesh to the inch and repair of any breaks in construction.  (B)

 

b)         Each facility shall maintain all plumbing fixtures and piping in good repair and properly functioning. Protect the potable water supply from contamination by providing and properly installing adequate, backflow protection devices or providing adequate air gaps on all fixtures that may be subject to backflow or back siphonage.

 

(Source:  Amended at 14 Ill. Reg. 14876, effective October 1, 1990)

 

Section 350.2020  Housekeeping

 

a)         Every facility shall have an effective plan for housekeeping including sufficient staff, appropriate equipment, and adequate supplies.  Each facility shall:  (B)

 

1)         Keep the building in a clean, safe, and orderly condition.  This includes all rooms, corridors, attics, basements, and storage areas.  (B)

 

2)         Keep floors clean and as non-slip as possible.  Throw rugs or scatter rugs with non-slip type backings may be utilized if they do not constitute a serious tripping hazard.

 

3)         Control odors within the housekeeping staff's areas of responsibility by effective cleaning procedures and by the proper use of ventilation systems.  Deodorants shall not be used to cover up persistent odors caused by unsanitary conditions or poor housekeeping practices.

 

b)         Attics, basements, stairways, and similar areas shall be kept free of accumulations of refuse, discarded furniture, old newspapers, boxes, discarded equipment, and other items.  (B)

 

c)         Bathtubs, shower stalls, and lavatories shall not be used for laundering, janitorial, or storage purposes.

 

d)         All cleaning compounds, insecticides, and all other potentially hazardous compounds or agents shall be stored in locked cabinets or rooms.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2030  Laundry Services

 

a)         Every facility shall have an effective means of supplying an adequate amount of clean linen for operation, either through an in-house laundry or a contract with an outside service.

 

1)         An adequate supply of clean linen shall be defined as the three sets of sheets, draw sheets, and pillow cases required to provide for the residents' needs.  Additional changes of linen may be required in consideration of laundering and transporting soiled linens.  If an in-house laundry service is provided, then the following conditions shall exist:

 

2)         The laundry area shall be maintained and operated in a clean, safe and sanitary manner.  No part of the laundry shall be used as a smoking or dining area.

 

3)         Written operating procedures shall be developed, posted and implemented which provide for the handling, transport and storage of clean and soiled linens.

 

4)         Laundry personnel must be in good health and practice good personal grooming.  Employees must thoroughly wash their hands and exposed portions of their arms with soap and warm water before starting work, during work as often as necessary to keep them clean and after smoking, eating, drinking, using the toilet and handling soiled linens.

 

5)         Clean linen shall be protected from contamination during handling, transport and storage.

 

6)         Soiled linen shall be handled, transported and stored in a manner that protects facility residents and personnel.

 

7)         If supplies and equipment not directly connected with the operation of the laundry are stored in the laundry or its accessory storage and handling areas, they shall be protected from contamination by the soiled linens and shall not contribute to contamination of the clean linens.

 

b)         If an outside laundry service is used, it shall comply with the requirements of in-house laundries and, in addition, shall provide for protection of clean linens during transport back to the facility.

 

c)         If the facility provides laundry service for residents' personal clothing, it must be handled, transported and stored in a manner that will not allow contamination of clean linen or allow contamination by soiled linen.  The facility shall assure that the personal clothing of each resident is returned to that individual resident after laundering.

 

(Source:  Amended at 14 Ill. Reg. 14876, effective October 1, 1990)

SUBPART K: FURNISHINGS, EQUIPMENT, AND SUPPLIES

 

Section 350.2210  Furnishings

 

a)         Each resident shall be provided with a separate bed suitable to meet the needs of the resident.  Each bed shall be at least 36 inches wide, have a headboard, be of sturdy construction and in good repair.  A double bed shall be provided for married couples if they request this arrangement, and there are no medical contraindications.  Double beds shall be provided for married couples at their request.

 

b)         Each bed shall be provided with satisfactory type springs in good repair and a clean, firm, comfortable mattress of appropriate size for the bed.

 

c)         Each bedroom shall have window shades, or equivalent, in good repair.

 

d)         A satisfactory reading lamp, or equivalent, shall be provided for each bed.

 

e)         Each bed shall be provided with a minimum of one clean, comfortable pillow. There shall be additional pillows available in the home to satisfactory serve the needs of the residents.

 

f)         Each bedroom shall be provided with a mirror, unless there is a mirror in a bathroom opening into this bedroom.  Each lavatory shall be provided with a mirror.

 

g)         Each living room for residents' use shall be provided with an adequate number of reading lamps, tables, and chairs or settees.  These furnishings shall be well constructed and of satisfactory design for the residents.

 

h)         Dining room furnishings shall be provided for each resident which are well constructed, comfortable, in good repair, and of satisfactory design for the residents. There shall be a sufficient number of tables, of a type that can be used by wheelchair residents, to accommodate all such residents in the facility.

 

i)          Office spaces, nurses' stations, treatment rooms, and other areas shall be satisfactorily furnished with desks, chairs, lamps, cabinets, benches, work tables, and other furnishings essential to the proper use of the area.

 

j)          For each bed there shall be furnished:

 

1)         A minimum of two adequately sized dresser drawers.

 

2)         A comfortable chair.

 

3)         An individual towel rack.

 

4)         A satisfactory reading light over, or at the side of, the bed.

 

5)         Adequate closet, locker, or wardrobe space for hanging clothing within the room.

 

6)         A satisfactory bedside cabinet or table.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2220  Equipment and Supplies

 

a)         The facility shall have a supply of thermometers, emesis basins, ice bags, hot water bottles or equivalent, bedpans, urinals, and sets of enema equipment sufficient to meet the needs of its residents.  (B)

 

b)         There shall be at least one privacy screen available in the facility for emergency use when resident privacy is needed.

 

c)         There shall be a sufficient supply of linen and bedding in good condition to provide proper care and comfort to the residents. (B)

 

d)         There shall be a first-aid kit or emergency box in every facility. This shall contain bandages, sterile gauze dressing, bandage scissors, tape, sling, burn ointment, and other equipment deemed necessary by the advisory physician or the medical advisory committee.  (B)

 

e)         Activity program supplies shall be provided to maintain an ongoing program to meet the varied interests and needs of the residents.  These shall include, but are not limited to, age-appropriate games, craft supplies, current magazines, books, radio, television, and record player.  A piano or organ is recommended as an important adjunct to the activity program equipment.

 

f)         Dishes and kitchen equipment shall be provided as set forth in Section 350.1900 and 350.1910.

 

g)         Cleaning equipment and supplies shall be provided as set forth in Subpart J: Maintenance, Housekeeping and Laundry.

 

h)         There shall be special equipment, implements, or utensils provided to residents as needed to assist them when eating.  (B)

 

(Source:  Amended at 14 Ill. Reg. 14876, effective October 1, 1990)

SUBPART L: WATER SUPPLY AND SEWAGE DISPOSAL

 

Section 350.2410  Codes

 

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

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2420  Water Supply

 

a)         Each facility shall be served by water from a municipal public water supply when available.  (B)

 

b)         When a municipal water supply is not available, the water supply shall comply with the Department's rules entitled "Drinking Water Systems" (77 Ill. Adm. Code 900).  (B)

 

c)         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 Department's rules entitled "Illinois Water Well Construction Code" (77 Ill. Adm. Code 920) and "Water Well Pump Installation Code" (77 Ill. Adm. Code 925).

 

d)         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.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2430  Sewage Disposal

 

a)         All sewage and liquid wastes shall be discharged into a public sewage system when available.  (B)

 

b)         When a public sewage system is not available, sewage and liquid wastes shall be collected, treated, and disposed of in a private sewage disposal system.  The design, construction, maintenance, and operation of the system shall comply with the Department's rules entitled "Private Sewage Disposal Code" (77 Ill. Adm. Code 905).  (B)

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2440  Plumbing

 

Each plumbing system shall comply with the Department's rules entitled "Illinois Plumbing Code" (77 Ill. Adm. Code 890) effective at the time of construction or approved acceptance by the Department.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

SUBPART M: CONSTRUCTION STANDARDS FOR NEW INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED

 

Section 350.2610  Applicability of These Standards

 

a)         These standards shall apply to all new Long-Term Care Facilities and major alterations and additions to existing Long-Term Care Facilities. (Major alterations are those that are not defined as minor alterations in Section 350.2610(f) of this Part.)  Long-Term Care Facilities contemplating construction shall contact the Health Facilities Planning Board for information concerning the current requirements. Projects for which working drawings and specifications have received final approval by the Department prior to the promulgation of these Standards are subject only to those Standards that were in effect at the time that the final approval was given.

 

b)         When construction is contemplated, either for new buildings or additions or major alterations to existing buildings coming within the scope of these standards, design development drawings and outline specifications shall be submitted to the Department for review.  Approval of design development drawings and specifications shall be obtained from the Department prior to starting final working drawings and specifications.  Comments or approval will be provided within 30 days of receipt by the Department.

 

c)         The final working drawings and specifications shall be submitted to the Department for review and approval prior to beginning of construction.  For final approval to remain valid, contracts must be signed within one year of the date of final approval.  Alternate methods of design development and construction such as fast track may be acceptable subject to the approval of the Department.  Comments of approval will be provided within 30 days of receipt by the Department.

 

d)         Any contract modifications which affect or change the function, design, or purpose of a facility shall be submitted to the Department for approval prior to authorizing the modifications.  Comments or approval will be provided within 30 days of receipt by the Department.

 

e)         The Department shall be notified at least 30 days before construction has been completed.  The Department will then complete a final inspection. Deficiencies noted during the final inspection must be completed before occupancy will be allowed.

 

f)         Minor alterations or remodeling changes which do not affect the structural integrity of the building, which do not change functional operation, which do not affect fire safety, and which do not add beds or facilities over those for which the Long-Term Care Facility is licensed need not be submitted for drawing approval.  However, the Health Facilities Planning Board requirements must be met for all alterations and remodeling projects.

 

g)         No system of water supply, plumbing, sewage, garbage or refuse disposal shall be installed, nor any such existing system materially altered or extended until complete plans and specifications for the installation, alteration or extension have been submitted to the Department and have been reviewed and approved.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2620  Codes and Standards

 

a)         Each facility shall comply with the applicable provisions of the following codes and standards:

 

1)         State of Illinois rules

 

A)        Illinois Plumbing Code, Department of Public Health

 

B)        Illinois Accessibility Code, Capital Development Board

 

C)        Food Code, Department of Public Health

 

D)        Boiler and Pressure Vessel Safety, Office of the State Fire Marshal

 

2)         Codes and standards

 

A)        NFPA 101: Life Safety Code, Chapter 18, and excluding Chapter 5, Performance Based Options, and all other references to performance-based options.  NFPA 101A:  Guide on Alternative Approaches to Life Safety shall not be allowed to establish equivalencies for new construction.  In addition to the publications referenced in Chapter 2, NFPA 99:  Health Care Facilities shall be applicable for all long-term care facilities.

 

B)        Underwriters Laboratories, Inc. (UL)

 

i)          Fire Resistance Directory

 

ii)         Building Material Directory

 

C)        American Society for Testing and Materials (ASTM), Standard E90-09, Standard Test Method for Laboratory Measurement of Airborne Sound Transmission Loss of Building Partitions and Elements

 

D)        American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE):

 

i)          Handbook of Fundamentals

 

ii)         Handbook of Applications

 

E)        International Building Code (IBC)

 

F)         American Society of Mechanical Engineers (ASME) International: ANSI/ASME Standard A17.1, Safety Code for Elevators and Escalators

 

G)        ANSI/ASHRAE/ASHE Standard 170-2008, Ventilation of Health Care Facilities, which may be accessed at:  http://sspc170.ashraepcs.org/pdf/170_2008_FINAL.pdf

 

b)         In addition to compliance with the standards set forth herein, all building codes, ordinances and regulations that are enforced by city, county or other local jurisdictions in which the facility is, or will be, located shall be observed.

 

c)         Where no local building code exists, the recommendations of the International Building Code shall apply.

 

d)         The local building code or the recommendations of the International Building Code shall apply insofar as its recommendations are not in conflict with the standards set forth in this Part, or with the NFPA 101.

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.2630  Preparation of Drawings and Specifications

 

a)         The preparation of drawings and specifications shall be executed by or be under the immediate supervision of an architect registered in the State of Illinois.

 

b)         The first submission shall be the design development drawings indicating in detail the assignment of all spaces, size or areas and rooms, and indicating in outline, the fixed and movable equipment and furniture.

 

c)         The plans shall be drawn at a scale sufficiently large to clearly present the proposed design.

 

d)         The drawing shall include:

 

1)         a plan of each floor including the basement or ground floor,

 

2)         roof plan,

 

3)         plot plan showing roads, parking areas, and sidewalks,

 

4)         elevations of all facades,

 

5)         sections through the building,

 

6)         identification of all fire and smoke compartmentation.

 

e)         Outline specifications shall provide a general description of the construction including finishes; acoustical material, floor covering; heating and ventilating systems; description of the electrical system including the emergency electrical system and the type of elevators.

 

f)         The total gross floor area and bed count shall be shown on the drawings.

 

g)         A brief narrative of the proposed program shall be submitted with the preliminary drawings and outline specifications.

 

h)         Following approval of the design development drawings and specifications, working drawings and specifications shall be submitted.  All working drawings shall be well prepared and clean and distinct prints submitted.  Drawings shall be accurately dimensioned and include all necessary explanatory notes, schedules and legends. Working drawings shall be complete and adequate for contract purposes.  Drawings shall be prepared for each of the following branches of work:  Architectural, Structural, Mechanical, Electrical and Plumbing.

 

1)         The architectural drawings shall show:

 

A)        Site plan showing all topography, newly established levels and grades, existing structures on the site (if any), new buildings and structures, roadways, walks, and the extent of the areas to be landscaped.  All structures which are to be removed under the construction contract shall be shown.

 

B)        Plan of each floor and roof.

 

C)        Elevation of each facade.

 

D)        Sections through building.

 

E)        Elevators and dumbwaiters.  Drawings delineating shaft details and dimensions, sizes of cab platforms and doors, travel distances including elevation height of landings, pit sizes, and machine rooms.

 

F)         Kitchen, laundry, clean and soiled utility room, special care areas, and similar areas shall be detailed at a scale to show the locations, type, size and connection of all fixed and movable equipment.

 

G)        Scale details as necessary; at a scale sufficiently large to properly indicate details of the work.

 

H)        Schedule of finishes.

 

2)         The structural drawings shall show:

 

A)        Plans of foundations, floors, roofs and all intermediate levels shall show the complete design with sizes, sections, and the relative location of the various members including:

 

B)        Schedule of beams, girders and columns.

 

C)        Notes on design data shall include the name of the governing building code, values of allowable unit stresses, assumed live loads, wind loads, earthquake load, and soil bearing pressures.

 

D)        Details of special connections, openings, pipe sleeves and expansion joints.

 

E)        Special structures shall include calculations defining load assumption, shear and moment diagrams and horizontal and vertical reactions.

 

3)         Mechanical drawings with specifications shall show the complete heating, cooling and ventilation systems; plumbing, drainage, stand pipe, and sprinkler systems.

 

A)        Heating, Cooling and Ventilation.

 

i)          Pumps, tanks, boilers and piping and boiler room accessories.

 

ii)         Air conditioning systems with required equipment, water and refrigerant piping, and ducts.

 

iii)        Supply and exhaust ventilating systems with connections and piping.

 

iv)        Air quantities for all rooms including supply and exhaust ventilating duct openings.

 

B)        Plumbing, Drainage and Stand Pipe Systems.

 

i)          Size and elevation of:  street sewer, house sewer, house drains, street water main and water service into the building.

 

ii)         Location and size of soil, waste, and vent stacks with connections to house drains, cleanouts, fixtures and equipment.

 

iii)        Size and location of hot, cold and circulating mains, branches, and risers from the service entrance, and tanks.

 

iv)        Riser diagram of all plumbing stacks with vents, water risers and fixture connections.

 

v)         Fuel and similar piped systems.

 

vi)        Stand pipe and sprinkler systems.

 

vii)       All fixtures and equipment that require water and drain connections.

 

4)         Electrical drawings shall show all electrical wiring, outlets, and equipment which require electrical connections.

 

A)        Electrical service entrance with switches and feeders to the public service feeders, characteristics of the light and power current, transformers and their connections.

 

B)        Location of main switchboard, power panels, light panels and equipment. Feeder and conduit sizes shall be shown with schedule of feeder breakers or switches.

 

C)        Light outlets, receptacles, switches, power outlets, and circuits.

 

D)        Telephone layout showing service entrance, telephone switchboard, strip boxes, telephone outlets and branch conduits as approved by the telephone company.  Where public telephones are used for inter-communication, provide separate room and conduits for racks and automatic switching equipment as required by the telephone company.

 

E)        Fire alarm system with stations, signal devices, control board and wiring diagrams.

 

F)         Emergency electrical system with outlets, transfer switch, source of supply, feeders, and circuits.

 

G)        All other electrically operated systems and equipment.

 

5)         When the project is an addition, details and information on the existing building shall be provided as follows:

 

A)        Type of activities within the existing building and distribution of existing beds

 

B)        Type of construction of existing building and number of stories in height.

 

C)        Plans and details showing attachment of new construction to the existing structure.

 

D)        Mechanical and Electrical systems showing connections to the existing system.

 

E)        The Department may require submission of drawings of all or any part of the existing structure.

 

6)         Specifications shall supplement the drawings and shall:  Describe, except where fully indicated and described on the drawings, the materials, workmanship, kind, sizes, capacities, finishes, and other characteristics of all materials, products, articles and devices.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2640  Site

 

a)         The facility shall be located on a reasonably flat or rolling, well drained site that is not subject to flooding; reasonably free from sources of excessive noise, noxious or hazardous smoke or fumes; not in deteriorated, unpleasant, or potentially hazardous area; and not near uncontrolled sources of insect and rodent breeding.

 

b)         The facility shall be  located so that the building or buildings can comply with all applicable local zoning ordinances, building restrictions and fire safety requirements. The Department may have additional requirements if the proposed locations of the building or buildings on the site would result in a hazard to or be detrimental to the health, welfare, or safety of the residents in the facility.

 

c)         The facility shall be located in or near a community which can provide the necessary supportive services for the home such as physician's services, social services, transportation, recreation, religious services, work, medical facilities, public utilities, or other acceptable substitutes; and be located on a well-maintained, all-weather road.  In those instances where the community does not provide these services, the facility shall do so.

 

d)         The facility shall be served by a potable water supply with water pressure and volume that is acceptable to the Department.  (B)

 

e)         The distance from the fire station, the accessibility of the facility, and capability of the fire department must be approved in writing by the Office of the State Fire Marshal.  (B)

 

f)         The facility shall have at least one municipal or private fire hydrant, located within 300 feet of every point on the perimeter of the building and satisfactory for use by the equipment of the fire department serving the building, or have an acceptable equivalent.  Additional hydrants may be required if needed to properly protect the residents from fire hazards.  Evaluation and written approval must be obtained from the Office of the State Fire Marshal.  (B)

 

g)         Plans showing the proposed building location must be submitted to the Illinois Department of Transportation, Division of Water Resources to determine compliance with Regulation of Construction within the State Flood Plain (92 Ill. Adm. Code 706) and Executive Order 79-4(c).

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2650  Administration and Public Areas

 

a)         Facilities for the physically handicapped (public, staff and residents) shall be provided in administration and public areas as well as in resident areas.

 

b)         Lobby shall include a reception and information counter or desk, waiting space and public telephones.  See the Department's rules entitled "Illinois Plumbing Code" (77 Ill. Adm. Code 890) for drinking fountain and toilet facilities requirements for staff and visitors.

 

c)         General or Individual Office shall have sufficient space to accommodate the following functions:  Administrative, Business/Financial Transactions, Professional Staff (Food Service Supervisor, Activity Director, and Social Service Director), and Professional Consultants (Dietitian and Social Worker).

 

d)         Multipurpose room shall be provided for conferences, meetings, interviews, and educational purposes.

 

e)         Provide adequate space for recording, reviewing and storing resident records.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2660  Nursing Unit

 

a)         The number of resident beds in a nursing unit shall not exceed 75 beds.  Not less than 60 percent of the resident beds shall be in  bedrooms with one or two beds.

 

b)         General Requirements for Bedrooms

 

1)         Resident bedrooms shall have an entrance directly off a corridor with an entrance door which swings into the room.

 

2)         Resident bedrooms shall have adequate and satisfactory artificial light and be equipped in accordance with Section 350.2740(d) and (c).

 

3)         Residents shall have access to a toilet room without entering the general corridor area.

 

4)         The facility shall provide a closet or wardrobe of at least six square feet for each resident.

 

5)         Resident bedroom floors shall be at or above grade level.

 

6)         Each room used as a resident bedroom shall have at least one outside window, and a total window area to the outside equal to at least one-tenth the floor area of the room.

 

7)         No resident bedroom shall be located more than 120 feet from the nurses' station, clean utility room, and soiled utility room.

 

c)         Resident Bedrooms

 

1)         Single resident bedroom shall contain at least l00 square feet. Multiple resident bedrooms shall contain at least 80 square feet per bed. Minimum usable floor area shall be exclusive of toilet rooms, closets, lockers, wardrobes, alcoves, vestibules, or clearly definable entryways.

 

2)         Multiple resident bedrooms shall not have more than four beds nor more than three beds deep from an outside wall.  All beds shall have a minimum clearance of three feet at the foot and sides of the bed.

 

d)         Special Care Room

 

1)         The facility shall provide a special care room for each 150 beds.

 

2)         This room shall be provided with a private toilet room containing water closet, lavatory, bathtub or shower and all other necessary facilities to meet the resident's needs.

 

3)         This room shall be located to allow direct visual supervision from the nurses' station.

 

4)         The room may be included in the authorized maximum bed capacity for the facility.  It is permissible for the room to be occupied by a resident, not in need of special care, provided the resident is clearly informed and understands he or she will be immediately transferred out of the room any time of day or night, whenever the room is needed to care for a resident requiring special care.

 

e)         Nurses' Station

 

1)         The facility shall provide a minimum of one station per floor with direct access to the corridor for each nursing unit.  The location of this station shall allow visual control of each resident room served without the use of mirrors. Separation shall be provided from the utility rooms.  (B)

 

2)         The nurses' station shall provide space for charting and storage for administrative supplies.  (B)

 

3)         A lounge with toilet room shall be provided near each station for nursing staff. Lockers for safekeeping of coats and personal effects may be provided within this space or in a convenient central location. (B)

 

f)         Bath and Toilet Rooms

 

1)         The resident bedroom toilet room shall serve no more than two resident rooms nor more than eight beds.  The toilet room shall contain a water closet and a lavatory.  The lavatory may be omitted from the toilet room when the resident room contains a lavatory.

 

2)         The facility shall provide one wheelchair resident toilet room for each sex residing in a nursing unit. The room shall be accessible from the corridor.  This room shall contain a water closet and lavatory.

 

3)         A special wheelchair resident toilet room is not required when all resident toilet rooms can accommodate wheelchair residents.

 

4)         The facility shall provide one training toilet room on each nursing floor that is accessible from the corridor.  Three-foot clearance at the front and both sides of the water closet shall be provided.  This room shall contain a lavatory accessible for wheelchair use.

 

5)         The facility shall provide one bathtub or shower for each ten resident beds per nursing unit which are not served by bathing or showering facilities in resident rooms.

 

6)         All shower stalls for residents not needing assistance shall be at least three feet square and shall have no curb.

 

7)         The facility shall provide at least one bathtub for assisted bathing per nursing unit. There shall be a clear area at least three feet wide at both sides and one end of the tub.

 

8)         The facility shall provide at least one shower stall for assisted showering per nursing unit.  The shower stall shall be at least four feet square with no curb.

 

9)         Provide a toilet room with a water closet and lavatory, accessible to the assisted bathtub and shower without entering the general corridor. This room may be arranged to serve as the training toilet facility.

 

10)         Grouped bathing and toilet facilities shall be partitioned or curtained for privacy.

 

g)         Utility Rooms

 

1)         The clean utility room shall have direct access to a corridor, or access may be through the nurses' station entrance.  This room shall contain work counters, single or double compartment sink with integral drainboard, storage cabinets, and an autoclave. (Autoclave may be waived in lieu of other methods if sterilization is approved by Department.)

 

2)         A clean linen storage room or closet within the clean utility room shall be provided. If a closed cart system is used, storage may be in an alcove.

 

3)         The soiled utility room shall have direct access to a corridor.  This room shall contain work counters, double compartment sink with integral drainboard, storage cabinets, a clinical rim flush sink, and sanitizer.

 

4)         The charging room for a linen chute shall be large enough to unload the collecting cart with the door closed.

 

h)         A medicine station shall be provided for convenient and prompt 24 hour distribution of medicine to residents.  The medicine station shall be under the nursing staff's visual control and contain a work counter, refrigerator, and locked storage for biologicals and drugs.  A sink for handwashing and preparation of medication shall be provided in the medicine station.

 

i)          A nourishment station shall be provided with a handwashing sink and equipment including refrigerator, and storage cabinets for serving nourishment between scheduled meals.  Ice for residents' use shall be provided only by icemaker dispenser units.

 

j)          A room for examination and treatment of residents shall be provided and shall have a minimum floor area of 100 square feet, excluding space for vestibule, closets and work counters (whether fixed or movable). The minimum room dimension shall be ten feet.  The room shall contain a lavatory or sink equipped for handwashing; a work counter; storage facilities; and a desk, counter, or shelf space for writing.

 

k)         Equipment storage rooms shall be provided for storage of equipment such as I.V. stands, inhalators, air mattresses, walkers, and wheelchairs.

 

l)          Parking space for wheelchairs shall be provided and located out of path of normal traffic.

 

(Source:  Amended at 18 Ill. Reg. 1432, effective January 14, 1994)

 

Section 350.2670  Dining, Living, Activities Rooms

 

a)         The combined area of these rooms shall not be less than 40 square feet per resident bed.

 

b)         Provide a minimum of one dining room with at least ten square feet per resident bed.

 

c)         Provide a minimum of one comfortably furnished living room on each floor in multiple story buildings having a total window area of at least one-tenth the floor area.

 

d)         Provide activities room based on program requirements.  This room may be combined with the living or dining room.

 

e)         Locate these rooms so that they are not an entrance vestibule from the outside.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2680  Therapy and Personal Care

 

a)         Physical and occupational therapy facilities shall be provided as required by the approved program.

 

b)         A separate room shall be provided with appropriate equipment for hair care and grooming needs of the residents.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2690  Service Departments

 

a)         Dietary facilities shall comply with the standards specified in the Department's rules entitled "Food Service Sanitation" (77 Ill. Adm. Code 750).  Food service facilities shall be designed and equipped to meet the requirements of the Narrative Program.  These may consist of an on-site conventional food preparing system, a convenience food service system, or an appropriate combination of the two.  (B)

 

b)         The kitchen consisting of food preparation, cooking, and serving areas, shall be approximately ten square feet per resident bed with a minimum area of at least 200 square feet.  It shall be properly located for efficient food service, and be large enough to accommodate the equipment and personnel needed to prepare and serve the number of meals required.  (B)

 

c)         The following facilities shall be provided as required to implement the type of food service selected:

 

1)         A control station shall be provided for receiving food supplies.

 

2)         Storage space shall be adequate to provide normal and emergency supply needs, approximately two and one-half square feet per patient bed, for bulk and daily food storage, located in a room convenient to the kitchen.

 

3)         Food Preparation Facilities:  Conventional food preparation systems required space and equipment for preparing, cooking, and baking.  Convenience food service systems such as frozen prepared meals, bulk packaged entrees, and individual packaged portions, or systems using contractual commissary service require space and equipment for thawing, portioning, heating, cooking, or baking.

 

4)         Handwashing facilities shall be located in the food preparation area.

 

5)         Residents' meal service facilities shall be provided as required for tray assembly and distribution.

 

6)         Warewashing space shall be located in a room or an alcove separate from food preparation and serving areas.  Commercial type dishwashing equipment shall be provided. Space shall also be provided for receiving, scraping, sorting, stacking and loading soiled tableware and for transferring clean tableware to the using areas.  A handwashing lavatory shall be provided.  (B)

 

7)         Potwashing facilities shall be located conveniently for washing and sanitizing cooking utensils.  (B, C)

 

8)         Storage areas shall be provided for cans, carts, and mobile tray conveyors.

 

9)         Waste storage facilities shall be located in a separate room easily accessible to the outside for direct pickup or disposal.

 

10)         Office or desk space shall be provided for the dietitian or the dietary service manager.

 

11)         Toilets shall be accessible to the dietary staff.  Handwashing facilities shall be immediately available.

 

12)         A janitors' closet for the exclusive use in food preparation areas shall be located within the dietary department.  It shall contain a floor receptor or service sink and storage space for housekeeping equipment and supplies.

 

13)         Self-dispensing icemaking facilities shall be provided.

 

14)         Provide adequate can, cart and mobile tray washing facilities as required.

 

d)         Linen Service

 

1)         Provide a laundry room with commercial type equipment designed to meet the needs of the facility unless a commercial laundry service is used.

 

2)         The laundry facilities shall be designed to provide for the processing of linens from soiled linen receiving/sorting through washing, through drying, through clean linen inspection, folding and storage, maintaining a separation between soiled and clean functions.

 

3)         Provide for the storage of laundry supplies and carts.

 

4)         If washers and dryers are provided for personal use of residents, they shall be located in a room separate from the facility's laundry room.

 

e)         Housekeeping and Storage

 

1)         Sufficient janitor's closets shall be provided throughout the facility as required to maintain a clean and sanitary environment.  Each shall contain a floor receptor or service sink and storage space for housekeeping equipment and supplies. Space for large housekeeping equipment and for back-up supplies may be centrally located.

 

2)         Provide a total area of approximately ten square feet per resident bed for the storage areas designated in this service department.  This does not include closets or wardrobes in residents' rooms.  Separate storage space with provisions for locking and security control shall be provided for residents' personal effects which are not kept in residents' bedrooms.

 

3)         Provide storage rooms for maintenance supplies and yard equipment.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2700  General Building Requirements

 

a)         Elevators

 

1)         Each facility of two or more stories in height shall have a minimum of one elevator.  The basement shall be considered as one story if it is used by residents.

 

2)         If 80 to 200 beds are located above the first floor, at least one additional elevator shall be provided.

 

3)         For facilities with more than 200 beds, the number of elevators shall be determined from a study of the use requirements and the estimated vertical transportation requirements.

 

4)         A minimum of one car shall be of institutional type having inside dimensions that will accommodate a stretcher and attendants and shall be at least five feet by seven feet, six inches. The car door shall have a clear opening of not less than three feet, eight inches.

 

5)         Elevators shall be equipped with an automatic leveling device of the two-way automatic maintaining type.

 

6)         Elevator controls, alarm buttons, and telephones shall be accessible to physically handicapped.  Refer to 71 Ill. Adm. Code 400.

 

7)         Elevator call buttons, control, and door safety stops shall be of a type that will not be activated by heat or smoke. 

 

8)         Elevators, except freight elevators, shall be equipped with a two-way special service key operated switch to permit cars to bypass all landing button calls and be dispatched directly to any floor. 

 

9)         Fireman's emergency operations shall be furnished in accordance with ANSI/ASME Standard A17.1 Elevator Safety Code.

 

10)         Inspections and tests shall be made and written certification be furnished to the Department that the installation meets the requirements set forth in this Section and all applicable safety regulations and codes. 

 

b)         Handrails and Grab Bars

 

1)         Handrails shall be provided on both sides of all corridors and ramps used by residents.

 

2)         Handrails shall be provided on all sides of elevator cab not provided with a door.

 

3)         Handrails on stairs used by residents shall be provided on both sides of the stairs including the platforms and landings.

 

4)         Handrail dimensions and detail shall conform to 71 Ill. Adm. Code 400. 

 

5)         Handrails shall be installed at a height of 32 inches measured vertically from the floor surface.

 

6)         Grab bars shall be provided for all resident use toilets, showers and tubs. 

 

7)         The ends of handrails and grab bars shall return to the wall. 

 

c)         Ceiling Heights

 

1)         All rooms occupied or used by residents shall have ceilings not less than eight feet.

 

2)         Corridors, storage rooms, toilet rooms and other minor rooms shall have ceilings not less than seven feet eight inches.

 

3)         Suspended tracks, rails and pipes located in the path of traffic shall be not less than six feet eight inches above the floor.

 

4)         Boiler rooms shall have ceiling clearances not less than two feet six inches above the main boiler header and connecting piping.

 

d)         Doors and Windows

 

1)         The main entrance and all exit doors shall swing outward and be provided with door closers and panic hardware. 

 

2)         All exterior doors shall be equipped with a signal that will alert the staff if a patient leaves the building.  Any exterior door that is supervised during certain periods may have a disconnect device for part-time use. If there is constant 24-hour a day supervision of the door, a signal is not required.

 

3)         Locks installed on resident bedroom doors shall be arranged so that they can be quickly and easily unlocked from the corridor side.  All bedroom door locks shall be arranged to permit exit from the room by a simple operation without the use of a key. The door may be lockable by the occupant if the door can be unlocked from the corridor side and keys are carried by staff at all times.

 

4)         Resident toilet rooms shall open directly into a corridor or into a resident bedroom.

 

5)         The doors for the toilet rooms used by residents shall have a minimum door width of three feet.  

 

6)         No toilet or bathroom door shall be provided with hardware that could allow a resident to become locked in the room.  All toilet or bathroom doors and hardware shall be designed to permit emergency ingress to the room. 

 

7)         Doors and windows shall fit snugly and be weathertight, yet open and close easily.

 

8)         Outside doors, other than required exits, and operable windows shall be equipped with tight-fitting, l6 mesh screens. Screen doors shall be equipped with self-closing devices.

 

9)         All doors to resident sleeping rooms shall be provided with automatic closers actuated by smoke detectors in the resident room. The doors shall normally be free swinging in the open and close directions, and be designed so they will remain in any position except when they are actuated by the detector.  They shall then close gently and shall latch when closed.  When so actuated they shall automatically close again if opened manually.  Each door shall be equipped with a light mounted on the wall adjacent to the door.  The light shall illuminate if the door has been closed as a result of the actuation of the controlling smoke detector.  Each door closer shall be activated only when its own detector annunciates a fire.  In addition, a centrally located monitor shall contain signals that identify the resident room in which the smoke detector has signaled the alarm.  The system shall be wired into the fire alarm system. 

 

e)         Floors

 

1)         Floors shall be smooth, free from cracks and finished so that they can be easily and properly cleaned.  Floors shall be covered wall to wall with water resistant material in wet areas including but not limited to bathrooms, kitchen, and utility rooms.

 

2)         Thresholds and expansion joints shall be flush with the floor to facilitate use of wheelchairs and carts.

 

f)         Mirrors shall be installed above all lavatories except handwashing lavatories in food preparation areas, or in clean and sterile supply areas or at the nurses' handwashing sink.

 

g)         Paper towel dispensers and waste receptacles or electric hand dryers shall be provided at all lavatories.

 

h)         Rooms containing heat-producing equipment (such as boiler or heater rooms and laundry rooms) shall be insulated and ventilated to prevent any floor surface above from exceeding a temperature of ten degrees Fahrenheit above the ambient room temperature.

 

i)          Sound Transmission Limitation

 

1)         Recreation rooms and exercise rooms, and similar spaces where impact noises may be generated, shall not be located directly over resident bed areas unless special provisions are made to minimize such noise.

 

2)         Sound transmission limitations shown in Table A shall apply to partitions, floors, and ceiling construction in resident areas.

 

j)          Materials used for wall and door construction shall be highly resistant to impact damage.

 

k)         Interior Finishes, Fire Extinguishers and Miscellaneous

 

1)         Interior finish flame spread ratings shall be in accordance with the NFPA 101.

 

2)         Fire extinguishers shall be installed and maintained in accordance with NFPA 10. At least one fire extinguisher shall be installed in all basements, furnace rooms, and kitchens, laundry rooms and beauty shops.  In addition, on each floor of the building, fire extinguishers shall be located so a person will not have to travel more than 50 feet from any point to reach one.  The facility shall ensure that they are inspected annually and recharged when necessary.  The date of checking and recharging shall be recorded on a tag attached to the extinguisher. 

 

3)         Containers of appropriate size and with proper covers shall be provided for daily storage of rubbish.

 

4)         Housekeeping throughout the building, including basements, attics, and unoccupied rooms shall be performed to minimize all fire hazards.

 

l)          The facility shall permit no other business not related to health care conducted in the building if it constitutes a hazard or annoyance to the residents.  Permitted businesses shall be in a segregated portion of the building and shall have a separate entrance.

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.2710  Structural

 

a)         General Structural Requirements

 

1)         The buildings and all parts thereof shall be of sufficient strength to support all dead, live, and lateral loads without exceeding the working stresses permitted for the materials of their construction in generally accepted good engineering practice. 

 

2)         Special provision shall be made for loads that have a greater load than the specified minimum live load, including partitions that are subject to change of location.

 

b)         Construction shall be in accordance with the requirements of the NFPA 101, Life Safety Code, and the minimum requirements of this Section

 

1)         Foundations shall rest on natural solid ground and shall be carried to a depth of not less than one foot below the estimated frost line or shall rest on leveled rock or load-bearing piles or caissons when solid ground is not encountered.  Footings, piers, and foundation walls shall be adequately protected against deterioration from the action of ground water.  Soil test borings shall be taken to establish proper soil-bearing values for the soil at the building site.

 

2)         Assumed live loads shall be in accordance with the IBC.

 

3)         The fire resistance rating of the structural members shall be as established by NFPA 220 Standard on Types of Building Construction.

 

c)         Provisions for Natural Disasters (B)

 

1)         Earthquakes:  In regions where, according to local experience, earthquakes have caused loss of life or extensive property damage, buildings and structures shall be designed to withstand the force assumptions specified in the IBC. Seismic zones are identified on the map found Chapter 16 of the IBC.

 

2)         Tornadoes and Floods:  Special provisions shall be made in the design of buildings including structural design, in regions where, according to local experience loss of life or damage to buildings has resulted from hurricanes, tornadoes, or floods.

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.2720  Mechanical Systems

 

a)         Mechanical systems shall be tested, balanced, and operated to demonstrate that the installation and performance of these systems conform to the requirements of this Section.

 

1)         Upon the completion of the contract, the owner shall be furnished with a complete set of manufacturer's operating and preventative maintenance instructions, a parts list with numbers and descriptions for each piece of equipment, and a copy of the air-balance report.  A complete set of these documents shall be kept on the premises.

 

2)         The owner shall be provided with instructions in the operational use of the systems and equipment.

 

b)         Thermal and Acoustical Insulation.  Thermal and acoustical insulation shall be provided as set forth in the ASHRAE Handbook of Fundamentals and the Handbook of Applications and NFPA 90A.  Commercial kitchen grease hoods shall be insulated according to NFPA 96 and in accordance with the insulation manufacturer's installation instructions.  Domestic water piping that is accessible to residents shall be insulated as required by the Illinois Accessibility Code.  Insulation shall be provided for the following:

           

1)         Boilers, smoke breeching, and stacks;

 

2)         Steam supply and condensate return piping;

 

3)         Hot water piping above l80 degrees Fahrenheit and all water heaters, generators, and convertors;

 

4)         Hot water piping above 125 degrees Fahrenheit that is exposed to contact by residents;

 

5)         Chilled water, refrigerant, other process piping and equipment operating with fluid temperatures below the ambient dew point;

 

6)         Water supply and drainage piping on which condensate may occur;

 

7)         Air ducts and casings with outside surface temperatures below the ambient dew point; and

 

8)         Other piping, ducts, and equipment as necessary to maintain the efficiency of the system.

 

c)         Insulation may be omitted from hot water and steam condensate piping that is not subject to contact by residents when the insulation is not necessary for preventing excessive system heat loss or excessive heat gain.

 

d)         Insulation including finishes and adhesives on exterior surfaces of ducts, pipes, and equipment shall have a flame spread rating of 25 or less and a smoke developed rating of 50 or less as determined by an independent testing laboratory in accordance with the American Society for Testing and Materials Standard E84.  Exception:  Duct, pipe and equipment coverings shall not be required to meet these requirements if they are located entirely outside of a building, or do not penetrate a wall or roof or do not create an exposure hazard. 

             

e)         Steam and Hot Water Systems. Supply and return mains and risers for cooling, heating and process steam systems shall be valved to isolate the various sections of each system. Each piece of equipment shall be valved at the supply and return ends.

 

f)         Thermal Hazards.  Any surface that is accessible to residents and exceeds a temperature of 140 degrees Fahrenheit (such as radiators, hot water or steam pipes, baseboard heaters, or therapy equipment) shall be provided with partitions, screens, shields, or other means to protect residents from injury.  Any protective device shall be designed and installed so that it does not present a fire or safety hazard or adversely affect the safe operation of the equipment.

 

g)         Heating, Ventilating and Air Conditioning Systems

 

1)         Areas of a nursing home used by residents of the nursing home shall be air conditioned and heated by means of operable air-conditioning and heating equipment. The areas subject to this air-conditioning and heating requirement include, without limitation, bedrooms or common areas such as sitting rooms, activity rooms, living rooms, community rooms, and dining rooms. (Section 3-202(8) of the Act)

 

A)        The mechanical system shall be capable of maintaining a temperature of at least 75 degrees Fahrenheit, pursuant to the requirements of Section 350.690(j).

 

B)        The air-conditioning system shall be capable of maintaining an ambient air temperature of between 75 degrees Fahrenheit and 80 degrees Fahrenheit, pursuant to the requirements of Section 350.690(j).

 

2)         All ventilation supply, return, and exhaust systems shall be mechanically operated.

 

3)         Outdoor air intakes shall be located as far as practical, but not less than l5 feet, from the exhaust outlets of ventilation systems, combustion equipment stacks, plumbing vent stacks, or areas that may collect vehicular exhaust and other noxious fumes, including the exhaust stream from fuel-fired heating, ventilating and air conditioning (HVAC) sections.  The bottom of outdoor air intakes serving central systems shall be located as high as practical, but not less than six feet above ground level, or, if installed above the roof, three feet above roof level. For fuel-fired heating sections of rooftop HVAC units, the exhaust vent may discharge not less than 36 inches above the highest point of the fresh air intake hood in lieu of the 15 foot separation.

 

4)         The ventilation systems shall be designed and balanced to provide the pressure relationships and ventilation rates as shown in Table B. 

 

5)         A differential pressure measuring device shall be installed across each filter bed serving a central air system.  The device may be a remote readout instrument if the remote readout is readily visible in a location accessible to the maintenance staff, or if the readout is displayed on an interactive screen.

 

6)         Air conditioning and ventilating systems shall be designed, installed, and maintained as required by NFPA 90A.  For areas within the footprint of the facility that are heated by fuel-fired appliances using an air-to-air heat exchanger, no fewer than two carbon monoxide (CO) detectors shall be installed in the area served by each heat exchanger.  One CO detector shall be installed within five feet of a supply duct and one within five feet of a return or exhaust duct.  CO detectors shall be line or system powered and shall signal the building fire alarm system when activated.  If detectors are line powered, a battery back-up or connection to the emergency power system is required.

 

7)         The hood and duct system for cooking equipment used in processes that produce smoke or grease-laden vapors shall comply with NFPA 96.  The hood's extinguishment system shall be connected to the building fire alarm system and shall initiate a general alarm when activated.  Duct insulation that is used in lieu of spacing from combustible construction members shall terminate at the top of the hood on the lower end, covering the duct collar, and shall pass through any combustible nailer opening in the roof/ceiling assembly and into the roof jack assembly.  The material used shall be installed exactly as the manufacturer's installations require.

 

8)         Boiler rooms and other rooms having combustion equipment shall be provided with sufficient outdoor air to maintain combustion rates of equipment and limit temperatures to 20 degrees Fahrenheit over ambient inside air in adjacent interior spaces.  If sealed combustion units are in use, the discharge line shall remain clear of any adjacent walk paths and shall be not less than 15 feet from any operable fenestration or air intakes.  NFPA 54 shall apply, including the calculations for combustion air openings. Effective temperature shall be as defined by the American Society of Heating, Refrigerating, and Air Conditioning Engineers Handbook of Fundamentals. 

 

9)         Rooms containing heat-producing equipment, such as boiler rooms, heater rooms, food preparation centers, laundries, and sterilizer rooms, shall be insulated and ventilated to prevent any floor surface above from exceeding a temperature of 10 degrees Fahrenheit above the ambient room temperature. The ventilation rates shown in Table B shall be considered as minimum acceptable rates and shall not be construed as precluding the use of higher ventilation rates.

 

10)        Access for filter changing shall be provided within equipment rooms.

 

(Source:  Amended at 35 Ill. Reg. 3461, effective February 14, 2011)

 

Section 350.2730  Plumbing Systems

 

a)         All plumbing systems shall be designed and installed in accordance with the requirements of the Department's rules entitled "Illinois Plumbing Code" except that the number of resident required (77 Ill. Adm. Code 890) water closets, lavatories, bathtubs, showers, and other fixtures shall be as required by these standards and the facility program.  (B)

 

b)         Plumbing Fixtures

 

1)         Plumbing fixtures shall be of non-absorptive acid-resistant materials.

 

2)         The water supply spout for lavatories and sinks required for filling pitchers, for nursing staff and food handlers' handwashing, shall be mounted so that its discharge point is a minimum distance of five inches above the rim of the fixture.  (B)

 

3)         Handwashing lavatories used by nursing staff and food handlers shall be trimmed with valves which can be operated without the use of hands. When blade handles are used for this purpose, the blade handles shall not exceed four and one-half inches in length, except the handles on clinical sinks shall not be less than six inches in length.

 

4)         Clinical rim flush sinks shall have an integral trap in which the upper portion of the trap seal provides a visible water surface.

 

5)         The potwashing sink shall be a three compartment sink with one compartment at least l4 inches deep.

 

6)         Shower bases and tub bottoms shall be designed with nonslip surfaces.  (B)

 

c)         Water Supply Systems

 

1)         Water supply systems shall be designed to supply water at sufficient pressure and volume to operate all fixtures and equipment during maximum demand periods.

 

2)         Each water service main, branch main, riser and branch to a group of fixtures shall be valved.  Stop valves shall be provided at each fixture.

 

3)         Flush valves installed on plumbing fixtures shall be of a quiet operating type, equipped with silencers.

 

4)         Hot water distribution systems shall be arranged to provide hot water of at least 100 degrees Fahrenheit at each hot water outlet at all times.

 

5)         Hot water available to residents at shower, bathing and handwashing facilities shall not exceed 110 degrees Fahrenheit  (A, B)

 

6)         Each hot water system serving resident areas shall include at least one of the following equipment requirements to insure that the water temperature does not exceed 110 degrees Fahrenheit:

 

A)        A thermostatically controlled mixing valve, or

 

B)        An aquastat which limits the water temperature in the water heater to a maximum temperature of 110 degrees Fahrenheit and a solenoid operated shut off valve activated by a sensing element in the water line which shuts off the water and activates an alarm at the nurses station when the water temperature exceeds 110 degrees Fahrenheit. (A, B)

 

d)         Hot Water Heaters and Tanks

 

1)         Capacity and Temperature Requirements

 

A)        The hot water heating equipment shall have sufficient capacity to supply water at the temperature and quantities in the following areas:

 

	Resident Service	Dietary	Laundry
gallons/hour/bed	6½	4	4½
Temperature (degrees Fahrenheit)	110	140*	180

 

            *180 degree Fahrenheit water is required at dishwasher and pot and pan sink.

 

B)        Water temperatures to be taken at the point of use or discharge of the hot water or inlet to processing equipment.

 

2)         Water storage tanks shall be fabricated of corrosion resistant metal or lined with noncorrosive material.

 

e)         Drainage Systems. Insofar as possible drainage piping shall not be installed above the ceiling nor installed in an exposed location in food preparation centers, food serving facilities, food storage areas, and other critical areas. Special precautions shall be taken to protect these areas from possible leakage or condensation from necessary overhead piping systems.  (B)

 

f)         Fire Extinguishing Systems

 

1)         A complete automatic sprinkler system shall be installed throughout all facilities regardless of construction type.  (A, B)

 

2)         All sprinkler and other fire extinguishing systems shall be designed and installed in accordance with National Fire Protection Association Standard 101l and referenced codes.  (A, B)

 

3)         All sprinkler systems shall be maintained in accordance with National Fire Protection Association Standard 13A.  (A, B)

 

(Source:  Amended at 14 Ill. Reg. 14876, effective October 1, 1990)

 

Section 350.2740  Electrical Systems

 

a)         General Electrical System Requirements

 

1)         All material including equipment, conductors, controls, and signaling devices shall be installed to provide a complete electrical system with the necessary characteristics and capacity to supply the electrical facilities required by these standards.  All materials shall be listed as complying with the applicable standards of Underwriters' Laboratories, Inc. or other similarly established standards.

 

2)         All electrical installations and systems shall be tested to show that the equipment is installed and operates as planned or specified and be in accordance with these this Subpart. 

 

3)         The installation shall meet all the requirements of NFPA 70.

 

b)         Switchboards and Power Panels. Circuit breakers or fusible switches that provide disconnecting means and overcurrent protection for conductors connected to switchboards and panelboards shall be enclosed or guarded to provide a dead-front type of assembly.  The main switchboard shall be located in a separate enclosure accessible only to authorized persons.  The switchboard shall be convenient for use, readily accessible for maintenance, clear of traffic lanes, and located in a dry ventilated space free of corrosive fumes or gases.  Overload protective devices shall be suitable for operating properly in ambient temperature conditions.

 

c)         Panelboards. Panelboards that serve lighting and appliance circuits shall be located on the same floor as the circuits they serve.  This requirement does not apply to emergency system circuits.

 

d)         Lighting

 

1)         All spaces occupied by people, machinery, and equipment within buildings, approaches to and exits from buildings, and parking lots shall have lighting.

 

2)         Resident's rooms shall have general lighting.  A vandal-proof reading light shall be provided for each resident.  At least one light fixture shall be switched at the entrance to each resident room.  All switches for control of lighting in residents' sleeping areas shall be of the quiet operating type.

 

e)         Receptacles (Convenience Outlets)

 

1)         Each resident room shall have at least three duplex grounding type receptacles:  One located on each side of the head of each bed; one for television if used; and one on another wall.  Receptacles shall be located between 12 to 30 inches above the finished floor.

 

2)         Resident bathrooms shall have at least one duplex receptacle.

 

3)         See Article 517 of NFPA 70 for grounding requirements.

 

4)         Duplex receptacles shall be installed approximately 50 feet apart in all corridors and within 25 feet from the ends of corridors.

 

f)         Door Alarm System. Each exterior door shall be equipped with a signal that will alert staff if a resident leaves the building.  Any exterior door that is supervised during certain periods may have a disconnect device for part-time use. If there is constant supervision of the door 24 hours a day, a signal is not required. 

 

g)         Fire Alarm System

 

1)         A manually and automatically operated fire alarm system shall be installed. 

 

2)         Automatic smoke detectors shall be installed in all resident rooms and at 30 feet on center in all corridors other than sleeping area corridors. 

 

h)         Emergency Electrical System

 

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.  The emergency system shall comply with NFPA 70, NFPA 99, AND NFPA 100, as applicable.

 

2)         The source of this emergency electrical service shall be a Level I or Level II, Class X, Type 10 emergency generating set approved by the Department.

 

3)         Details

 

A)        The life safety branch and critical branch shall be in operation within ten seconds after the interruption of normal electric power supply. 

 

B)        Receptacles connected to emergency power shall be distinctively marked.

 

C)        The emergency generator shall not be solely dependent upon a public utility gas system for the fuel supply.  The facility shall maintain a written procedure for automatically transferring from one fuel supply to another when dual fuel supplies are used.

 

D)        When fuel storage facilities are provided on the site, the fuel tank shall have minimum capacity for 24-hour operation of the generator.

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

SUBPART N: CONSTRUCTION STANDARDS FOR EXISTING INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED

 

Section 350.2910  Applicability

 

a)         This Subpart N applies to all existing Long-Term Care Facilities and all minor alterations or remodeling changes to existing facilities.  See Section 350.2610(b) for New Construction and Major Additions and Alterations. Minor alterations or remodeling changes which do not affect the structural integrity of the building, which do not change functional operations, which do not affect fire safety, and which do not add beds or facilities over those for which the Long-Term Care Facility is licensed need not be submitted for drawing approval.  However, the Health Facilities Planning Board Requirements must be met for all alteration and remodeling projects.

 

b)         Sheltered Care Facilities having architectural drawings and specifications, or the building, first approved by the Department for licensure after October l, 1974, must meet the applicable requirements of Subpart M to convert to an Intermediate Care Facility for the Developmentally Disabled.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2920  Codes and Standards

 

a)         Nothing stated herein shall relieve the sponsor from compliance with building codes, ordinances and regulations which are enforced by city, county or other local jurisdictions.  (B)

 

b)         The 1981 Edition of the National Fire Protection Association (NFPA) Standard No. 101, Life Safety Code for existing structures and all appropriate references under Appendix "B" of that Code, but no subsequently amended edition of the Code, shall apply to and become a part of these standards. Pursuant to the Medicare-Medicaid certification requirements of 42 CFR 442.507(c) (1983), but no subsequently amended editions of these Federal regulations, any facility that on November 26, 1982 complied with the requirements of the 1967 edition of the Life Safety Code, rather than the 1981 edition of the Life Safety Code, will be accepted by the Department for licensure and certification as long as the facility continues to remain in compliance with the 1967 edition of the Code. (A, B)

 

c)         The following exceptions to the 1967 Life Safety Code have been established by the Department:

 

1)         Facilities shall be of the heights and construction types with sprinkler requirements identified in Table C. (B)

 

2)         Dead-end corridors greater than 50 feet in length shall be altered so that exits are accessible in at least two directions from all points in aisles, passageways, and corridors.  (B)

 

3)         Exit discharge doors and resident sleeping doors must be at least 34 inches in width. Width required is the width of the door leaf.

 

4)         All corridors shall be at least four feet wide.

 

d)         The following equivalencies have been established by the Department:

 

1)         Where corridor partition walls are not continuous from the floor slab to the underside of the floor or roof slab above, through any concealed spaces such as those above the suspended ceilings and through interstitial structural and mechanical spaces, the following equivalencies are permitted:  (B)

 

A)        A membrane ceiling which may be lath and plaster or drywall or a lay-in ceiling with all tiles clipped down and with all clips remaining in place, or with all the tiles weighing at least one pound per square foot.  The ceiling may be suspended but it must be constructed continually from exterior wall to exterior wall and must be part of a one hour rated assembly.  All recessed lights, all duct outlets and all speaker outlets must be properly protected in accordance with Code.  Plenums are not allowed unless each outlet is properly protected. This concept is applicable only to two-hour fire resistive and one-hour protected noncombustible construction.

 

B)        A membrane ceiling of at least a one hour rating (such as two layers of five-eighths inch Fire Code drywall) is acceptable for noncombustible, one hour protected ordinary, ordinary, one hour protected wood frame, wood frame and heavy timber construction.

 

C)        Corridor walls need not run up in two-hour fire resistive and one-hour protected noncombustible construction if automatic sprinklers are installed throughout.

 

D)        Smoke detectors may be used in lieu of continuous corridor wall construction all building construction types which are equipped throughout with an automatic extinguishment system required by these Standards.  Automatic heat detectors, in lieu of automatic smoke detectors, may be installed in kitchens, laundry rooms, boiler-furnace rooms and attic spaces.

 

2)         This equivalency is applicable only to those facilities which are in conformance with these requirements on the date of promulgation of these standards and only if the facility remains in conformance.  The equivalency is applicable to facilities with nonconforming construction type.  The following requirements must be met for facilities four stories or more in height of protected ordinary construction.

 

A)        The fire resistance rating of all structural members must meet the two-hour fire resistive classification of NFPA 220, Standard Types of Building Construction, dated May, 196l, except that floor and roof framing members and nonbearing walls may be of combustible construction.

 

B)        Smoke detectors must be installed in all resident rooms, corridors, living areas, day rooms and in all hazardous and severely hazardous areas throughout the facility.  However, automatic heat detectors may be installed, in lieu of automatic smoke detectors, in kitchens, laundry rooms, boiler-furnace rooms and attic spaces (places where smoke, dust and humidity sometimes activate smoke alarms when no fire is present, resulting in false fire alarms), if the facility chooses to do so for the purpose of reducing the number of false fire alarms.  A zone readout identifying areas involved in a fire must be provided.

 

C)        All electrical systems shall meet the National Electrical Code in effect at the time of acceptance of the facility.

 

D)        Facility shall establish and enforce written procedures to prohibit smoking in resident sleeping rooms and corridors.  Smoking is permitted only in controlled areas.

 

E)        A complete automatic extinguishment system shall be installed throughout the facility.

 

F)         All health survey deficiencies must be corrected.

 

G)        The physically handicapped residents shall be housed on the lowest sleeping room floor and ambulant residents may be housed on any floor.

 

H)        Complete smoke barriers including one-hour rated walls and one and three-quarters inch thick solid core wood corridor doors with closers shall be installed as directed by the Department.

 

e)         The following rules  which were effective at the date of approval by the Department of the final drawings and specifications or the final inspection of the building apply:  (B)

 

1)         Illinois State Plumbing Code (77 Ill. Adm. Code 890), Department of Public Health

 

2)         Illinois Accessibility Code (71 I11. Adm. Code 400), Capitol Development Board

 

3)         Fire Prevention and Safety (41 Ill. Adm. Code 100), Office of the State Fire Marshal

 

4)         Food Service Sanitation (77 Ill. Adm. Code 750), Department of Public Health

 

5)         Boiler and Pressure Vessel Safety (41 Ill. Adm. Code 120, Office of State Fire Marshal

 

f)         The requirements in this Part govern in cases of differences between this Part and the rules listed in this Section.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2930  Preparation of Drawings and Specifications

 

Drawings and specifications which are prepared for work which is required by this Part shall be prepared in accordance with Section 350.2630.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2940  Site

 

a)         Each facility shall comply with all applicable zoning ordinance and be located on a reasonably flat or rolling, well-drained site that is: not subject to flooding; reasonably free from sources of excessive noise, noxious or hazardous smoke or fumes; not in a deteriorated, unpleasant, or potentially hazardous area; and not near uncontrolled sources of insect and rodent breeding.

 

b)         Each facility shall be located in or near a community which can provide the necessary supportive services for the facility such as physicians' services, social services, transportation, recreational services, religious services, work, medical facilities, public utilities, or other acceptable substitutes; and be located on a well-maintained, all-weather road.

 

c)         Each facility shall be served by a potable water supply with water pressure and volume that is acceptable to this Department.

 

d)         Each facility shall have at least one municipal or private fire hydrant, located within 300 feet of the building and satisfactory for use by the equipment of the fire department serving the building, or have an acceptable equivalent. Additional hydrants may be required if needed to properly protect the residents from fire hazards.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2950  Administration and Public Areas

 

a)         Facilities for the physically handicapped (public, staff and residents) shall be provided in administration and public areas as well as in resident areas.

 

b)         Each facility shall be provided with sufficient administrative office space for clerical, financial, and managerial functions and provide satisfactory space which can be used for privacy in interviewing applicants, for discussion with relatives, and other necessary functions.

 

c)         Each facility shall be provided with satisfactory space or an office for the administrator.

 

d)         Each facility shall be served by reliable telephone service.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2960  Nursing Unit

 

a)         General Requirements for Bedrooms

 

1)         Resident bedrooms shall have an entrance directly off a corridor with an entrance door that swings into the room. Rooms used as bedrooms and included in the licensed capacity as of December 24, 1987, which do not open directly into corridors but instead open into large living/dining/activity areas, are exempt from this rule. However, no additional such rooms will be permitted to be established after December 24, 1987.

 

2)         Resident bedroom shall have adequate and satisfactory artificial light and be equipped in accordance with Section 350.3040(c)(2) and (d).

 

3)         Resident toilet rooms shall open directly into a corridor or into a resident's bedroom.  (B)

 

4)         A closet or wardrobe at least six square feet shall be provided for each resident.

 

5)         Each bedroom floor shall be no more than three feet below the adjacent ground level.

 

6)         Each room used as a resident bedroom shall have at least one outside window, and a total window area to the outside equal to at least one-tenth the floor area of the room.

 

b)         Resident Bedrooms

 

1)         Each single resident bedroom shall contain at least 100 square feet of usable floor area.  Each multiple resident bedroom shall contain at least 80 square feet per bed of usable floor area.   Minimum usable floor area shall be exclusive of toilet rooms, closets, lockers, wardrobes, alcoves, vestibules, or clearly definable entryways.  Those bedrooms for which facilities had waivers to this subsection (b)(1) on (and continuously since) December 24, 1987, and which have at least 90 square feet for single bedrooms and 70 square feet per bed for multi-bedrooms, are exempt from this subsection (b)(1).  Those bedrooms for which facilities had waivers to this subsection (b)(1) on (and continuously since) December 24, 1987, but which have less than 90 square feet for single bedrooms and 70 square feet per bed or multi-bedrooms, continue to be subject to waiver procedures on an annual basis. (See Section 350.320.)

 

2)         Maximum room capacity shall be four residents.  Beds shall be at least three feet apart and no more than three deep from an outside wall.  There shall be a minimum of ten feet between walls or a wall and any built-in furniture or storage space.

 

c)         Special Care Room

 

1)         Provide a special care room for each 150 beds.

 

2)         Provide this room with a toilet lavatory and all other necessary facilities to meet the resident's needs and as required to care for an ill resident.

 

3)         This room shall be located to provide proper and efficient supervision of the resident by the nursing staff.

 

4)         The room may be included in the authorized maximum bed capacity for the facility.  It is permissible for the room to be occupied by a resident, not in need of special care, provided the resident is clearly informed and understands he will be immediately transferred out of the room any time of day or night, whenever the room is needed to care for a resident requiring special care.

 

d)         Nurses' Station

 

1)         Provide a minimum of one nurses' station on each floor.  The station shall have direct access to a corridor, shall be located near the area it will serve, and shall be designed to provide visual control of the area. It shall be separated satisfactorily from the nurses' utility rooms.  In Intermediate Care Facilities for the Developmentally Disabled one nurses' station serving two floors housing residents is acceptable if there are less than l5 beds on an adjacent floor which are served by the nurses' station. (B)

 

2)         At least one nurses' station shall have a medicine sink with hot and cold running water, a work counter, a medicine cabinet, and necessary equipment and furnishings.

 

3)         Provide a nurses' toilet and handwashing sink convenient to the nurses' station.

 

e)         Bath and Toilet Rooms

 

1)         The maximum capacity of resident beds on each floor shall be used to determine the number of fixtures required even though some of the beds are not occupied.

 

A)        Provide a minimum of one water closet, one lavatory, and one bathtub or shower for each sex on each floor occupied by residents.

 

B)        Provide a minimum of one lavatory and one water closet for each ten resident beds on each floor.

 

C)        Provide a minimum of one bathtub or shower for each 15 resident beds on each floor.

 

D)        Each lavatory shall be provided with a well-illuminated mirror.

 

2)         All bath and toilet rooms shall be easily accessible, and conveniently located.  Group bath and toilet facilities shall be partitioned or curtained for privacy.

 

3)         All showers, other than those for residents needing assistance in bathing, shall have minimum dimensions of three feet by three feet.

 

4)         Shower stalls shall have a low or no curb at the entrance opening. Under certain circumstances this may be waived but in no instances can the curb be higher than three inches.

 

5)         If toilet rooms provided adjacent to residents' bedrooms are not large enough to permit use by wheelchair residents, at least one toilet room or enclosure measuring five feet by six feet shall be provided on each floor housing residents. Provide a lavatory usable by wheelchair residents in this room.

 

6)         Provide on each floor at least one bathing facility or enclosure of not less than eight feet, six inches by eight feet, six inches with an acceptable system for assistance in bathing persons with physical disabilities.  If a shower is installed instead of a bathtub, such shower shall have a minimum dimension of four feet wide by three feet six inches deep.  These showers shall have a water inlet to which is connected a flexible hose with spray or shower head attached to the end of the hose.  If desired, a conventional shower head installation may also be provided but it must be valved off from the lower water inlet.

 

(Source:  Amended at 16 Ill. Reg. 13910, effective September 1, 1992)

 

Section 350.2970  Living, Dining, Activities Rooms

 

a)         Provide at least one comfortably furnished living room and dining room for use of residents.

 

1)         The room shall be an outside room. Their combined areas shall be not less than 40 square feet per resident bed.

 

2)         The dining room shall be sufficient in area to allow for proper and comfortable service for the residents.

 

3)         Be located so that the room is not an entrance vestibule from the out-of-doors.

 

4)         The furniture shall be arranged so that it is not an obstruction to traffic in or out of the facility.

 

b)         The activity room may be combined with the living or dining room.

 

c)         In multiple story buildings living rooms must be provided on each floor unless a variance to this requirement is approved in writing by the Department.

 

d)         Additional interior rooms may be used for television, craft, or similar activities.

 

e)         Under no circumstances shall any of these rooms be used as a bedroom.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2980  Treatment and Personal Care

 

Space and appropriate equipment shall be provided to meet the resident's needs for treatment, grooming and hair care.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.2990  Service Department

 

a)         Kitchen

 

1)         Provide a kitchen area, not including food storage area, of approximately ten square feet per resident bed; this may be reduced for a facility with 75 or more beds.  Any deviation from this requirement must receive approval from the Department.  (B)

 

2)         Provide kitchen equipment in an arrangement for convenient operation, good sanitation, healthful working conditions and control of heat, noise and odors.  (B)

 

3)         Provide appropriate equipment for preparation and serving of meals.  (B)

 

4)         Provide refrigeration of perishable foods. (B)

 

5)         The kitchen shall be equipped with a two compartment sink for washing and sanitizing dishes, pots, pans and utensils.  (B)  A commercial type dishwasher is recommended.

 

6)         The kitchen shall be provided with a handwashing lavatory.  (B)

 

7)         The walls and ceilings of all food handling rooms shall be finished with smooth, washable, light colored surfaces.

 

8)         All openings to the outside shall be effectively screened during fly seasons, and screen doors shall be equipped with self-closing devices; or a satisfactory alternative method.

 

9)         The kitchen shall be located so that no resident must pass through it to reach a bathroom, resident's bedroom, the living room, dining room, or the out-of-doors.  (B)

 

10)         Provide approximately two and one-half square feet per patient bed for bulk and daily food storage located in a room convenient to the kitchen.

 

b)         Laundry

 

1)         Provide a laundry room equipped with adequate facilities for satisfactorily doing all laundering, unless a commercial laundry service is used.

 

2)         Provide satisfactory and separate areas for soiled holding and sorting and clean linen storage.  These may be in the same room if well defined and adequate separation is provided.

 

3)         The laundry facilities shall not be located in a room used by residents, or for food storage, preparation or serving.  It shall be located so that soiled linens are not carried through a food handling area to reach it.  (B)

 

c)         Storage

 

1)         Provide a total area of approximately seven and one-half square feet per resident bed for the storage area required in this section.

 

2)         Provide adequate storage space for personal possessions of residents and staff, linens, supplies, and other items.  This storage shall be such that it does not constitute a fire or accident hazard and will not be in the way of residents or staff.

 

3)         Provide adequate storage space in the facility, out of the way of residents and staff, to store wheelchairs, walkers, and similar equipment temporarily not being used.

 

4)         Provide closets for cleaning supplies, janitor's sinks, linen closets, storerooms for luggage, and furniture replacements.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3000  General Building Requirements

 

a)         Elevators

 

1)         Provide a minimum of one elevator in all buildings of three or more stories in height.  Additional elevators shall be provided as determined by the Department. The basement, if it is used by residents, shall be considered as one story.

 

2)         If 60 to 200 beds are located above the second floor, at least one additional elevator shall be provided. If over 200 beds are located above the second floor, the number of additional elevators shall be determined by the Department.

 

3)         The administrator of the facility must be able to demonstrate to the Department the ability to transfer a patient according to physician's orders using existing elevators and elevator doors.

 

b)         Handrails and Grab Bars

 

1)         Handrails shall be provided on both sides of all corridors, stairs, and ramps.  Handrails shall be one and one-half inches in diameter and one and one-half inches minimum clear of the wall.  The height shall be 30 to 34 inches measured vertically from floor surface. Refer to the rules of the Capital Development Board entitled "Illinois Accessibility Code" (71 Ill. Adm. Code 400) for other acceptable handrail dimensions and details.  (B)

 

2)         Grab bars shall be provided at all resident toilets, showers, tubs, and sitz bath Refer to the rules of the Capital Development Board entitled "Illinois Accessibility Code" (71 Ill. Adm. Code 400) for grab bar dimensions and details.  (B)

 

c)         Ceiling Heights

 

1)         All rooms occupied by or used by residents shall have not less than eight feet ceiling height.

 

2)         Corridors, storage rooms, toilet rooms and other minor rooms shall not be less than seven feet, eight inches ceiling height.

 

3)         Suspended pipes and similar features located in the path of traffic shall not be less than six feet, eight inches above the floor.

 

d)         Doors and Windows

 

1)         Main entrance and exit doors shall swing outward and be provided with door closers and panic-hardware.  (B)

 

2)         All exterior doors shall be equipped with a signal that will alert the staff if a resident leaves the building.  Any exterior door that is supervised during certain periods may have a disconnect device for part-time use.  If there is constant 24 hour a day supervision of the door, a signal is not required.  (B)

 

3)         Locks installed on resident bedroom doors shall be so arranged that they can be quickly and easily unlocked from the corridor side.  All such locks shall be arranged to permit exit from the room by a simple operation without the use of a key. The door may be lockable by the occupant if the door can be unlocked from the corridor side and the keys are carried by the attendents at all times.  (B)

 

4)         Resident toilet rooms shall open directly into a corridor or into a resident's bedroom.

 

5)         The doors for the toilet rooms used by residents shall have a minimum door width of 30 inches.

 

6)         No toilet or bathroom door shall be provided with hardware which could allow a resident to become locked in the room.  All toilet or bathroom doors and hardware shall be designed to permit emergency ingress to the room.

 

7)         Thresholds or parting strips in doorways used by residents shall be flush with the floor.

 

8)         Doors and windows shall fit snugly and be weather tight, and shall open and close easily.

 

9)         Outside doors, other than required exits, and operable windows shall be equipped with tight-fitting, l6-mesh screens.  Screen doors shall be equipped with self-closing devices.

 

e)         Floors

 

1)         Floors shall be smooth, free from cracks and finished so that they can be easily and properly cleaned.  (B)

 

2)         Floors in bathrooms, kitchens, and utility rooms shall be completely covered with water resistant material.  (B)

 

f)         Walls and Ceilings

 

1)         Walls and ceilings shall have sound construction, covered with plaster or sheet rock or similar material in good repair, and free from cracks or holes to permit proper cleaning.

 

2)         Walls and ceilings shall be constructed and maintained so as to prevent the entrance and harborage of rats, mice, flies, and other vermin.

 

g)         Exit corridor walls shall be one hour fire rated construction. Adjoining open spaces shall not be greater than 600 square feet.  Facilities shall provide direct visual supervision of these open spaces and equip them with an electrically supervised smoke detection system.  (B)

 

h)         There shall be at least one approved fire extinguisher in all basements, furnace rooms, and kitchens.  In addition, there shall be on each floor of the building, extinguishers located so a person will not have to travel more than 50 feet from any point to reach one.  They shall be inspected annually and recharged when necessary.  The date of checking and recharging shall be recorded on a tag attached to the extinguisher.  (B)

 

i)          Approved containers with proper covers shall be provided for daily storage of rubbish. (B)

 

j)          Housekeeping throughout the building, including basements, attics, and unoccupied rooms, shall be adequately performed to minimize all fire hazards.(B)

 

k)         Facilities shall comply with any reasonable additional fire protection measures recommended by the Department over and above these requirements or the Office of the State Fire Marshal if conditions in and around building, including its location, indicate that such additional protection is needed.  (B)

 

l)          The building in which a facility is located shall have no other business that is unrelated to health care that constitutes a hazard or annoyance to the residents. The business shall be in a segregated portion of the building and shall have a separate entrance. (A,B)

 

(Source:  Amended at 16 Ill. Reg. 13910, effective September 1, 1992)

 

Section 350.3010  Structural

 

a)         Buildings and all parts thereof shall be maintained structurally to support all dead, live and lateral loads.  (B)

 

b)         Buildings shall be maintained in good repair.  Buildings that show signs of distress shall be repaired immediately.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3020  Mechanical Systems

 

a)         Mechanical systems shall be maintained to assure proper working order and safe operation.  Instructions in the operational use of the systems and equipment shall be available at the facility. 

 

b)         Thermal and Acoustical Insulation. Insulation shall be provided for the following:

 

1)         Boilers, smoke breeching, and stacks;

 

2)         Steam supply and condensate return piping;

 

3)         Hot water piping above l80 degrees Fahrenheit and all water heaters, generators, and converters;

 

4)         Hot water piping above 125 degrees Fahrenheit that is exposed to contact by residents;

 

5)         Chilled water, refrigerant, and other process piping and equipment operating with fluid temperatures below the ambient dew point;

 

6)         Water supply and drainage piping on which condensation may occur;

 

7)         Air ducts and casings with outside surface temperature below the ambient dew point; and

 

8)         Other piping, ducts, and equipment as necessary to maintain the efficiency of the system.

 

c)         Insulation may be omitted from hot water and steam condensate piping that is not subject to contact by residents when the insulation is not necessary for preventing excessive system heat loss or excessive heat gain.

 

d)           Insulation on cold surfaces shall include an exterior vapor barrier.

 

e)           Insulation, including finishes and adhesives on exterior surfaces of ducts, pipes, and equipment, shall have a flame spread rating of 25 or less and a smoke developed rating of 50 or less as determined by an independent testing laboratory in accordance with ASTM Standard E 84.  Exception: Duct, pipe, and equipment coverings shall not be required to meet these requirements if they are located entirely outside of a building, do not penetrate a wall or roof, or do not create an exposure hazard.

 

f)         Steam and Hot Water Systems.  Supply and return mains and risers for cooling, heating, and process steam systems shall be valved to isolate the various sections of each system.  Each piece of equipment shall be valved at the supply and return ends.

 

g)         Thermal Hazards.  Any surface that is accessible to residents and exceeds a temperature of 140 degrees Fahrenheit (such as radiators, hot water or steam pipes, baseboard heaters, or therapy equipment) shall be provided with partitions, screens, shields, or other means to protect residents from injury.  Any protective device shall be designed and installed so that it does not present a fire or safety hazard or adversely affect the safe operation of the equipment.

 

h)         Heating, Ventilating, and Air Conditioning Systems

 

1)         Areas of a nursing home used by residents of the nursing home shall be air conditioned and heated by means of operable air-conditioning and heating equipment. The areas subject to this air-conditioning and heating requirement include, without limitation, bedrooms or common areas such as sitting rooms, activity rooms, living rooms, community rooms, and dining rooms. (Section 3-202(8) of the Act)

 

A)        The mechanical system shall be capable of maintaining a temperature of at least 75 degrees Fahrenheit, pursuant to the requirements of Section 350.690(j).

 

B)        The air-conditioning system shall be capable of maintaining an ambient air temperature of between 75 degrees Fahrenheit and 80 degrees Fahrenheit, pursuant to the requirements of Section 350.690(j).

 

2)         Heaters or furnaces of a type to be installed under, in, or on the floor are not permitted. 

 

3)         All ventilation supply, return, and exhaust systems shall be mechanically operated.

 

4)         The kitchen shall be provided with ventilation for reasonable comfort and with sufficient make-up air for the rangehood exhaust. 

 

5)         The laundry shall be provided with ventilation for reasonable comfort, with air flowing from clean areas to soiled areas and with exhaust to the outdoors. 

 

6)         Outdoor air intakes shall be located as far as practical, but not less than 15 feet, from the exhaust outlets of ventilation systems, combustion equipment stacks, plumbing vent stacks, or areas that may collect vehicular exhaust and other noxious fumes.  The bottom of outdoor air intakes serving central systems shall be located as high as practical, but not less than six feet above ground level, or, if installed above the roof, three feet above roof level.

 

7)         Air conditioning and ventilating systems shall be maintained to comply with the requirements of NFPA 90A. 

 

8)         The hood and duct system for cooking equipment used in processes that produce smoke or grease-laden vapors, such as griddle frying or deep frying, shall comply with NFPA 96.  The hood's extinguishment system shall be connected to the building fire alarm system and shall initiate a general alarm when activated.  Duct insulation that is used in lieu of spacing from combustible construction members shall terminate at the top of the hood on the lower end, covering the duct collar, and shall pass through any combustible nailer opening in the roof/ceiling assembly and into the roof jack assembly.  The material used shall be installed exactly as the manufacturer's instructions require.

 

9)         Boiler rooms and other rooms housing combustion equipment shall be provided with sufficient outdoor air to maintain proper combustion rates of equipment and to limit room temperatures to 20 degrees Fahrenheit over ambient inside air in adjacent interior spaces.  If sealed combustion units are in use, the discharge line is to remain clear of any adjacent walk paths and shall be not less than 15 feet from any operable fenestration or air intakes.  NFPA 54 shall apply, including the calculations for combustion air openings. 

 

10)         For areas within the footprint of the facility that are heated by fuel-fired appliances using an air-to-air heat exchanger, no fewer than two carbon monoxide (CO) detectors shall be installed in the area served by each heat exchanger.  One CO detector shall be installed within five feet of a supply duct and one within five feet of a return or exhaust duct.  CO detectors shall be line or system powered and shall signal the building fire alarm system when activated.  If detectors are line powered, a battery back-up or connection to the emergency power system is required.

 

(Source:  Amended at 35 Ill. Reg. 3461, effective February 14, 2011)

 

Section 350.3030  Plumbing Systems

 

a)         All plumbing systems shall be designed and installed in accordance with the requirements of the Department's rules entitled "Illinois Plumbing Code" (77 Ill. Adm. Code 890) except that the number of water closets, lavatories, bath tubs, showers and other fixtures shall be as required by these Requirements and the facility program.  (B)

 

b)         Plumbing Fixtures

 

1)         Plumbing fixtures shall be of non-absorptive acid-resistant materials and shall be kept in good repair.

 

2)         Clinical rim flush sinks shall have an integral trap in which the upper portion of the trap seal provides a visible water surface.

 

3)         When existing showers or tubs are replaced or additional showers or tubs provided, the shower bases and tub bottoms shall be designed with nonslip surfaces.

 

c)         Water Supply Systems

 

1)         Water supply systems shall be designed to supply potable water at sufficient pressure and volume to operate all plumbing fixtures and equipment during maximum demand periods.

 

2)         It is recommended that each water service main, branch main, riser and branch to a group of fixtures be valved.  Stop valves should be provided at each fixture.

 

3)         Hot water distribution systems shall be arranged to provide hot water of at least 100 degrees Fahrenheit at each hot water outlet at all times.

 

4)         Hot water available to residents at shower bathing and handwashing facilities shall not exceed 110 degrees Fahrenheit  (A,B)

 

5)         Protective measures, such as but not limited to, installation of a mixing valve, limited access to controls, and checking water temperatures daily at various points, shall be implemented to insure that the temperature of hot water available to residents at shower, bathing and handwashing facilities shall not exceed 110 degrees Fahrenheit (A,B)

 

d)         Hot Water Heaters and Tanks.  Water storage tanks shall be fabricated of corrosion resistant metal or lined with non-corrosive material.

 

e)         Drainage Systems.  Special precautions shall be taken to protect food preparation, serving or storage areas from possible leakage or condensation from necessary overhead piping systems.  (B)

 

f)         Fire Extinguishment Systems.  All fire extinguishment systems shall be designed and installed in accordance with NFPA 101 and NFPA l3.  All fire extinguishment systems shall be maintained in accordance with NFPA l3A.  (A, B)

 

(Source:  Amended at 14 Ill. Reg. 14876, effective October 1, 1990)

 

Section 350.3040  Electrical Requirements

 

a)         The electrical installation for existing facilities shall continue to meet all the requirements of the National Electrical Code, effective at the time of approval by the Department of final drawings and specification or the inspection of the building.  (A, B)

 

b)         Circuit breakers or fusible switches that provide disconnecting means and overcurrent protection for conductors connected to switchboards and panelboards shall be enclosed or guarded to provide a dead-front type of assembly.  Overload protective devices shall be suitable for operating properly in ambient temperature conditions.

 

c)         Lighting

 

1)         All spaces occupied by people, machinery, or equipment within buildings, approaches to buildings, and parking lots shall have lighting.

 

2)         Resident's rooms shall have general lighting.  A vandal-proof reading light shall be provided for each resident.

 

d)         Receptacles (Convenience Outlets).  Each resident room shall have adequate duplex type receptacles.

 

e)         Door Alarm System.  See Section 350.300(d)(2).  (B)

 

f)         Fire Alarm System

 

1)         A manually-operated, electrically-supervised fire alarm system shall be installed.  Pre-signal systems are not permitted.  (A, B)

 

2)         There shall be an approved fire detection and alarm system throughout the facility. (A, B)

 

3)         The fire alarm signals shall automatically transmit the alarm to any available municipal fire department by direct private line or through an approved central station.  (A, B)

 

4)         Fire alarms shall be activated by manual stations and all detection systems and flow alarm devices and sprinkler systems.  (A, B)

 

g)         Emergency Electrical Requirements  (B)

 

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.  (B)

 

2)         The source of this emergency electrical service shall be one of the following:  (B)

 

A)        An emergency generating set when the normal service is supplied by only one central station transmission line.

 

B)        Automatic battery operated systems or equipment that will be effective for four or more hours and will be capable of supplying power for lighting for exit signs, exit corridors, stairways, nurses' stations, communication system, and all alarm systems, including the nurses' call system.

 

C)        An approved dual source of normal power.  Such a dual source of normal power shall consist of two or more electrical services fed from separate generator sets or a utility distribution network having multiple power input sources and arranged to provide mechanical and electrical separation so that a fault between the facility and the generating sources will not likely cause an interruption of more than one of the facility service feeders.  An automatic transfer switch is required between the facility service feeders.

 

3)         Provide emergency electrical service for: (B)

 

A)        illumination of 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 and detection systems,

 

D)        communication systems which are used for issuing instructions,

 

E)        task illumination in the nurses' station.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

SUBPART O: RESIDENT'S RIGHTS

 

Section 350.3210  General

 

a)         No resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the Constitution of the State of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of a facility.  (Section 2-101 of the Act)

 

b)         A resident shall be permitted to retain and use or wear his or her personal property in his or her immediate living quarters, unless deemed medically inappropriate by a physician and so documented in the resident's clinical record. (Section 2-103 of the Act)

 

c)         If clothing is provided to the resident by the facility it shall be of a proper fit. (Section 2-103 of the Act)

 

d)         The facility shall provide adequate storage space for the personal property of the resident. (Section 2-103 of the Act)

 

e)         The facility shall provide a means of safeguarding small items of value for its residents in their rooms or in any other part of the facility so long as the residents have daily access to such valuables.  (Section 2-103 of the Act)

 

f)         The facility shall make reasonable efforts to prevent loss and theft of residents' property.  Those efforts shall be appropriate to the particular facility and may include, but are not limited to, staff training and monitoring, labeling property, and frequent property inventories. (Section 2-103 of the Act)

 

g)         The facility shall develop procedures for investigating complaints concerning theft of residents' property and shall promptly investigate all such complaints.  (Section 2-103 of the Act)

 

h)         The administrator shall ensure that married residents residing in the same facility be allowed to reside in the same room within the facility unless there is no room available in the facility or it is deemed medically inadvisable by the residents' attending physician and so documented in the residents' medical records.  (Section 2-108(e) of the Act)

 

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

 

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

 

k)         A resident may refuse to perform labor for a facility. (Section 2-113 of the Act)

 

l)          A resident shall be permitted the free exercise of religion. Upon a resident's request, and if necessary at his expense, the facility administrator shall make arrangements for a resident's attendance at religious services of the resident's choice.  However, no religious beliefs or practices, or attendance at religious services, may be imposed upon any resident. (Section 2-109 of the Act)

 

m)        All facilities shall comply with the Election Code.

 

n)         A facility shall immediately notify the identified resident's next of kin, resident's representative and physician of the resident's death or when the resident's death appears to be imminent.  (Section 2-208 of the Act)

 

o)         The facility shall immediately notify the resident's family, guardian, representative, conservator and any private or public agency financially responsible for the resident's care whenever unusual circumstances such as accidents, sudden illness, disease, unexplained absences, extraordinary resident charges, billings, or related administrative matters arise.

 

p)         Where a resident, a resident's representative or a resident's next of kin believes that an emergency exists each of them, collectively or separately, may file a verified petition to the circuit court for the county in which the facility is located for an order placing the facility under the control of a receiver.  (Section 3-503 of the Act) As used in Section 3-503 of the Act, "emergency" means a threat to the health, safety or welfare of a resident that the facility is unwilling or unable to correct. (Section 3-501 of the Act)

 

q)         Residents and their guardians or other resident representatives, if any, shall be notified, on a form provided by the Department, of any violation of the Act or this Part pursuant to Section 2-217 of the Act, or of violations of the requirements of Titles XVIII or XIX of the Social Security Act or rules promulgated thereunder, with respect to the health, safety, or welfare of the resident. (Section 2-115 of the Act)

 

r)          When the Department issues any notice pursuant to Section 3-119, 3-119.1, 3-301, 3-303, 3-307, or 3-702 of the Act or a notice of federal Medicaid certification deficiencies, the facility shall provide notification of the violations and deficiencies within 10 days after receiving a notice described within this subsection (r) to every resident and the resident's representative or guardian identified or referred to anywhere within the Department notice or the CMS 2567 as having received care or services that violated State or federal standards. The notification shall include a Department-prescribed notification letter and a copy of the notice and CMS 2567, if any, issued by the Department. A facility's failure to provide notification pursuant to this Section to a resident and the resident's representative or guardian, if any, shall constitute a Type "B" violation. Section 2-217 of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.3220  Medical and Personal Care Program

 

a)         A resident shall be permitted to retain the services of his or her own personal physician at his or her own expense under an individual or group plan of health insurance, or under any public or private assistance program providing such coverage.  However, the facility is not liable for the negligence of any such personal physician.  (Section 2-104(a) of the Act)

 

b)         The Department shall not prescribe the course of medical treatment provided to an individual resident by the resident's physician in a facility. (Section 3-201 of the Act)

 

c)         A resident shall be permitted to retain the services of his or her own personal physician at his or her own expense under an individual or group plan of health insurance, or under any public or private assistance program providing such coverage.  However, the facility is not liable for the negligence of any such personal physician.  Every resident shall be permitted to obtain from his or her own physician or the physician attached to the facility complete and current information concerning his or her medical diagnosis, treatment and prognosis in terms and language the resident can reasonably be expected to understand.  (Section 2-104(a) of the Act)

 

d)         Every resident shall be permitted to participate in the planning of his or her total care and medical treatment to the extent that his or her condition permits.  (Section 2-104(a) of the Act)

 

e)         No resident shall be subjected to experimental 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 Director.  (Section 2-104(a) of the Act)

 

f)         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 registered nurse staff within 24 hours after such orders have been issued to assure facility compliance with such orders. (Section 2-104(b) of the Act)

 

g)         Every woman resident of child-bearing age shall receive routine obstetrical and gynecological evaluations as well as necessary prenatal care. (Section 2-104(b) of the Act) In addition, women residents shall be referred immediately for diagnosis whenever pregnancy is suspected.

 

1)         "Routine obstetrical evaluations" and "necessary prenatal care" shall include, at a minimum, the following:

 

A)        Early diagnosis of pregnancy;

 

B)        A comprehensive health history, including menstrual history, methods of family planning that the patient has used, a detailed record of past pregnancies, and data on the current pregnancy that allow the physician to estimate the date of delivery;

 

C)        Identification of factors in the current pregnancy that help to identify the patient at high risk, such as maternal age, vaginal bleeding, edema, urinary infection, exposure to radiation and chemicals, ingestion of drugs and alcohol, and use of tobacco;

 

D)        A comprehensive physical examination, including an evaluation of nutritional status; determination of height, weight and blood pressure; examination of the head, breasts, heart, lungs, abdomen, pelvis, rectum, and extremities;

 

E)        The following laboratory tests, as early in pregnancy as possible. Findings obtained from the history and physical examination may determine the need for additional laboratory evaluations:

 

i)          Hemoglobin or hematocrit measurement;

 

ii)         Urinalysis, including microscopic examination or culture;

 

iii)        Blood group and Rh type determination;

 

iv)        Antibody screen;

 

v)         Rubella antibody titer measurement;

 

vi)        Syphilis screen;

 

vii)       Cervical cytology; and

 

viii)      Viral hepatitis (HBsAg) testing.

 

F)         A risk assessment that, based on the findings of the history and physical examination, should indicate any risk factors that may require special management, such as cardiovascular disease, maternal age more than 35 years, neurologic disorder, or congenital abnormalities;

 

G)        Return visits, the frequency of which will be determined by the patient's needs and risk factors.  A woman with an uncomplicated pregnancy shall be seen every four weeks for the first 28 weeks of pregnancy, every two to three weeks until 36 weeks of gestation, and weekly thereafter;

 

H)        Determinations of blood pressure, measured fundal height, fetal heart rate, and, in later months, fetal presentation, urinalysis for albumin and glucose.  Hemoglobin or hematocrit level shall be measured again early in the third trimester. Glucose screening is recommended for women who are 30 years of age or older;

 

I)         Evaluation and monitoring of nutritional status and habits;

 

J)         Education for health promotion and maintenance;

 

K)        Counseling concerning exercise and child birth education programs;

 

L)        Postpartum review and evaluation four to eight weeks after delivery, including determination of weight and blood pressure and assessment of status of breasts, abdomen, and external and internal genitalia.

 

2)         "Routine gynecological evaluations" shall include, at a minimum, the following:

 

A)        An initial examination, the basic components of which are:

 

i)          History; any present illnesses; menstrual, reproductive, medical, surgical, emotional, social, family, and sexual history; medications; allergies; family planning; and systems review;

 

ii)         Physical examination, including height, weight, nutritional status, and blood pressure; head and neck, including thyroid gland; heart; lungs; breasts; abdomen; pelvis, including external and internal genitalia; rectum; extremities, including signs of abuse; lymph nodes; and

 

iii)        Laboratory tests, including urine screen; hemoglobin or hematocrit determination and, if indicated, complete blood cell count; cervical cytology; rubella titer.

 

B)        Annual updates, including but not limited to:

 

i)          History, including the purpose of the visit; menstrual history; interval history, including systems review; emotional history;

 

ii)         Physical examination, including weight, nutritional status and blood pressure; thyroid gland; breasts; abdomen; pelvis, including external and internal genitalia; rectum; other areas as indicated by the interval history;

 

iii)        Laboratory, including urine screen; cervical cytology, unless not indicated; hemoglobin or hematocrit determinations; and

 

iv)        Additional laboratory tests, such as screening for sexually transmitted disease, shall be performed as warranted by the history, physical findings, and risk factors.

 

3)         When a resident is referred for a diagnosis of pregnancy and/or for prenatal care, the facility shall send the health care provider a copy of the resident's medical record, including a list of prescription medications taken by the resident; the resident's use of alcohol, tobacco and illicit drugs; and any exposure of the resident to radiation or chemicals during the preceding three months.

 

h)         Cancer screening.  Cancer screening for women shall include the following:

 

1)         A periodic Pap test.  The frequency and administration of Pap tests shall be according to the Guidelines for Women's Health Care, published by the American College of Obstetricians and Gynecologists; and

 

2)         Mammography.  The frequency and administration of mammograms shall be according to the Guidelines for Women's Health Care.

 

i)          Every resident shall be permitted to refuse medical treatment and to know the consequences of such action, unless such refusal would be harmful to the health and safety of others and such harm is documented by a physician in the resident's clinical record.  (Section 2-104(c) of the Act)

 

j)          Every resident, resident's guardian, or parent if the resident is a minor shall be permitted to inspect and copy all of the resident's clinical and other records concerning the resident's care and maintenance kept by the facility or by the resident's physician. (Section 2-104(d) of the Act)

 

k)         A resident shall be permitted respect and privacy in his or her medical and personal care program.  Every resident's case discussion, consultation, examination and treatment shall be confidential and shall be conducted discreetly, and those persons not directly involved in the resident's care must have the resident's permission to be present.  (Section 2-105 of the Act)

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.3230  Restraints (Repealed)

 

(Source:  Repealed at 22 Ill. Reg. 16557, effective September 18, 1998)

 

Section 350.3240  Abuse and Neglect

 

a)         An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident.  It is the duty of any facility employee or agent who becomes aware of such abuse or neglect to report it as provided in the Abused and Neglected Long Term Care Facility Residents Reporting Act.  (Section 2-107 of the Act)

 

b)         A facility employee or agent who becomes aware of abuse or neglect of a resident prohibited by Section 2-107 of the Act shall immediately report the matter to the Department and to the facility administrator.  (Section 3-610(a) of the Act)

 

c)         A facility administrator who becomes aware of abuse or neglect of a resident prohibited by Section 2-107 of the Act shall immediately report the matter by telephone and in writing to the resident's representative, and to the Department. (Section 3-610(a) of the Act)

 

d)         Any person may report a violation of Section 2-107 of the Act to the Department. (Section 3-610(a) of the Act)

 

e)         Employee as perpetrator of abuse.  When an investigation of a report of suspected abuse of a resident indicates, based upon credible evidence, that an employee of a long-term care facility is the perpetrator of the abuse, that employee shall immediately be barred from any further contact with residents of the facility, pending the outcome of any further investigation, prosecution or disciplinary action against the employee. (Section 3-611 of the Act)

 

f)         Resident as perpetrator of abuse.  When an investigation of a report of suspected abuse of a resident indicates, based upon credible evidence, that another resident of the long-term care facility is the perpetrator of the abuse, that resident's condition shall be immediately evaluated to determine the most suitable therapy and placement for the resident, considering the safety of that resident as well as the safety of other residents and employees of the facility.  (Section 3-612 of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.3250  Communication and Visitation

 

a)         Every resident shall be permitted unimpeded, private and uncensored communication of his choice by mail, public telephone or visitation. (Section 2-108 of the Act)

 

b)         The administrator shall ensure that correspondence is conveniently received and mailed, and that telephones are reasonably accessible. (Section 2-108(a) of the Act)

 

c)         The administrator shall ensure that residents may have private visits at any reasonable hour unless such visits are not medically advisable for the resident as documented in the resident's clinical record by the resident's physician.  (Section 2-108(b) of the Act)

 

d)         The facility shall allow daily visiting between 10 A.M. and 8 P.M.  These visiting hours shall be posted in plain view of visitors.

 

e)         The administrator shall ensure that space for visits is available and that facility personnel knock, except in an emergency, before entering any resident's room.  (Section 2-108(c) of the Act)

 

f)         Unimpeded, private and uncensored communication by mail, public telephone, and visitation may be reasonably restricted by a physician only in order to protect the resident or others from harm, harassment or intimidation provided that the reason for any such restriction is placed in the resident's clinical record by the physician and that notice of such restriction shall be given to all residents upon admission.  (Section 2-108(d) of the Act)

 

g)         Notwithstanding subsection (f), all letters addressed by a resident to the Governor, members of the General Assembly, Attorney General, judges, state's attorneys, officers of the Department, or licensed attorneys at law shall be forwarded at once to the persons to whom they are addressed without examination by facility personnel.  Letters in reply from the officials and attorneys mentioned above shall be delivered to the recipient without examination by facility personnel. (Section 2-108(d) of the Act)

 

h)         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 resident of any facility, but only if there is neither a commercial purpose nor effect to such access and if the purpose is to do any of the following:

 

1)         Visit, talk with and make personal, social, and legal services available to all residents;

 

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

 

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

 

4)         Engage in other methods of asserting, advising and representing residents so as to extend to them full enjoyment of their rights. (Section 2-110(a) of the Act)

 

i)          No visitor shall enter the immediate living area of any resident without first identifying himself or herself and then receiving permission from the resident to enter.  The rights of other residents present in the room shall be respected. (Section 2-110(b) of the Act)

 

j)          A resident may terminate at any time a visit by a person having access to the resident's living area under this Section. (Section 2-110(b) of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.3260  Resident's Funds

 

a)         A resident shall be permitted to manage his or her own financial affairs unless he or she or his or her guardian or if the resident is a minor, his or her parent, authorizes the administrator of the facility in writing to manage such resident's financial affairs under subsections (b) through (o). (Section 2-102 of the Act)

 

b)         The facility shall at the time of admission, provide, in order of priority,  each resident, or the resident's guardian, if any, or the resident's representative, if any, or the resident's immediate family member, if any, with a written statement explaining to the resident and the resident's spouse their spousal impoverishment rights as defined at Section 5-4 of the Illinois Public Aid Code, and at Section 303 of Title III of the Medicare Catastrophic Coverage Act of 1988 (P.L. 100 360), and the resident's rights regarding personal funds and listing the services for which the resident will be charged.  The facility shall obtain a signed acknowledgment from each resident or the resident's guardian, if any, or the resident's representative, if any, or the resident's immediate family member, if any, that such person has received the statement.  (Section 2-201(1) of the Act)

 

c)         The facility may accept funds from a resident for safekeeping and managing, if it receives written authorization from, in order of priority, the resident or the resident's guardian, if any, or the resident's representative, if any, or the resident's immediate family member, if any; such authorization shall be attested to by a witness who has no pecuniary interest in the facility or its operations, and who is not connected in any way to facility personnel or the administrator in any manner whatsoever.  (Section 2-201(2) of the Act)

 

d)         The facility shall maintain and allow, in order of priority, each resident or the resident's guardian, if any, or the resident's representative, if any, or the resident's immediate family member, if any, access to a written record of all financial arrangements and transactions involving the individual resident's funds. (Section 2-201(3) of the Act)

 

e)         The facility shall provide, in order of priority, each resident, or the resident's guardian, if any, or the resident's representative, if any, or the resident's immediate family member, if any, with a written itemized statement at least quarterly, of all financial transactions involving the resident's funds.  (Section 2-201(4) of the Act)

 

f)         The facility shall purchase a surety bond, or otherwise provide assurance satisfactory to the Departments of Public Health and Financial and Professional Regulation that all residents' personal funds deposited with the facility are secure against loss, theft, and insolvency. (Section 2-201(5) of the Act)

 

1)         If a surety bond is secured, it shall be issued by a company licensed to do business in Illinois, the amount of bond shall be equal to or greater than all resident funds managed by the facility, and the obligee named in the bond shall be the Illinois Department of Public Health or its assignees.

 

2)         If an alternative to a surety bond is secured, the alternative shall provide a protection equivalent to that afforded by a surety bond.  To be acceptable, the alternative shall have a person or persons or entity or entities designated who can collect in case of loss (e.g., residents, the Department).  The alternative shall also provide a guarantee that lost funds will be repaid.  The guarantee may be made by either an independent entity (e.g., a bank) or the facility.  If the facility provides the guarantee, it shall be backed by facility money at least equal to resident funds.  This money shall be reserved solely for the purpose of assuring the security of resident funds.  Two examples of acceptable alternatives to surety bonds are letters of credit and self-insurance.  Both surety bonds and alternatives shall protect the full amount of residents' funds deposited with the facility.

 

3)         Any alternative to a surety bond shall be submitted to the Department for review and approval.

 

g)         The facility shall keep any funds received from a resident for safekeeping in an account separate from the facility's funds, and shall at no time withdraw any part or all of such funds for any purpose other than to return the funds to the resident upon the request of the resident or any other person entitled to make such request, to pay the resident his or her allowance, or to make any other payment authorized by the resident or any other person entitled to make such authorization. (Section 2-201(6) of the Act)

 

h)         The facility shall deposit any funds received from a resident in excess of $100 in an interest bearing account insured by agencies of, or corporations chartered by, the State or federal government.  The account shall be in a form which clearly indicates that the facility has only a fiduciary interest in the funds and any interest from the account shall accrue to the resident.  (Section 2-201(7) of the Act)

 

i)          The facility may keep up to $100 of a resident's money in a non-interest bearing account or petty cash fund, to be readily available for the resident's current expenditures.  (Section 2-201(7) of the Act)

 

j)          The facility shall return to the resident, or the person who executed the written authorization required in subsection (c) of this Section, upon written request, all or any part of the resident's funds given the facility for safekeeping, including the interest accrued from deposits.  (Section 2-201(8) of the Act)

 

k)         The facility shall place any monthly allowance to which a resident is entitled in that resident's personal account, or give it to the resident, unless the facility has written authorization from the resident or the resident's guardian, or if the resident is a minor, his parent, to handle it differently.  (Section 2-201(9) of the Act)

 

l)          Unless otherwise provided by State law, upon the death of a resident, the facility shall provide the executor or administrator of the resident's estate with a complete accounting of all the resident's personal property, including any funds of the resident being held by the facility.  (Section 2-201(10) of the Act)

 

m)        If an adult resident is incapable of managing his funds and does not have a resident's representative, guardian, or an immediate family member the facility shall notify the Office of the State Guardian of the Guardianship and Advocacy Commission. (Section 2-201(11) of the Act)

 

n)         If the facility is sold, the seller shall provide the buyer with a written verification by a public accountant of all residents' monies and properties being transferred, and obtain a signed receipt from the new owner.  (Section 2-201(12) of the Act)

 

o)         The facility shall take all steps necessary to ensure that a personal needs allowance that is placed in a resident's personal account is used exclusively by the resident or for the benefit of the resident.  Where such funds are withdrawn from the resident's personal account by any person other than the resident, the facility shall require such person to whom funds constituting any part of a resident's personal needs allowance are released to execute an affidavit that such funds shall be used exclusively for the benefit of the resident, with verifiable receipts.  (Section 2-201(9)(b) and (c) of the Act) "Personal needs allowance," for the purposes of this subsection, refers to the monthly allowance allotted by the Illinois Department of Healthcare and Family Services to public aid recipients.

 

(Source:  Amended at 48 Ill. Reg. 2546, effective January 30, 2024)

 

Section 350.3270  Residents' Advisory Council

 

Each resident shall have the right to participate in a residents' advisory council as indicated in Section 350.650(a) through (m).

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3280  Contract With Facility

 

Each resident shall have the right to contract with the facility as indicated in Section 350.640(a) through (s).

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3290  Private Right of Action

 

a)         Each resident shall have the right to maintain a private right of action against a facility as described in subsections (b) through (i).

 

b)         The owner and licensee are liable to a resident for any intentional or negligent act or omission of their agents or employees which injures the resident. (Section 3-601 of the Act)

 

c)         The licensee shall pay the actual damages and costs and attorney's fees to a facility resident whose rights, as specified in Part l of Article II of the Act, are violated. (Section 3-602 of the Act)

 

d)         A resident may maintain an action under the Act for any other type of relief, including injunctive and declaratory relief, permitted by law. (Section 3-603 of the Act)

 

e)         Any damages recoverable under subsections (b) through (i), including minimum damages as provided by those subsections, may be recovered in any action which a court may authorize to be brought as a class action pursuant to the Civil Practice Law.  The remedies provided in subsections (b) through (i) are in addition to and cumulative with any other legal remedies available to a resident.  Exhaustion of any available administrative remedies shall not be required prior to commencement of a suit hereunder. (Section 3-604 of the Act)

 

f)         The amount of damages recovered by a resident in an action brought under subsections (b) through (i) shall be exempt for purposes of determining initial or continuing eligibility for medical assistance under the Illinois Public Aid Code, and shall neither be taken into consideration nor required to be applied toward the payment or partial payment of the cost of medical care or services available under the Illinois Public Aid Code. (Section 3-605 of the Act)

 

g)         Any waiver by a resident or his or her legal representative of the right to commence an action under subsections (b) through (i), whether oral or in writing, shall be null and void, and without legal force or effect. (Section 3-606 of the Act)

 

h)         Any party to an action brought under subsections (b) through (i) shall be entitled to a trial by jury and any waiver of the right to a trial by jury, whether oral or in writing, prior to the commencement of an action, shall be null and void, and without legal force or effect. (Section 3-607 of the Act)

 

i)          A licensee or its agents or employees shall not transfer, discharge, evict, harass, dismiss, or retaliate against a resident, a resident's representative, or an employee or agent who makes a report under Section 2-107 of the Act, brings or testifies in an action under subsections (b) through (i) of this Section, or files a complaint under Section 3-702 of the Act, because of the report, testimony, or complaint. (Section 3-608 of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.3300  Transfer or Discharge

 

a)         A resident may be discharged from a facility after he or she gives the administrator, a physician, or a nurse of the facility written notice of his or her desire to be discharged.  If a guardian has been appointed for a resident or if the resident is a minor, the resident shall be discharged upon written consent of his or her guardian or if the resident is a minor, his or her parent unless there is a court order to the contrary.  In such cases, upon the resident's discharge, the facility is relieved from any responsibility for the resident's care, safety or well-being. (Section 2-111 of the Act)

 

b)         Each resident's rights regarding involuntary transfer or discharge from a facility shall be as described in subsections (c) through (z) and in Sections 350.636(a) and 350.637(a).

 

c)         Reasons for Transfer or Discharge

 

1)         A facility may involuntary transfer or discharge a resident only for one or more of the following reasons:

 

A)        for medical reasons as determined by the IDT and as ordered by the resident's attending physician;

 

B)        for the resident's physical safety;

 

C)        for the physical safety of other residents, the facility staff or facility visitors; or

 

D)        for either late payment or nonpayment for the resident's stay, except as prohibited by Titles XVIII and XIX of the federal Social Security Act.  For purposes of this Section, "late payment" means non-receipt of payment after submission of a bill.  If payment is not received within 45 days after submission of a bill, a facility may send a notice to the resident and responsible party requesting payment within 30 days.  If payment is not received within such 30 days, the facility may thereupon institute transfer or discharge proceedings by sending a notice of transfer or discharge to the resident and responsible party by registered or certified mail.  The notice shall state, in addition to the requirements of Section 3-403 of the Act and subsection (e), that the responsible party has the right to pay the amount of the bill in full up to the date the transfer or discharge is to be made and then the resident shall have the right to remain in the facility.  Such payment shall terminate the transfer or discharge proceedings.  This subsection does not apply to those residents whose care is provided under the Illinois Public Aid Code. (Section 3-401 of the Act)

 

2)         Prohibition of Discrimination

 

A)        A facility participating in the Medical Assistance Program is prohibited from failing or refusing to retain as a resident any person because he or she is a recipient of or an applicant for the Medical Assistance Program under Article V of the Illinois Public Aid Code.  (Section 3-401.1(a) of the Act) For the purposes of this Section, a recipient or applicant shall be considered a resident in the facility during any hospital stay totaling 10 days or less following a hospital admission. (Section 3-401.1(a-10) of the Act) The day on which a resident is discharged from the facility and admitted to the hospital shall be considered the first day of the 10-day period.

 

B)        A facility which violates subsection (c)(2)(A) shall be guilty of a business offense and fined not less than $500 nor more than $1,000 for the first offense and not less than $1,000 nor more than $5,000 for each subsequent offense.  (Section 3-401.1(b) of the Act)

 

d)         Involuntary transfer or discharge of a resident from a facility shall be preceded by the discussion required under subsection (k) of this Section and by a minimum written notice of 21 days, except in one of the following instances:

 

1)         When an emergency transfer or discharge is attending physician because of the resident's health care needs; or

 

2)         When the transfer or discharge is mandated by the physical safety of other residents, the facility staff, or facility visitors, as documented in the clinical record. The Department shall be notified prior to any such involuntary transfer or discharge. The Department shall immediately offer transfer, or discharge and relocation assistance to residents transferred or discharged under this subsection (d), and the Department may place relocation teams as provided in Section 3-419 of the Act.  (Section 3-402 of the Act) Risks to physical safety means behavior that has not changed, or risks that have not been reduced, after appropriate assessment, program changes, behavioral intervention, and expert consultation, as determined by the IDT, and among which may include, but are not limited to, such behaviors as the following:

 

A)        The resident has displayed aggression to self or to others;

 

B)        The resident has committed property destruction that caused injury to the resident or to others;

 

C)        The resident habitually leaves the facility and, because of his or her lack of safety skills, is likely to be in danger of harming himself or herself, or others. 

 

e)         The notice required by subsection (d) of this Section shall be on a form prescribed by the Department and shall contain all of the following:

 

1)         The stated reason for the proposed transfer or discharge; (Section 3-403(a) of the Act)

 

2)         The effective date of the proposed transfer or discharge; (Section 3-403(b) of the Act)

 

3)         A statement in not less than 12-point type, which reads:

 

"You have a right to appeal the facility's decision to transfer or discharge you.  If you think you should not have to leave this facility, you may file a request for a hearing with the Department of Public Health within 10 days after receiving this notice.  If you request a hearing, it will be held not later than 10 days after your request, and you generally will not be transferred or discharged during that time. If the decision following the hearing is not in your favor, you generally will not be transferred or discharged prior to the expiration of 30 days following receipt of the original notice of the transfer or discharge.  A form to appeal the facility's decision and to request a hearing is attached.  If you have any questions, call the Department of Public Health at the telephone number listed below.  ";(Section 3-403(c) of the Act)

 

4)         A hearing request form, together with a postage paid, preaddressed envelope to the Department; (Section 3-403(d) of the Act)

 

5)         The name, address, and telephone number of the person charged with the responsibility of supervising the transfer or discharge; and (Section 3-403(e) of the Act)

 

6)         Confirmation that the Independent Service Coordination (ISC) agency has been formally notified in writing of the facility's intent to involuntarily discharge a resident, and the facility:

 

A)        Has requested assistance from the ISC agency in the resident's relocation, transfer, or discharge; and

 

B)        Has included supporting documentation with the request for assistance that demonstrates the effort the facility has made to address the resident's needs, such as program plans, behavioral intervention plans, consultation reports and other supportive documentation.

 

f)         The parties to a hearing arising from this Section shall be the resident and the facility. All hearings arising from this Section shall proceed unless the resident, the resident's guardian, or the resident's authorized representative voluntarily withdraws the request for hearing. Once the resident has made a request for hearing, the facility shall not have the ability to terminate the proceedings unless the facility meets the following two criteria:

 

1)         The facility withdraws the Notice of Involuntary Transfer or Discharge; and

 

2)         The resident shall be allowed to return to the facility.

 

g)         A request for a hearing made under subsection (m) shall stay a transfer pending a hearing or appeal of the decision, unless a condition which would have allowed transfer or discharge in less than 21 days as described under subsections (d)(1) and (2) develops in the interim. (Section 3-404 of the Act)

 

h)         A copy of the notice required by subsection (d) shall be placed in the resident's clinical record and a copy shall be transmitted to the Department, the resident, and the resident's representative.  (Section 3-405 of the Act)

 

i)          When the basis for an involuntary transfer or discharge is the result of an action by the Department of Healthcare and Family Services with respect to a recipient of assistance under Title XIX of the Social Security Act and a hearing  request is filed with the Department of Healthcare and Family Services, the 21-day written notice period shall not begin until a final decision in the matter is rendered by the Department of Healthcare and Family Services or a court of competent jurisdiction and notice of that final decision is received by the resident and the facility. (Section 3-406 of the Act)

 

j)          When nonpayment is the basis for involuntary transfer or discharge, the resident shall have the right to redeem up to the date that the discharge or transfer is to be made and then shall have the right to remain in the facility.  (Section 3-407 of the Act)

 

k)         The planned involuntary transfer or discharge shall be discussed with the resident, the resident's representative and person or agency responsible for the resident's placement, maintenance, and care in the facility.  The explanation and discussion of the reasons for involuntary transfer or discharge shall include the facility administrator or other appropriate facility representative as the administrator's designee.  The content of the discussion and explanation shall be summarized in writing and shall include the names of the individuals involved in the discussions and made a part of the resident's clinical record. (Section 3-408 of the Act)

 

l)          The facility shall offer the resident counseling services before the transfer or discharge of the resident.  (Section 3-409 of the Act)

 

m)        A resident subject to involuntary transfer or discharge from a facility, the resident's guardian or if the resident is a minor, his or her parent shall have the opportunity to file a request for a hearing with the Department within 10 days following receipt of the written notice of the involuntary transfer or discharge by the facility.  (Section 3-410 of the Act)

 

n)         The Department of Public Health, when the basis for involuntary transfer or discharge is other than action by the Department of Healthcare and Family Services with respect to the Title XIX Medicaid recipient, shall hold a hearing at the resident's facility not later than 10 days after a hearing request is filed, and render a decision within 14 days after the filing of the hearing request. (Section 3-411 of the Act)

 

o)         The hearing before the Department provided under subsection (m) shall be conducted as prescribed under Section 3-703 of the Act.  In determining whether a transfer or discharge is authorized, the burden of proof in this hearing rests on the person requesting the transfer or discharge. (Section 3-412 of the Act)

 

p)         If the Department determines that a transfer or discharge is authorized under subsection (c), the resident shall not be required to leave the facility before the 34^th day following receipt of the notice required under subsection (d), or the 10^th day following receipt of the Department's decision, whichever is later, unless a condition which would have allowed transfer or discharge in less than 21 days as described under subsections (d)(1) and (2) develops in the interim.  (Section 3-413 of the Act)

 

q)         The Department of Healthcare and Family Services shall continue Title XIX Medicaid funding during the appeal, transfer, or discharge period for those residents who are recipients of assistance under Title XIX of the Social Security Act affected by subsection (c). (Section 3-414 of the Act)

 

r)          The Department may transfer or discharge any resident from any facility required to be licensed under the Act and this Part when any of the following conditions exist:

 

1)         Such facility is operating without a license; (Section 3-415(a) of the Act)

 

2)         The Department has suspended, revoked or refused to renew the license of the facility as provided under Section 3-119 of the Act; (Section 3-415(b) of the Act)

 

3)         The facility has requested the aid of the Department in the transfer or discharge of the resident and the Department finds that the resident consents to transfer or discharge; (Section 3-415(c) of the Act)

 

4)         The facility is closing or intends to close and adequate arrangement for relocation of the resident has not been made at least 30 days prior to closure; or (Section 3-415(d) of the Act)

 

5)         The Department determines that an emergency exists which requires immediate transfer or discharge of the resident; or (Section 3-415(e) of the Act)

 

6)         The facility is a distressed facility.

 

s)         In deciding to transfer or discharge a resident from a facility under subsection (r), the Department shall consider the likelihood of serious harm which may result if the resident remains in the facility. (Section 3-416 of the Act)

 

t)          The Department shall offer transfer or discharge and relocation assistance to residents transferred or discharged under subsections (c) through (r) including information on available alternative placements.  Residents shall be involved in planning the transfer or discharge and shall choose among the available alternative placements, except that where an emergency makes prior resident involvement impossible, the Department may make a temporary placement until a final placement can be arranged.  Residents may choose their final alternative placement and shall be given assistance in transferring to such place.  No resident may be forced to remain in a temporary or permanent placement.  Where the Department makes or participates in making the relocation decision, consideration shall be given to proximity to the resident's relatives and friends.  The resident shall be allowed three visits to potential alternative placements prior to removal, except where medically contraindicated or where the need for immediate transfer or discharge requires reduction in the number of visits. (Section 3-417 of the Act)

 

u)         The Department shall prepare resident transfer or discharge plans to assure safe and orderly removals and protect residents' health, safety, welfare and rights.  In nonemergencies and where possible in emergencies, the Department shall design and implement such plans in advance of transfer or discharge. (Section 3-418 of the Act)

 

v)         The Department may place relocation teams in any facility from which residents are being discharged or transferred for any reason, for the purpose of implementing transfer or discharge plans. (Section 3-419 of the Act)

 

w)        In any transfer or discharge conducted under subsections (r) through (u) the Department shall:

 

1)         Provide written notice to the facility prior to the transfer or discharge.  The notice shall state the basis for the order of transfer or discharge and shall inform the facility of its right to an informal conference prior to transfer or discharge under this Section, and its right to a subsequent hearing under subsection (y).  If a facility desires to contest a nonemergency transfer or discharge, prior to transfer or discharge it shall, within four working days after receipt of the notice, send a written request for an informal conference to the Department.  The Department shall, within four working days from the receipt of the request, hold an informal conference in the county in which the facility is located.  Following this conference, the Department may affirm, modify or overrule its previous decision. Except in an emergency, transfer or discharge may not begin until the period for requesting a conference has passed or, if a conference is requested, until after a conference has been held; and (Section 3-420(a) of the Act)

 

2)         Provide written notice to any resident to be removed, to the resident's representative, if any, and to a member of the resident's family, where practicable, prior to the removal.  The notice shall state the reason for which transfer or discharge is ordered and shall inform the resident of the resident's right to challenge the transfer or discharge under subsection (y). The Department shall hold an informal conference with the resident or the resident's representative prior to transfer or discharge at which the resident or the representative may present any objections to the proposed transfer or discharge plan or alternative placement. (Section 3-420(b) of the Act)

 

x)         In any transfer or discharge conducted under subsection (r)(5), the Department shall notify the facility and any resident to be removed that an emergency has been found to exist and removal has been ordered, and shall involve the residents in removal planning if possible.  Following emergency removal, the Department shall provide written notice to the facility, to the resident, to the resident's representative, if any, and to a member of the resident's family, where practicable, of the basis for the finding that an emergency existed and of the right to challenge removal under subsection (y).  (Section 3-421 of the Act)

 

y)         Within ten days following transfer or discharge, the facility or any resident transferred or discharged may send a written request to the Department for a hearing under Section 3-703 of the Act to challenge the transfer or discharge.  The Department shall hold the hearing within 30 days after receipt of the request.  The hearing shall be held at the facility from which the resident is being transferred or discharged, unless the resident or resident's representative, requests an alternative hearing site. If the facility prevails, it may file a claim against the State under the Court of Claims Act for payments lost less expenses saved as a result of the transfer or discharge.  No resident transferred or discharged may be held liable for the charge for care which would have been made had the resident remained in the facility. If a resident prevails, the resident may file a claim against the State under the Court of Claims Act for any excess expenses directly caused by the order to transfer or discharge. The Department shall assist the resident in returning to the facility if assistance is requested. (Section 3-422 of the Act)

 

z)         Any owner of a facility licensed under the Act shall give 90 days' notice prior to voluntarily closing a facility or closing any part of a facility, or prior to closing any part of a facility if closing such part will require the transfer or discharge of more than 10% of the residents.  Such notice shall be given to the Department, to any resident who must be transferred or discharged, to the resident's representative, and to a member of the resident's family, where practicable. Notice shall state the proposed date of closing and the reason for closing.  The facility shall offer to assist the resident in securing an alternative placement and shall advise the resident on available alternatives.  Where the resident is unable to choose an alternate placement and is not under guardianship, the Department shall be notified of the need for relocation assistance.  The facility shall comply with all applicable laws and regulations until the date of closing, including those related to transfer or discharge of residents.  The Department may place a relocation team in the facility as provided under subsection (v).  (Section 3-423 of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.3310  Complaint Procedures

 

a)         A resident shall be permitted to present grievances on behalf of himself or herself or others to the administrator, the DD Facility Advisory Board, the residents' advisory council, State governmental agencies or other persons without threat of discharge or reprisal in any form or manner whatsoever. (Section 2-112 of the Act)

 

b)         The administrator shall provide all residents or their representatives with the name, address, and telephone number of the appropriate State governmental office where complaints may be lodged.  (Section 2-112 of the Act)

 

c)         A person who believes that the Act or this Part may have been violated may request an investigation.  The request may be submitted to the Department in writing, by telephone, or by personal visit.  An oral complaint shall be reduced to writing by the Department. (Section 3-702(a) of the Act)

 

d)         The substance of the complaint shall be provided in writing to the licensee, owner or administrator no earlier than at the commencement of the on-site inspection of the facility which takes place pursuant to the complaint. (Section 3-702(b) of the Act)

 

e)         The Department shall not disclose the name of the complainant unless the complainant or resident consents in writing to the disclosure or the investigation results in a judicial proceeding, or unless disclosure is essential to the investigation.  The complainant shall be given the opportunity to withdraw the complaint before disclosure.  Upon the request of the complainant, the Department may permit the complainant or a representative of the complainant to accompany the person making the on-site inspection of the facility. (Section 3-702(c) of the Act)

 

f)         Upon receipt of a complaint, the Department shall determine whether the Act or this Part has been or is being violated. The Department shall investigate all complaints alleging abuse or neglect within seven days after the receipt of the complaint except that complaints of abuse or neglect which indicate that a resident's life or safety is in imminent danger shall be investigated within 24 hours after receipt of the complaint.  All other complaints shall be investigated within 30 days after the receipt of the complaint.  All complaints shall be classified as "an invalid report," "a valid report," or "an undetermined report." For any complaint classified as "a valid report," the Department must determine within 30 working days if the Act or this Part has been or is being violated. (Section 3-702(d) of the Act)

 

g)         Upon the request of a resident or complainant, the Department may permit the resident or complainant or a representative of the complainant to accompany the person making the on-site inspection of the facility. (Section 3-702(c) of the Act)

 

h)         In all cases, the Department shall inform the complainant of its findings within 10 days of its determination unless otherwise indicated by the complainant, and the complainant may direct the Department to send a copy of such findings to another person.  The Department's findings may include comments or documentation provided by either the complainant or the licensee pertaining to the complaint.  The Department shall also notify the facility of such findings within 10 days of the determination, but the name of the complainant or residents shall not be disclosed in this notice to the facility. The notice of such findings shall include a copy of the written determination; the correction order, if any; the inspection report; the warning notice, if any; and the State licensure form on which the violation is listed. (Section 3-702(e) of the Act)

 

i)          A written determination, correction order, or warning notice concerning a complaint shall be available for public inspection, but the name of the complainant or resident shall not be disclosed without his or her consent. (Section 3-702(f) of the Act)

 

j)          A complainant who is dissatisfied with the determination or investigation by the Department may request a hearing under subsection (k).  The facility shall be given notice of any such hearing and may participate in the hearing as a party.  If a facility requests a hearing under subsection (k) which concerns a matter covered by a complaint, the complainant shall be given written notice and may participate in the hearing as a party.  A request for a hearing by either a complainant or a facility shall be submitted in writing to the Department within 30 days after the mailing of the Department's findings as described in subsection (h).  Upon receipt of the request the Department shall conduct a hearing as provided under subsection (k). (Section 3-702(g) of the Act)

 

k)         Any person aggrieved by a decision of the Department rendered in a particular case that affects the legal rights, duties or privileges created under the Act may have the decision reviewed pursuant to Sections 3-703 through 3-712 of the Act.

 

l)          When the Department finds that a provision of Article II of the Act regarding residents' rights has been violated with regard to a particular resident, the Department shall issue an order requiring the facility to reimburse the resident for injuries incurred, or $100, whichever is greater.

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.3320  Confidentiality

 

a)         The Department shall respect the confidentiality of a resident's record and shall not divulge or disclose the contents of a record in a manner which identifies a resident, except upon a resident's death to a relative or guardian, or under judicial proceedings.  This Section shall not be construed to limit the right of a resident or a resident's representative to inspect or copy the resident's records. (Section 2-206(a) of the Act)

 

b)         Confidential medical, social, personal, or financial information identifying a resident shall not be available for public inspection in a manner which identifies a resident. (Section 2-206(b) of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

 

Section 350.3330  Facility Implementation

 

a)         A facility shall establish written policies and procedures to implement the responsibilities and rights provided in Article II of the Act.  The policies shall include the procedure for the investigation and resolution of resident complaints under Section 3-702 of the Act.  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 type, shall be distributed to each resident and representative. (Section 2-210 of the Act)

 

b)         The facility shall provide copies of these policies and procedures upon request to next of kin, sponsoring agencies, and the public.

 

c)         Each resident and resident's guardian or other person acting for the resident shall be given a written explanation, prepared by the Office of the State Long-Term Care Ombudsman, of all the rights enumerated in Part 1 of Article II of the Act and in Part 4 of Article III of the Act.  For residents of facilities participating in Title XVIII or XIX of the Social Security Act, the explanation shall include an explanation of residents' rights enumerated in that Act.  The explanation shall be given at the time of admission to a facility or as soon thereafter as the condition of this resident permits, but in no event later than 48 hours after admission, and again at least annually thereafter.  If a resident is unable to read such written explanation, it shall be read to the resident in a language the resident understands.  In the case of a minor or a person having a guardian or other person acting for him, both the resident and the parent, guardian or other person acting for the resident shall be fully informed of these rights. (Section 2-211 of the Act)

 

d)         The resident, resident's representative, guardian, or parent of a minor resident shall acknowledge in writing the receipt from the facility of a copy of all resident rights set forth in Article II of the Act and a copy of all facility policies implementing those rights.

 

e)         The facility shall ensure that its staff is familiar with and observes the rights and responsibilities enumerated in Article II of the Act and this Part. (Section 2-212 of the Act)

 

(Source:  Amended at 46 Ill. Reg. 10519, effective June 2, 2022)

SUBPART P: SPECIAL STANDARDS FOR INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED OF 16 BEDS OR LESS

 

Section 350.3710  Applicability of Other Provisions of this Part

 

a)         An Intermediate Care Facility for the Developmentally Disabled of 16 Beds or Less - is a facility licensed as an intermediate care facility for the developmentally disabled (ICF/DD) for 16 or fewer residents.

 

b)         The standards and regulations stated in other divisions of this publication shall apply to this type of facility unless indicated otherwise in this Subpart P, by substitutions or additions.

 

c)         An Intermediate Care Facility for the Developmentally Disabled of 16 Beds or Less shall consist of no more than one building housing a maximum of 16 residents.

 

1)         Housing for developmentally disabled persons shall be located on non-adjacent sites and shall be similar in design and construction as other buildings and dwellings within the area.  An ICF/DD-16 Bed or Less Facility shall not be physically part of another facility or residential program licensed or funded by the state.  A distance of at least 300 feet must separate an ICF/DD-16 Bed or Less facility from other state licensed or state funded residential facilities.  (A, B)

 

2)         Any facility which is already licensed as an ICF/DD of 16 Beds or Less, and which does not meet the criteria listed in subsection (c)(1) of this Section, may continue to operate as it was prior to the effective date of this Subpart P, as long as it remains continuously licensed.  However, the criteria listed in subsection (c)(1) of this Section shall apply on any date the license terminates by operation of law, such as a change of ownership, voluntary closing of the facility by the licensee, or the license being revoked by the Department.

 

3)         Any facility having submitted an application for a permit or having been issued a permit from the Illinois Health Facilities Planning Board to establish an ICF/DD of 16 Beds or Less which does not meet the criteria listed in subsection (c)(1) of this Section may establish and operate such a facility, if it is licensed no later than six months after the effective date of the permit.  However, the criteria listed in subsection (c)(1) of this Section shall apply if the facility fails to obtain a license within six months after the effective date of the permit, or on any date the license of such facility terminates by operation of law, such as a change of ownership, voluntary closing of the facility by the licensee, or the license being revoked by the Department.

 

d)         Every facility applying for licensure as ICF/DD of 16 Beds or Less, after the effective date of this Subpart P, shall meet all the requirements contained in this Subpart P.  This is required both for newly constructed buildings and existing buildings converting to this type of licensure.

 

e)         Any person wishing to establish an ICF/DD of 16 Beds or Less facility must obtain a permit from the Illinois Health Facilities Planning Board.  See Section 350.110(f).

 

(Source:  Amended at 15 Ill. Reg. 466, effective January 1, 1991)

 

Section 350.3720  Administration

 

a)         The administrator is responsible for ensuring that the facility remains in compliance with the Act and this Subpart P, and that all resident care plans are carried out as written.  The administrator need not be full-time as required by Section 350.510(a), but shall spend at least four hours per week in the facility in the performance of these duties.  (B)

 

b)         No person shall be the Administrator of more than four licensed ICF/DD of 16 Beds or Less.

 

c)         In the absence of the Administrator, the Resident Services Director shall be responsible for the overall operation of the facility.  (I)

 

d)         In the absence of both the Administrator and the Resident Services Director, there shall be delegated written adequate authority and supervisory responsibility to a person at least 18 years of age who is capable of acting in an emergency during their absence.  Such administrative assignments shall not interfere with resident care and supervision.  (B)

 

e)         One person may perform the functions of both an Administrator and Resident Services Director.  However this person must meet the requirements as set forth in Subpart B as modified by this Section.  (B)

 

(Source:  Amended at 15 Ill. Reg. 466, effective January 1, 1991)

 

Section 350.3730  Admission and Discharge Policies

 

a)         Residents shall only be admitted who have had a comprehensive evaluation covering physical, emotional, social and cognitive factors, reviewed by an appropriately constituted interdisciplinary team (IDT).  As part of this evaluation, the resident's capabilities for self-preservation shall be determined. (B)

 

b)         No residents shall be denied admission solely on the basis of mobility limitations. If a resident has mobility limitations:

 

1)         The interdisciplinary team in the comprehensive evaluation shall conclude and document that:

 

A)        the person's needs (medical, social, psychological, and developmental) can be met at the facility; and

 

B)        admission to the facility is in the best interest of the person; and

 

C)        admission of the person to the facility will not adversely affect any resident currently at the facility.

 

2)         The physical plant and equipment must not be a barrier to the person's achieving all adjudged capabilities.

 

3)         The physical plant must comply with Impractical Evacuation Capability (21-2.2.4) as defined in Chapter 21 of the Life Safety Code (National Fire Protection Association Standard Number 101, 1985 edition); or there must be adequate available trained staff, as evaluated by the Department and as determined by the calculation of the Level of Evacuation Difficulty as defined in Appendix F of the Life Safety Code (NFPA 101, 1985 edition) so as to meet Slow Evacuation Capability (21-2.2.3) or Prompt Evacuation Capability (21-2.2.2).

 

c)         Each resident of an ICF/DD of 16 Beds or Less shall be either employed or enrolled in an external day program, off the grounds of the facility, at least 240 days per year, five hours per day. A resident may participate in more than one program to meet this requirement.

 

1)         The provision of employment or enrollment in a day program shall be documented in the resident's individual habilitation plan.

 

2)         Each interdisciplinary team review shall include a review of the resident's day program to assure consistent program planning and implementation.

 

3)         When possible, representatives from the resident's employment or day program shall participate in the interdisciplinary team review.

 

d)         Nothing in this Part shall excuse facility compliance with accessibility or reasonable accommodation requirements of state or federal law.

 

(Source:  Amended at 17 Ill. Reg. 19517, effective November 1, 1993)

 

Section 350.3740  Personnel

 

a)         The Resident Services Director shall be responsible for ensuring that all recommendations in the individual plan of care are carried out as stated in the plan.  The Resident Services Director shall spend at least two hours per week per resident in the performance of these duties.

 

b)         All new employees shall receive orientation and in-service training in accordance with Section 350.670(f) of this Part.

 

(Source:  Amended at 30 Ill. Reg. 13876, effective August 7, 2006)

 

Section 350.3750  Consultation Services and Nursing Services

 

Residents needing nursing care shall be admitted to an ICF/DD of 16 Beds or Less only if the facility has adequate professional nursing services to meet the resident's needs.  Arrangements shall be made through formal contract for the services of a licensed nurse to visit as required.  A responsible staff member shall be on duty at all times who is immediately accessible, and to whom residents can report injuries, symptoms of illness, and emergencies (see Section 350.810(a)). The consultant nurse shall provide consultation on the health aspects of the individual plan of care and shall be in the facility not less than two hours per month.

 

(Source:  Amended at 19 Ill. Reg. 11481, effective July 29, 1995)

 

Section 350.3760  Medication Policies

 

a)         In order for each resident to attain the highest possible level of independent functioning, all residents shall be permitted to participate in their total health care program.  This program shall include, but not be limited to, resident training in preventive health and self-medication procedures provided by a licensed nurse. Every facility shall adopt written preventative health and self-medication policies and procedures, which are consistent with the purpose of the Act and this Part and which shall be followed in the operation of the facility, for assisting residents in obtaining preventative health and self-medication skills. These policies and procedures shall be developed with consultation from an Illinois registered professional nurse and a registered pharmacist. These policies and procedures shall be part of the written program of care and services.  (See Section 350.620.)

 

b)         No facility shall operate a pharmacy.

 

c)         A facility may stock only drugs which are regularly available without prescription at a commercial pharmacy, such as:  noncontrolled cough syrups, laxatives, and analgesics.  These shall be given to a resident only upon the written order of the physician, dentist, or podiatrist; shall be administered from the original containers; and shall be recorded in the resident's clinical record.

 

d)         No emergency medication kit shall be maintained in this type of facility.

 

e)         Nursing stations are not required in this type of facility.

 

f)         Current medical references are not required in this type of facility.

 

g)         All medications on individual prescription or from the physician's personal supply shall be properly labeled as set forth in subsection (r).

 

1)         All other medications shall be authorized by a physician for individual resident use, and shall be clearly identified with the resident's name.

 

2)         Attending physicians shall review the medication regimen of each resident at least every six months.  Documentation of this review shall be entered in the resident's record.

 

h)         All medications used by residents shall be properly recorded by facility staff at time of use.  (See Section 350.1620(g).)  A medication record need not be kept for those residents for whom the attending physician has given permission to keep their medication in their room and to be fully responsible for taking the medications in the correct dosage and at the proper times themselves.

 

i)          Bottled oxygen may not be administered in a facility, except in an emergency. Not more than one 12 pound portable size tank of oxygen for such an emergency use shall be kept in the facility. However, use of an oxygen concentrator is permitted when prescribed by a physician for a resident.  The facility must be in compliance with directions for use of such equipment as established by the manufacturer.

 

j)          All discontinued legend or controlled drugs, all medications having an expiration date that has passed, and all medications of residents who have expired shall be disposed of in accordance with the regulations of the Federal Drug Enforcement Administration by the prescribing physician or the consultant pharmacist.  A notation of their disposition shall be made in the resident's record.

 

k)         All medications taken by residents in this type of facility must be administered by a nurse or physician licensed to practice in Illinois unless the medication is self-administered by the resident. Facility staff shall not administer medication to residents unless the staff person is a properly licensed nurse or physician.

 

1)         All residents shall be evaluated by the facility's interdisciplinary team to determine their self-medication capability. Each resident determined to have the capability to learn to administer his/her own medications shall have written training and habilitation objectives developed by the interdisciplinary team based upon this evaluation and stated in specific behavioral terms that permit the progress of the resident to be assessed and recorded.

 

2)         The facility shall provide, either directly or through arrangements with the consultant nurse, training and supervision necessary for identified residents to gain independence in self-administering their own medications as approved in writing by the resident's personal physician, and documented in the resident's individual plan.

 

3)         Facility staff may assist a resident in the self-administration of medications by taking the medication from the locked area where it is stored and handing it to the resident. If the resident is physically unable to open the container, a staff member may open the container for the resident. Facility staff may also assist physically impaired residents, such as those who have arthritis, cerebral palsy, or Parkinson's disease, in the removal of the medication from the container and in assisting the resident in consuming or applying the medication when requested to do so by the resident.  (For example, a staff member may place a dose of medicine in a container and place the container to the mouth of a resident who would not be able to do so without spilling it.)

 

4)         To be considered "capable of self-administering their own medications," residents must, at a minimum, be able to identify their medication by size, shape, or color and know when they should take it, and the amount to be taken each time.

 

l)          Medication may be administered by non-licensed direct care staff who have been trained and authorized in accordance with 59 Ill. Adm. Code 116 (Administration of Medication in Community Settings).  In addition to the requirements set forth in 59 Ill. Adm. Code 116.50, medications shall be given "as needed" or "PRN" only as follows:

 

1)         Only over-the-counter medications such as those listed in 59 Ill. Adm. Code 116.50(e), with the exception of laxatives, shall be administered PRN;

 

2)         Facilities may develop and follow policies limiting the administration of PRN medication;

 

3)         Each client's medical record shall state what medications may be administered PRN and shall include documentation of administration of PRN medication; and

 

4)         A licensed professional shall be notified within 24 hours after the administration of PRN medication by unlicensed direct care personnel.

 

m)        All medications shall be stored under lock and key at all times. The storage area shall be well lighted and of sufficient size to permit storage without crowding. This area may be a metal container, drawer, cabinet, closet, or room.  A separate medication room is not required.

 

n)         The key to the medicine area shall be the responsibility of, and in the possession of, the staff persons responsible for overseeing the self-administration of medications by residents.

 

1)         The medicine area shall not be used for any other purpose. However, for those persons whom the attending physician has given written permission to handle their own medication, medications may be stored in a locked metal container, drawer, or cabinet in the resident's room along with other possessions of that resident.

 

2)         Residents for whom the attending physician has given permission to be totally responsible for their own medication shall maintain possession of the key, or combination of the lock, to their own medication storage area.  A duplicate key or a copy of the combination shall be kept by the facility in its safe, or some other secure place, for emergency use, such as if residents lose or misplace their key, or forget the combination.

 

o)         Medications for external use shall be kept in a separate location in the medicine area or in a separate locked area.

 

p)         All poisonous substances and other hazardous compounds shall be kept in a separate locked area away from medications.

 

q)         Biologicals or medications requiring refrigeration shall be  kept in a separate, securely fastened locked container in a refrigerator, or in a locked refrigerator.

 

r)          The label of each individual medication container filled by a pharmacist shall clearly indicate the resident's full name, physician's name, prescription number, name and strength of drug, amount of drug, date of issue, expiration date of all time-dated drugs; name, address, and telephone number of pharmacy issuing the drug; and the initials of the pharmacist filling the prescription. If the individual medication container is filled by a physician from the physician's own supply, the label shall clearly indicate all the preceding information except that pertaining to the identification of the pharmacy, pharmacist, and prescription number.

 

s)         Medication containers having soiled, damaged, incomplete, illegible, or makeshift labels shall be returned to the issuing pharmacist, pharmacy, or dispensing physician for relabeling or disposal. Containers having no labels shall be destroyed in accordance with Federal and State laws.

 

t)          The medications of each resident shall be kept and stored in their originally received containers.  Medications shall not be transferred between containers.

            Attorney General's Opinion File No. S-1033, dated January 9, 1976, concluded that the administration of medication to residents of licensed long-term care facilities is a nursing procedure, as defined in the Illinois Nursing Act and, as such, cannot be performed by persons who are not licensed as either Registered Professional Nurses or Licensed Practical Nurses.  The opinion concluded by stating that "nursing aides, orderlies, attendants, and other auxiliary workers who are employed in nursing homes are not permitted to administer medications to patients in nursing homes."

 

(Source:  Amended at 25 Ill. Reg. 6499, effective May 15, 2001)

 

Section 350.3770  Food Services

 

a)         The food service in each facility shall be under the operational supervision of a manager or supervisor who has been certified in food service sanitation in accordance with Subpart C of the Department's rules entitled, Food Service Sanitation Code (77 Ill. Adm. Code 750). This person need not be a dietitian or a dietetic service supervisor as required in Section 350.1810(a)(1).  This person shall be responsible for ensuring that the  food service is in compliance with Section 350.3770 of this Part.  This person shall spend at least four hours a week in the performance of these duties.  (B)

 

b)         If the person responsible for the food services is not a dietitian he or she shall consult with a dietitian no less than two hours per month.

 

c)         Food should be prepared and served family style to approximate, as nearly as possible, a family living situation.  Residents should be allowed and encouraged to serve themselves the appropriate amount of food for a properly balanced diet.  Residents shall be allowed and encouraged to choose their own seating arrangements.

 

d)         The facility shall have available at least one copy of a current diet manual acceptable to this Department, located in the kitchen and available to dietary personnel.

 

e)         New or replacement kitchen equipment need not be of an institutional type.

 

f)         ICF/DD of 16 Beds or Less shall also comply with the Sections of the Department's rules entitled, Food Service Sanitation Code (77 Ill. Adm. Code 750) which are listed in Table D.

 

(Source:  Amended at 15 Ill. Reg. 466, effective January 1, 1991)

 

Section 350.3780  Codes and Standards

 

a)         In addition to compliance with the Standards set forth herein, all building codes, ordinances and regulations which are enforced by City, County or other local jurisdictions in which the facility is, or will be located must be observed.

 

b)         The Federal Government under the certification process requires conformance with the 1967 Life Safety Code for lodging or rooming house occupancy. Since the requirements contained in this Subpart P are more stringent than lodging or rooming house occupancy of the 1967 Life Safety Code, certification must be based on compliance with the requirements contained in this Subpart P.

 

c)         See Section 350.2620(a) for all the required Codes and Standards.  The following Codes and Standards listed in Section 350.2620(a)(2) are not required for ICF/DD of 16 Beds or Less.

 

1)         National Fire Protection Association

 

A)        NFPA 13-1976, Installation of Sprinkler Systems

 

B)        NFPA 13A-1976, Care and Maintenance of Sprinkler Systems

 

C)        NFPA 56F-1974, Standard for Non-Flammable Medical Gas Systems

 

D)        NFPA 90A-1976, Air Conditioning and Ventilating Systems

 

E)        NFPA 96-1076, Vapor Removal from Cooking Equipment

 

F)         NFPA 253-1978, Flooring Radiant Heat Energy Test

 

2)         Underwriter's Laboratory, Inc. (UL), Standard No. 181-1974,  Factory made Air Duct Materials and Air Duct Connectors

 

3)         American Society for Testing and Materials (ASTM), Standard No. E90-1975, Recommended Practice for Laboratory Measurement of Airborne Sound Transmission Loss of Building Partitions

 

4)         American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE)

 

A)        Handbook of Fundamentals, 1977

 

B)        Standard No. 52-76, Methods of Testing Air Cleaning Devices Used in General Ventilation for Removing Particulate Matters

 

5)         Uniform Building Code (1976 Edition)

 

6)         National Standard Plumbing Code (1976 Edition)

 

7)         Standard No. A17.1-1971, American National Safety Code for Elevators, Dumbwaiters, Escalators, and Moving Stairs

 

8)         HUD FT/TS-24, A Guide to Air Borne, Impact and Structure Borne Noise Control in  Multi-Family Dwellings

 

(Source:  Amended at 15 Ill. Reg. 466, effective January 1, 1991)

 

Section 350.3790  Administration and Public Areas

 

Accommodations (ramps, low thresholds, toilets, lavatories, and drinking fountains) for the physically handicapped (public, staff) shall be provided in administration and public areas, if these areas are located within the facility.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3800  Bedrooms

 

a)         Each single bedroom used for a resident shall have at least 80 square feet of usable net floor area, not including any space taken up for closets, wardrobes, bathrooms, and clearly definable entryway areas.

 

b)         Each multiple bedroom used for residents shall have for each resident housed in the room at least 60 square feet of usable floor area.  Usable area does not include any space utilized for closets, wardrobes, bathrooms, and clearly definable entryway areas. Maximum room capacity shall be two residents.

 

c)         Any resident sleeping room below grade must be dry, and have a window area which shall be at least ten percent of the floor area, and the window sill height must not exceed a maximum of three feet above the floor.  Any such room shall have two approved exits to grade level as described in the 1967 Edition of the Life Safety Code for Lodging and Rooming House Occupancy.

 

d)         Vandalproof reading lights are not required as specified in Section 350.3040(c)(2).

 

e)         Each resident shall have access to a toilet room.  Access to the toilet does not have to be directly from the bedroom.

 

f)         A closet or wardrobe of at least six square feet shall be provided for each resident.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3810  Nurses Station

 

A nurses station is not a required in Intermediate Care Facilities for the Developmentally Disabled of 16 Beds or Less.

 

(Source:  Amended at 15 Ill. Reg. 466, effective January 1, 1991)

 

Section 350.3820  Bath and Toilet Rooms

 

a)         Bathing facility shall be provided for each eight resident beds per floor which is not otherwise served by bathing facilities adjacent to the resident room.

 

1)         At least one bathtub or shower and one toilet shall be provided on each floor where resident bedrooms are located.

 

2)         Each tub or shower shall be in an individual room or enclosure which provides space for the private use of the bathing fixture. This room shall be large enough to provide space for drying and dressing.

 

3)         Showers shall be at least three feet square.

 

4)         Shower stalls do not have to be constructed with a low curb or no curb at all.

 

b)         One toilet room shall serve no more than eight beds.

 

1)         The toilet room shall contain a water closet and a lavatory.

 

2)         The lavatory may be omitted from a toilet room which serves a resident bedroom if each such resident room contains a lavatory. There shall be at least one toilet on each floor on which bedrooms are located.

 

c)         Provide a toilet room with a water closet and a lavatory for staff and visitors.

 

d)         Wheelchair toilets for residents are not required.

 

e)         Training toilets for residents are not required.

 

f)         Bathtubs and shower stalls for assisted bathing are not required.

 

g)         Bathing and toilet facilities are not required to be in the same room.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3830  Utility Rooms

 

a)         A clean utility room and soiled utility room are not required.

 

b)         A charging room for a linen chute is not required.

 

c)         A nourishment station is not required.

 

d)         An examination and treatment room is not required.

 

e)         Equipment storage rooms for IV stands, inhalators, air mattresses, walkers, and wheelchairs are not required.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3840  Living, Dining, Activity Rooms

 

a)         Provide a minimum of one dining room with at least ten square feet per resident bed.

 

b)         Provide a minimum of one comfortably furnished living room having a total window area of at least one-tenth the floor area.  Living room to have a minimum of ten square feet per resident bed.

 

c)         The living, dining, and activity rooms may be combined into one room, and the combined area of these rooms shall not be less than 20 square feet per resident bed.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3850  Therapy and Personal Care

 

a)         Physical and occupational therapy facilities are not required in an ICF/DD of 16 or fewer beds.

 

b)         A separate room for hair care and grooming needs is not required in an ICF/DD of 16 or fewer beds.

 

(Source:  Amended at 25 Ill. Reg. 6499, effective May 15, 2001)

 

Section 350.3860  Kitchen

 

a)         Every facility shall have a kitchen area, not including food storage area, of approximately ten square feet per resident bed.

 

b)         Provide satisfactory facilities for washing and sanitizing dishes and cooking utensils. A residential type dishwasher is recommended.  (B)

 

c)         A separate bulk food storage room is not required.

 

d)         A storage area for cans, carts, and mobile tray conveyors is not required. 

 

e)         A janitor's closet for the exclusive use of food preparation area is not required.

 

f)         A separate handwashing lavatory, in addition to the two compartment sink, is not required in the kitchen.

 

g)         The two compartment sink does not have to meet the requirement of Section 350.3030 (b)(3).

 

h)         For facilities which were licensed on or before October 1, 1987, and for which the Department has waived compliance with Section 350.2990(a)(9) prior to that date, compliance with that Section is not required as long as the facility continues to comply with the conditions of the waiver.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3870  Laundry Room

 

a)         Provide a laundry room equipped with appropriate and satisfactory type equipment of a design to meet the needs of the facility, unless a commercial laundry is used.

 

b)         Laundry facilities shall not be located in rooms used for food storage, preparation, or serving; however, packaged foods, including packaged single-service food articles, may be stored in the laundry room.

 

c)         The laundry room need not be equipped with commercial type equipment, but must be equipped with appropriate and satisfactory type equipment of a design to meet the needs of the facility and the residents.

 

d)         Provide space for the storage of clean linen.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3880  General Building Requirements

 

a)         Stairway Dimensions

 

1)         If a facility has a stairway, the stairway must have a minimum headroom of six feet, eight inches and a maximum height of 12 feet between landings.  A minimum clear width of three feet is required, except for handrails which may project three and one-half inches on each side.  A handrail is required only on one side of the stairs.  Width of treads, exclusive of nosing or projection, may not be less than nine inches.  Risers may not be more than eight inches.  Every stairway landing shall be at least as deep as the width of any stairway door which opens onto the landing.  Stairways with triangular or winding treads are permissible providing the stairways are at least three feet wide and the width of each tread is not narrower than six inches at any point. A stairway consisting of a single riser is not acceptable.  (B)

 

2)         For facilities licensed on or before October 1, 1987, the following exceptions to subsection (a)(1) of this Section shall apply:

 

A)        For all stairways, a minimum clear width of 26 inches (rather than three feet) is required.

 

B)        For stairways with triangular or winding treads, the stairway may be no less than 26 inches wide (rather than three feet) and the width of each tread may be narrower than six inches for up to 25 percent of the tread.

 

C)        Such facilities must comply with any additional requirements which may be imposed by the State Fire Marshal.

 

b)         Handrails at stairways shall be one and one-half inches in diameter and one and one-half inches minimum clear of the wall.

 

c)         Every facility shall have a ceiling height of seven feet, six inches or more, throughout all rooms occupied or used by residents.  Any projection from the ceiling shall have a clearance of at least six feet, eight inches from the floor. Ceiling heights of basements may be seven feet.

 

d)         Every required exit door to the outside shall be of the side hinged swinging type, and have a minimum width of 36 inches.

 

e)         Locks on exterior doors shall not require the use of a key for operation from the inside of the building.

 

f)         Every door shall have a latch or other fastening device, which can be released by a simple type of releasing device, such as a knob, handle or panic bar.  The method of operating all such releasing devices shall be obvious, even in the dark.

 

g)         The floor on both sides of a door in a means of egress shall be the same elevation on both sides of the door, a distance equal to the width of the widest single door shall be maintained at the landing.  When the door discharges to the outside or to an exterior balcony, exterior exit, or exterior exit access, the floor level outside the door may be one step lower than the inside, but not more than eight inches lower. However, at the two required exits at the first floor there can be no step.  This is to provide accessibility for handicapped staff or visitors, if administration and public areas are located within the facility.

 

h)         Every facility shall have either swinging or sliding exterior doors. However, all exterior doors in required means of egress must be of the side-hinged, swinging type. Door closers and panic hardware are not required.

 

i)          The doors for the toilet rooms used by residents shall have a minimum door width of 28 inches.  (B)

 

j)          The doors for the resident bedrooms shall have a minimum door width of 30 inches.  Automatic closers are not required on resident bedroom doors.  (B)

 

k)         Elevators are not required in an ICF/DD of 16 Beds or Less.

 

(Source:  Amended at 15 Ill. Reg. 466, effective January 1, 1991)

 

Section 350.3890  Corridors

 

a)         In every facility all corridors used by residents shall have a minimum unobstructed width of three feet, and shall be lighted properly at night and at other times when necessary.  If there are handrails, and they project more than three and one-half inches, the width of the corridor shall be measured between handrails. Handrails are not required.

 

b)         Corridor doors shall be a minimum of one and three-eighths inches thick solid core wood.  Louvers in doors shall not be permitted except as approved by the Department.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3900  Special Care Room

 

A special care room is not required in Intermediate Care Facilities for the Developmentally Disabled of 16 Beds or Less.

 

(Source:  Amended at 15 Ill. Reg. 466, effective January 1, 1991)

 

Section 350.3910  Exit Facilities and Subdivision of Floor Areas

 

a)         At least two exits, remote from each other, shall be provided for each floor or fire section of the building used by residents.  All exits shall be so arranged as to provide a safe path of travel to the outside of the building without traversing any corridor or space exposed to an unprotected vertical opening, except that traversing unprotected vertical openings may be permitted in existing sprinklered buildings.  At the upper floor level, at least one of the required means of egress shall consist of an interior stairway enclosed at the top and bottom, an enclosed outside stairway, or a horizontal exit. Every sleeping room, unless it has two doors providing separate ways of escape, or has a door opening directly to the outside of the building, shall have at least one outside window which can be opened from the inside, without the use of tools, to provide a clear opening of not less than 16 inches in least dimension and 400 square inches in area, with the bottom of the opening not more than four feet above the floor.

 

b)         An unenclosed outside stairway may be used as one of the two required means of egress from the second floor, only in existing buildings, subject to the approval of the Department, as determined by an onsite inspection.  The inspector will examine the stair for structural stability, height of risers, width of treads, width of stairway, handrails, and maintenance, including decay or dry rot in accordance with standards found in Section 350.3880(a) and (b).

 

1)         Unenclosed outside stairways shall not constitute more than 50 percent of the required exit capacity, in any case.  No more than one of the exits from the second floor may be an unenclosed outside stairway.  (B)

 

2)         Fire escapes need not be of non-combustible construction.

 

c)         Means of egress shall be so arranged that there are no dead end pockets, hallways, corridors, passageways, or courts whose depth exceeds 20 feet.  (B)

 

d)         Corridor walls shall have a fire-resistive rating of at least one hour.  Corridor walls may terminate at the underside of the ceiling.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3920  Stairways, Vertical Openings and Doorways

 

a)         Interior stairways must be enclosed with a minimum of one and three-eighths inch solid core wood door, with a self-closing device at the top and bottom of the stairway.  (B)

 

b)         There shall be no variation exceeding one-fourth inch in the depth of treads or in height of risers in any flight.

 

c)         Usable space under stairs shall not be used for storage.  (B)

 

d)         Means of egress such as stairs, stair landings, balconies, ramps and aisles, located along the edge of open-sided floors and mezzanines, shall have guards to prevent falls over the open side.  Each stair shall have handrails on at least one side. (B)

 

e)         Any light or ventilation shaft, chute and other vertical opening between stories shall be enclosed with construction having a one hour fire resistance rating.  (B)

 

f)         All required exit doors shall be free from any obstruction, chain locking, or holding device.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3930  Hazardous Areas and Combustible Storage

 

Walls at enclosure of hazardous areas shall have a one-hour fire resistive rating. Doors at enclosure of hazardous areas shall be a minimum of one and three-eighths inches thick solid core wood, with automatic closer.  Hazardous areas include the following:  kitchens, furnace and heater rooms, landries Rooms or spaces, including repair shops, used for the storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3940  Mechanical Systems

 

Thermal and acoustical insulation requirements in Section 350.2720(b) of this Part do not apply to ICF/DD Facilities of 16 Beds or Less.

 

(Source:  Amended at 15 Ill. Reg. 466, effective January 1, 1991)

 

Section 350.3950  Heating, Cooling, and Ventilating Systems

 

a)         Air conditioning and ventilation systems shall be designed, installed and maintained as required by NFPA 90B.  (B)

 

b)         Compliance with pressure relationships and ventilation rates as shown in Table B is not required.

 

c)         Vapor removal from cooking equipment in conformance with NFPA Standard 96 is not required.

 

d)         Provide a range hood with fan for the removal of smoke or grease-laden vapors.  If the hood does not discharge directly to the outside, then a recirculating type exhaust hood with cleaning and deodorizing elements is acceptable.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3960  Plumbing Systems

 

a)         Wrist blade handles are not required on lavatories.

 

b)         Clinical rim flush sinks are not required.

 

c)         Plumbing fixtures are not required to have quiet operating type flush valves.

 

d)         Hot water distribution systems shall be arranged to provide hot water at each hot water outlet.  Hot water may be higher than 110 degrees Fahrenheit if the hot water taps are in supervised areas and the purpose of the higher temperature is to train residents in the use of hot water.  If a temperature higher than 110 degrees Fahrenheit is used, all residents having access to those hot water taps must be able to demonstrate the ability to mix water appropriately and safely.  (B)

 

e)         Hot water need not be 140 degrees Fahrenheit for washing dishes or 180 degrees Fahrenheit for doing laundry, but rather be set at the equipment manufacturer's recommended settings, when residential type dishwashing and laundry equipment are used in this type of facility instead of commercial type equipment.  (B)

 

f)         Existing ordinary and frame buildings of less than one hour rated construction are required to be sprinklered.  All other construction types do not require sprinklers.  Facilities of eight beds or less will not be required to have a sprinkler system, if the facility has been inspected by the Office of the State Fire Marshal and found not to need a sprinkler system, as evidenced by a written report to the Department from the Office of the State Fire Marshal so stating.  (B)

 

g)         A separate sink for potwashing is not required.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3970  Electrical Systems

 

a)         Resident's rooms shall have general lighting.  At least one light fixture shall be switched at the entrance to each resident room.

 

b)         Duplex Receptacles in Resident Bedrooms

 

1)         There shall be one duplex receptacle for each 12 lineal feet of wall space in bedrooms.  Doors are not included in measuring wall space.  Receptacles shall be located at convenient places.

 

2)         For facilities which are licensed on or before October 1, 1987, and for which the Department has waived compliance with subsection (b)(1) of this Section prior to that date, compliance with that subsection is not required as long as the facility continues to comply with the conditions of the waiver.

 

c)         At least one duplex receptacle shall be installed in all corridors which are ten feet or longer in length.

 

d)         Panelboards serving lighting and appliance circuits are not required to be located on the same floor as the circuits they serve.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3980  Fire Alarm and Detection System

 

a)         An approved automatic smoke detection system shall be installed on each floor level. Such system shall be installed in accordance with NFPA 101, Section 6-3 of the 1976 edition of the Life Safety Code, and with NFPA Standard 72, 1975 edition.  The smoke detectors shall be installed in all rooms and corridors except toilets and closets.  In no case shall smoke detectors be spaced further apart than 30 feet on center, or more than 15 feet from any wall.  The automatic smoke detection system shall be electrically interconnected to the fire alarm system.  Facilities of eight beds or less will be required to have this automatic smoke detection system.  However, this automatic smoke detection system will not have to be electrically connected to the fire alarm system in accordance with this Section, if the facility has been inspected by the Office of the State Fire Marshal and found not to need such electrical connection to the fire alarm system, as evidenced by a written report to the Department from the Office of the State Fire Marshal to that effect.  (A, B)

 

b)         The fire alarm system shall automatically transmit the alarm to any available municipal fire department by direct private line or through any approved central station.  Facilities of eight beds or less will not be required to have this automatic fire alarm system in accordance with this Section, if the facility has been inspected by the Office of the State Fire Marshal and found not to need such fire alarm system, as evidenced by a written report to the Department from the Office of the State Fire Marshal to that effect.  (A, B)

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.3990  Emergency Electrical System

 

a)         The facility shall have an emergency electrical service which shall provide services as follows:

 

1)         Illumination for means of egress

 

2)         Fire detection and alarm system  (A, B)

 

b)         Emergency electrical service is not required to provide lighting for exit signs or a nurses station, nor for providing power to a communication system, including a nurse's call system.

 

c)         Facilities of eight beds or less will not be required to provide emergency electrical service for illumination for means of egress, or for fire detection and alarm system, in accordance with the provisions of this Section, if the facility has been inspected by the Office of the State Fire Marshal and found not to need such an emergency electrical service, as evidenced by a written report to the Department from the Office of the State Fire Marshal to that effect.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.4000  Fire Protection

 

The Department, or, upon request, the Fire Prevention Division of the Office of the State Fire Marshal, will make inspections for fire safety and compliance with these standards.  The Fire Prevention Division shall call to the attention of the Department of Public Health any violations of these standards pertaining to fire protection found during a requested inspection.  The Department, or, upon request, the Fire Prevention Division, shall be privileged to make as many subsequent visits as deemed necessary by the Department for assurance of compliance.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.4010  Construction Types

 

a)         Buildings shall be of fire resistive, protected noncombustible, one hour protected ordinary, one hour protected wood frame, heavy timber, or unprotected noncombustible type construction.  (B)

 

b)         Buildings shall be no more than two stories in height.  Basements are permitted for use as resident living and activity areas.  Basements are also permitted for resident dining and sleeping areas if they are dry, have a window area which is at least ten percent of the floor area, the window sill height does not exceed a maximum of three feet above the floor and there are two approved exits to grade level.  Attics are not permitted for any kind of resident use.  However, both attics and basements may be used as storage space and for various staff use functions such as offices, and sleeping quarters.

 

c)         Any ICF/DD of 16 Beds or Less which shares a common wall with any other occupancy must be separated from that occupancy by a minimum of one hour rated fire wall.  (B)

 

(Source:  Amended at 15 Ill. Reg. 466, effective January 1, 1991)

 

Section 350.4020  Equivalencies

 

Existing facilities which are in substantial compliance with this Subpart P, but which have any deficiencies, will be considered for approval, if alternative construction exists which will provide health and safety features that are equivalent to this Subpart P.

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)

 

Section 350.4030  New Construction Requirements

 

The requirements listed in Sections 350.3780 through 350.4010 for existing facilities also apply to new construction unless modified by this Section .  This Section applies only to new construction.

 

a)         Single resident bedrooms shall contain at least 100 square feet in area. Multiple resident bedrooms shall contain at least 75 square feet per bed in area.  Minimum usable floor areas do not include any space utilized for closets, free-standing wardrobe units, bathrooms, and clearly definable entryways.

 

b)         Provide a closet or wardrobe of at least six square feet in area for each resident.

 

c)         The living, dining, and activity functions may be combined into one room, or may be in separate rooms.  However, the combined area of these functions shall not be less than 30 square feet per resident bed.

 

d)         Corridor doors shall be a minimum of one and three-quarters inches thick solid core wood.  Louvers in doors shall not be permitted except as approved by the Department.  (B)

 

e)         Interior stairways must be enclosed with a minimum of one hour rated walls and a minimum of one and three-quarters inch solid core wood doors, with a self-closing device, at the top and bottom of the each stairway.  (B)

 

f)         In every facility all corridors used by residents shall have a minimum unobstructed width of four feet, and shall be lighted properly at night and at other times when necessary.

 

g)         Facilities shall be of the heights and construction types with sprinkler requirements identified in the Table E. (B)

 

h)         Hazardous areas, including combustible storage, as listed in Section 350.3930, must have walls of one hour fire resistive rating.  Doors at enclosure of hazardous areas shall be a minimum of three-fourths hour "C" label, with automatic closer.  (B)

 

i)          The following additional codes are required for new construction.

 

1)         NFPA 13-1976 Edition, Installation of Sprinkler Systems

 

2)         NFPA 13A-1976 Edition, Care and Maintenance of Sprinkler Systems

 

3)         NFPA 13D-1975 Edition, Installation of Sprinkler Systems in One- and Two-Family Dwellings and Mobile Homes

 

4)         NFPA 70-1978 Edition, National Electric Code (B)

 

j)          Unenclosed outside stairways shall not be accepted as constituting any part of the required means of egress for new buildings. (B)

 

(Source:  Amended at 13 Ill. Reg. 6040, effective April 17, 1989)