Illinois Compiled Statutes
Information maintained by the Legislative Reference Bureau
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HEALTH FACILITIES AND REGULATION210 ILCS 135/1
(210 ILCS 135/) Community-Integrated Living Arrangements Licensure and Certification Act.
(210 ILCS 135/1)
(from Ch. 91 1/2, par. 1701)
This Act shall be known and may be cited as the
Community-Integrated Living Arrangements Licensure and Certification Act.
(Source: P.A. 85-1250.)
210 ILCS 135/2
(210 ILCS 135/2)
(from Ch. 91 1/2, par. 1702)
The purpose of this Act is to promote the operation of
community-integrated living arrangements for the supervision of persons with
mental illness and persons with a developmental disability by licensing
community mental health or developmental services agencies to provide an array
of community-integrated living arrangements for such individuals. These
community-integrated living arrangements are intended to promote independence
in daily living and economic self-sufficiency. The licensed community mental
health or developmental services agencies in turn shall be required to certify
to the Department that the programs and placements provided in the
community-integrated living arrangements comply with this Act, the Mental
Health and Developmental Disabilities Code, and applicable Department rules and
(Source: P.A. 88-380.)
210 ILCS 135/3
(210 ILCS 135/3)
(from Ch. 91 1/2, par. 1703)
As used in this Act, unless the context requires otherwise:
(a) "Applicant" means a person, group of persons, association, partnership
or corporation that applies for a license as a community mental health or
developmental services agency under this Act.
(b) "Community mental health or developmental services agency" or "agency"
means a public or private agency, association, partnership, corporation or
organization which, pursuant to this Act, certifies community-integrated living
arrangements for persons with mental illness or persons with a developmental
(c) "Department" means the Department of Human Services (as successor to
the Department of Mental Health and Developmental Disabilities).
(d) "Community-integrated living arrangement" means a living arrangement
certified by a community mental health or developmental services agency
under this Act where 8 or fewer recipients with mental illness or recipients
with a developmental disability who reside under the supervision of the agency.
Examples of community integrated living arrangements include but are not
limited to the following:
(1) "Adult foster care", a living arrangement for
recipients in residences of families unrelated to them, for the purpose of providing family care for the recipients on a full-time basis;
(2) "Assisted residential care", an independent
living arrangement where recipients are intermittently supervised by off-site staff;
(3) "Crisis residential care", a non-medical living
arrangement where recipients in need of non-medical, crisis services are supervised by on-site staff 24 hours a day;
(4) "Home individual programs", living arrangements
for 2 unrelated adults outside the family home;
(5) "Supported residential care", a living
arrangement where recipients are supervised by on-site staff and such supervision is provided less than 24 hours a day;
(6) "Community residential alternatives", as defined
in the Community Residential Alternatives Licensing Act; and
(7) "Special needs trust-supported residential care",
a living arrangement where recipients are supervised by on-site staff and that supervision is provided 24 hours per day or less, as dictated by the needs of the recipients, and determined by service providers. As used in this item (7), "special needs trust" means a trust for the benefit of a beneficiary with a disability as described in Section 15.1 of the Trusts and Trustees Act.
(e) "Recipient" means a person who has received, is receiving, or is in need
of treatment or habilitation as those terms are defined in the Mental Health
and Developmental Disabilities Code.
(f) "Unrelated" means that persons residing together in programs or
placements certified by a community mental health or developmental services
agency under this Act do not have any of the following relationships by blood,
marriage or adoption: parent, son, daughter, brother, sister, grandparent,
uncle, aunt, nephew, niece, great grandparent, great uncle, great aunt,
stepbrother, stepsister, stepson, stepdaughter, stepparent or first cousin.
(Source: P.A. 99-143, eff. 7-27-15.)
210 ILCS 135/4
(210 ILCS 135/4)
(from Ch. 91 1/2, par. 1704)
(a) Any community mental health or developmental services agency who
wishes to develop and support a variety of community-integrated living
arrangements may do so pursuant to a license issued by the Department under this Act.
However, programs established under or otherwise subject to the Child
Care Act of 1969, the Nursing Home Care Act, the Specialized Mental Health Rehabilitation Act of 2013, the ID/DD Community Care Act, or the MC/DD Act, as now or
hereafter amended, shall remain
subject thereto, and this Act shall not be construed to limit the
application of those Acts.
(b) The system of licensure established under this Act shall be for the purposes of:
(1) ensuring that all recipients residing in
community-integrated living arrangements are receiving appropriate community-based services, including treatment, training and habilitation or rehabilitation;
(2) ensuring that recipients' rights are protected
and that all programs provided to and placements arranged for recipients comply with this Act, the Mental Health and Developmental Disabilities Code, and applicable Department rules and regulations;
(3) maintaining the integrity of communities by
requiring regular monitoring and inspection of placements and other services provided in community-integrated living arrangements.
The licensure system shall be administered by a quality assurance unit
within the Department which shall be administratively independent of units
responsible for funding of agencies or community services.
(c) As a condition of being licensed by the Department as a community
mental health or developmental services agency under this Act, the agency
shall certify to the Department that:
(1) all recipients residing in community-integrated
living arrangements are receiving appropriate community-based services, including treatment, training and habilitation or rehabilitation;
(2) all programs provided to and placements arranged
for recipients are supervised by the agency; and
(3) all programs provided to and placements arranged
for recipients comply with this Act, the Mental Health and Developmental Disabilities Code, and applicable Department rules and regulations.
(d) An applicant for licensure as a community mental health or
developmental services agency under this Act shall submit an application
pursuant to the application process established by the Department by rule
and shall pay an application fee in an amount established by the
Department, which amount shall not be more than $200.
(e) If an applicant meets the requirements established by the Department
to be licensed as a community mental health or developmental services
agency under this Act, after payment of the licensing fee, the Department
shall issue a license valid for 3 years from the date thereof unless
suspended or revoked by the Department or voluntarily surrendered by the agency.
(f) Upon application to the Department, the Department may issue a
temporary permit to an applicant for up to a 2-year period to allow the holder
of such permit reasonable time to become eligible for a license under this Act.
(g)(1) The Department may conduct site visits to an agency licensed under this
Act, or to any program or placement certified by the agency, and inspect
the records or premises, or both, of such agency, program or placement as
it deems appropriate, for the
purpose of determining compliance with this Act, the Mental Health and
Developmental Disabilities Code, and applicable Department rules and regulations. The Department shall conduct inspections of the records and premises of each community-integrated living arrangement certified under this Act at least once every 2 years.
(2) If the Department determines that an agency licensed under this Act
is not in compliance with this Act or the rules and regulations promulgated
under this Act, the Department shall serve a notice of violation
upon the licensee. Each notice of violation shall be prepared in writing
and shall specify the nature of the violation, the statutory provision or
rule alleged to have been violated, and that the licensee
submit a plan of correction to the Department if required. The notice shall also
inform the licensee of any other action which the Department might take
pursuant to this Act and of the right to a hearing.
(g-5) As determined by the Department, a disproportionate number or percentage of licensure complaints; a disproportionate number or percentage of substantiated cases of abuse, neglect, or exploitation involving an agency; an apparent unnatural death of an individual served by an agency; any egregious or life-threatening abuse or neglect within an agency; or any other significant event as determined by the Department shall initiate a review of the agency's license by the Department, as well as a review of its service agreement for funding. The Department shall adopt rules to establish the process by which the determination to initiate a review shall be made and the timeframe to initiate a review upon the making of such determination.
(h) Upon the expiration of any license issued under this Act, a license
renewal application shall be required of and a license renewal fee in an
amount established by the Department shall be
charged to a community mental health or
developmental services agency, provided that such fee shall not be more than $200.
(i) A public or private agency, association, partnership, corporation, or organization that has had a license revoked under subsection (b) of Section 6 of this Act may not apply for or possess a license under a different name.
(Source: P.A. 99-180, eff. 7-29-15; 100-58, eff. 8-11-17; 100-313, eff. 8-24-17; 100-863, eff. 8-14-18.)
210 ILCS 135/5
(210 ILCS 135/5)
(from Ch. 91 1/2, par. 1705)
(a) The Department may conduct an investigation upon receipt of a complaint
to insure that the agency is in compliance with this Act.
If, based upon the results of its
investigation, the Department determines that the agency is not in
compliance with this Act, it shall serve a notice of violation upon the
agency as set forth in paragraph (2) of subsection (g) of Section 4 above.
Upon request by a complainant,
the Department shall notify the complainant of the results of any
investigation of a complaint.
(b) The complaint, a copy of the complaint, or a record published,
released or otherwise disclosed to the agency shall not disclose the name of
the complainant unless the complainant consents in writing to the
disclosure or the investigation results in a judicial proceeding, or unless
disclosure is essential to the investigation.
(c) An agency licensed under this Act or its agents shall not transfer,
harass, dismiss, or
retaliate against a recipient who is the subject of a complaint
under this Act.
(Source: P.A. 85-1250.)
210 ILCS 135/6
(210 ILCS 135/6)
(from Ch. 91 1/2, par. 1706)
(a) The Department shall deny an application for a license,
or revoke or refuse to renew the license of a community mental health or
developmental services agency, or refuse to issue a license to the holder
of a temporary permit, if the Department determines that the applicant,
agency or permit holder has not complied with a provision of this Act, the
Mental Health and Developmental Disabilities Code, or applicable Department
rules and regulations. Specific grounds for denial or revocation of a
license, or refusal to renew a license or to
issue a license to the holder of a temporary permit, shall include but not be limited to:
(1) Submission of false information either on
Department licensure forms or during an inspection;
(2) Refusal to allow an inspection to occur;
(3) Violation of this Act or rules and regulations
promulgated under this Act;
(4) Violation of the rights of a recipient;
(5) Failure to submit or implement a plan of
correction within the specified time period; or
(6) Failure to submit a workplace violence
prevention plan in compliance with the Health Care Workplace Violence Prevention Act.
(b) If the Department determines that the operation of a community mental health
or developmental services agency or one or more of the programs or
placements certified by the agency under this Act jeopardizes the health,
safety or welfare of the recipients served by the agency, the Department
may immediately revoke the agency's license and may direct the agency to
withdraw recipients from any such program or placement. If an agency's license is revoked under this subsection, then the Department or the Department's agents shall have unimpeded, immediate, and full access to the recipients served by that agency and the recipients' medications, records, and personal possessions in order to ensure a timely, safe, and smooth transition of those individuals from the program or placement.
(c) Upon revocation of an agency's license under subsection (b) of this Section, the agency shall continue providing for the health, safety, and welfare of the individuals that the agency was serving at the time the agency's license was revoked during the period of transition. The private, not-for-profit corporation designated by the Governor to administer the State plan to protect and advocate for the rights of persons with developmental disabilities under Section 1 of the Protection and Advocacy for Persons with Developmental Disabilities Act, contingent on State funding from the Department, shall have unimpeded, immediate, and full access to recipients and recipients' guardians to inform them of the recipients' and recipients' guardians' rights and options during the revocation and transition process.
(d) The Office of Inspector General of the Department of Human Services shall continue to have jurisdiction over an agency and the individuals it served at the time the agency's license was revoked for up to one year after the date that the license was revoked.
(Source: P.A. 100-313, eff. 8-24-17.)
210 ILCS 135/7
(210 ILCS 135/7)
(from Ch. 91 1/2, par. 1707)
(a) Except in emergency situations, no license may be denied
or revoked unless the applicant
or licensee is given written notice of the grounds for the Department's
action. The applicant or licensee may appeal the Department's proposed
action and shall do so within 15 days after receipt of the Department's written notice by
making written request to the Department for a hearing. Notice of the
time, place and nature of the hearing shall be given to the applicant or
licensee not less than 2 weeks prior to the date of the hearing. The
hearing shall proceed, and the notice shall be delivered, in accordance
with The Illinois Administrative Procedure Act, as now or hereafter amended.
(b) If the applicant or licensee does not submit a request for a hearing
as provided for in this Section, or if after conducting the hearing the
Department determines that the license should not be issued or renewed or
that the license should be revoked or denied, the Department shall issue an
order to that effect. If the order is to revoke the license, it shall
specify that the order takes effect upon receipt by the licensee, and that
the agency shall not operate during the pendency of any proceeding for
judicial review of the Department's decision, except under court order.
(c) Final administrative decisions shall be subject to judicial review
exclusively as provided in the Administrative Review Law, as now or
hereafter amended, except that any petition for judicial review of
a Department action under this Act shall be filed within 15 days after
receipt of notice of the Department's final determination. The term
"administrative decision" has the meaning ascribed to it in Section 3-101
of the Code of Civil Procedure.
(Source: P.A. 85-1250.)
210 ILCS 135/8
(210 ILCS 135/8)
(from Ch. 91 1/2, par. 1708)
(a) Any community mental health or developmental services agency
that continues to operate after its license is revoked under this Act, or
after its license expires and the Department refuses to renew the license,
is guilty of a business offense and shall be fined an amount in excess of
$500 but not exceeding $2,000, and each day of violation is a separate
offense. All fines shall be paid to the Mental Health Fund.
(b) Whenever the Department is advised or has reason to believe that any
person, group of persons, association, partnership or corporation is
operating an agency without a license or permit in violation of this Act,
the Department may investigate to ascertain the facts, may notify the
person or other entity that he is in violation of this Act, and may make
referrals to appropriate investigatory or law enforcement agencies. Any person,
group of persons, association, partnership or corporation who continues to
operate a community mental health or developmental services agency as
defined in subsection (b) of Section 3 of this Act without a
license or temporary permit issued by the Department, after receiving notice
from the Department that such operation is in violation of this Act,
be guilty of a business offense and shall be fined an amount in excess of
$500 but not exceeding $2,000, and each day of operation after receiving
such notice is a separate offense. All fines shall be paid to the Mental
(Source: P.A. 85-1250.)
210 ILCS 135/9
(210 ILCS 135/9)
(from Ch. 91 1/2, par. 1709)
By July 1, 1989, the Department shall adopt rules pursuant to
the Illinois Administrative Procedure Act to establish minimum standards
for licensing community-integrated living arrangements under this Act.
These rules shall govern the operation and conduct of community-integrated
living arrangements and shall provide for the license application
process; agency standards and financial requirements; licensing,
certification and license renewal procedures; revocation of licenses;
notification to recipients of their rights and the ability to contact the
Guardianship and Advocacy Commission; emergency actions which can be taken
by the Department to protect recipients' rights, welfare, and safety; and
any other rules deemed necessary to implement the provisions of this Act.
By December 31, 1996, the Department shall adopt rules under the Illinois
Administrative Procedure Act that specify the components of reimbursement for
community-integrated living arrangements and include costs as reported on the
Interagency Statistical and Financial Report.
By December 31, 2011, the Department shall adopt rules under the Illinois Administrative Procedure Act that govern the assignment and operations of monitors and receiverships for community-integrated living arrangements wherein the Department has identified systemic risks to individuals served. The rules shall specify the criteria for determining the need for independent monitors and receivers, their conduct once established, and their reporting requirements to the Department. These monitors and receivers shall be independent entities appointed by the Department and not staff from State agencies. This paragraph does not limit, however, the Department's authority to take necessary action through its own or other State staff.
(Source: P.A. 97-441, eff. 8-19-11.)
210 ILCS 135/9.1
(210 ILCS 135/9.1)
Recipient's funds; protection.
(a) To protect a recipient's funds, a service provider:
(1) May accept funds from a recipient for safekeeping
and management if the service provider receives written authorization from the recipient or the recipient's guardian.
(2) Shall maintain a written record of all financial
arrangements and transactions involving each individual recipient's funds and shall allow each recipient, or the recipient's guardian, access to that written record.
(3) Shall provide, in order of priority, each
recipient, or the recipient's guardian, if any, or the recipient's immediate family member, if any, with a written itemized statement of all financial transactions involving the recipient's funds or a copy of the recipient's checking or savings account register for the period. This information shall be provided at least quarterly.
(4) Shall purchase and maintain a surety bond or
other commercial policy with crime coverage in an amount equal to or greater than all of the recipient's personal funds deposited with the service provider to which employees of the service provider have access to secure against loss, theft, and insolvency. The insurance company that provides the surety bond or commercial policy with crime coverage shall inform the Division of Developmental Disabilities of the Department of Human Services of any reduction or cancellation of the surety bond or commercial policy with crime coverage.
(5) Shall keep any funds received from a recipient in
an account separate from the service provider's funds for safekeeping, and shall not withdraw all or any part of the recipient's funds unless the service provider is (i) returning the funds to the recipient upon the request of the recipient or any other person entitled to make the request, (ii) paying the recipient his or her allowance, or (iii) making any other payment authorized by the recipient or any other person entitled to make that authorization.
(6) Shall deposit any funds received from a recipient
in excess of $100 in an interest-bearing account insured by agencies of, or corporations chartered by, the State or the federal government. The account shall be in a form that clearly indicates that the service provider has only a fiduciary interest in the funds and that any interest earned on funds in the account shall accrue to the recipient. The service provider may keep up to $100 of a recipient's funds in a non-interest-bearing account or petty cash fund, to be readily available for the recipient's current expenditures.
(7) Shall, upon written request of a recipient or the
recipient's guardian, return to the recipient or the recipient's guardian of the estate all or any part of the recipient's funds given to the service provider for safekeeping, including the accrued interest earned on the deposits of the recipient's funds.
(8) Shall (i) place any monthly allowance that a
recipient is entitled to in the recipient's personal account or give the monthly allowance directly to the recipient, unless the service provider has written authorization from the recipient, the recipient's guardian, or the recipient's parent if the recipient is a minor, to handle the monthly allowance differently, (ii) take all steps necessary to ensure that a monthly allowance that is placed in a recipient's personal account is used exclusively by the recipient or for the recipient's benefit, and (iii) require any person other than the recipient who withdraws funds from the recipient's personal account that constitute any portion of the recipient's monthly allowance to execute an affidavit that the funds will be used exclusively for the benefit of the recipient.
(9) If an adult recipient is incapable of managing
his or her funds and does not have a guardian or immediate family member, the service provider shall notify the Office of the State Guardian of the Guardianship and Advocacy Commission.
(b) Upon the death of a recipient, unless otherwise provided by State law, the service provider shall provide the executor or administrator of the recipient's estate with a complete accounting of all the recipient's personal property, including any funds of the recipient being held by the service provider.
(c) If a recipient changes service providers, the former service provider shall provide the new service provider with a written verification by a public accountant of all the recipient's money and property being transferred and shall obtain a signed receipt for the money and property from the new service provider upon transfer of the recipient's money and property.
(d) If a service provider is sold, the service provider shall provide the new owner with a written verification by a public accountant of all the recipient's money and property being transferred and shall obtain a signed receipt for the money and property from the new owner upon transfer of the recipient's money and property.
(Source: P.A. 98-1073, eff. 8-26-14.)
210 ILCS 135/9.2
(210 ILCS 135/9.2)
Emergency contacts and required records.
An agency shall collect and securely store identifying and contact information for each resident. Unless otherwise required by statute or an agency's rules or policies, this information may include, but not be limited to, a current photograph, personal contact
information, guardian or emergency contact information, a log of all off-site overnight visits, current identification card, medical card, social security number, and birth certificate. A resident's individual service coordination agency shall maintain copies of the documents as well. The log of all off-site overnight visits shall not apply to intermittent community-integrated living arrangements or in situations where the resident leaves to stay with parents and family. This information shall be updated periodically.
(Source: P.A. 100-313, eff. 8-24-17.)
210 ILCS 135/10
(210 ILCS 135/10)
(from Ch. 91 1/2, par. 1710)
(a) Community-integrated living arrangements
shall be located so as to enable residents to participate in and be
integrated into their community or neighborhood. The location of such
arrangements shall promote community integration of persons with mental
(b) Beginning January 1, 1990, no Department of State government, as
defined in the Civil
Administrative Code of Illinois, shall place any person in or utilize any
services of a community-integrated living arrangement which is not
certified by an agency under this Act.
(Source: P.A. 100-602, eff. 7-13-18.)
210 ILCS 135/11
(210 ILCS 135/11)
All agencies previously licensed under the Community Residential
Alternatives Licensing Act are subject to and shall be licensed under this
(Source: P.A. 90-423, eff. 8-15-97.)
210 ILCS 135/12
(210 ILCS 135/12)
Subject to appropriation, the Department shall adjust its rate methodology for community-integrated living arrangements using as a guide the findings and recommendations of the CILA nursing services reimbursement working group established by Senate Resolution 514 of the 94th General Assembly in order to improve the efficient and effective utilization of nursing personnel, to increase the levels of nursing services, and to improve access and availability of nursing services for residents of community-integrated living arrangements.
(Source: P.A. 95-577, eff. 8-31-07.)
210 ILCS 135/13
(210 ILCS 135/13)
Fire inspections; authority.
(a) Per the requirements of Public Act 96-1141, on January 1, 2011 a report titled "Streamlined Auditing and Monitoring for Community Based Services: First Steps Toward a More Efficient System for Providers, State Government, and the Community" was provided for members of the General Assembly. The report, which was developed by a steering committee of community providers, trade associations, and designated representatives from the Departments of Children and Family Services, Healthcare and Family Services, Human Services, and Public Health, issued a series of recommendations, including recommended changes to Administrative Rules and Illinois statutes, on the categories of deemed status for accreditation, fiscal audits, centralized repository of information, Medicaid, technology, contracting, and streamlined monitoring procedures. It is the intent of the 97th General Assembly to pursue implementation of those recommendations that have been determined to require Acts of the General Assembly.
(b) For community-integrated living arrangements licensed under this Act, the Office of the State Fire Marshal shall provide the necessary fire inspection to comply with licensing requirements. The Office of the State Fire Marshal may enter into an agreement with another State agency to conduct this inspection if qualified personnel are employed by that agency. Nothing in this Section shall limit a local authority with jurisdiction from conducting local code inspection and enforcement or from conducting fire incident planning activities.
(Source: P.A. 100-313, eff. 8-24-17; 100-593, eff. 6-22-18.)
210 ILCS 135/13.1
(210 ILCS 135/13.1)
Registry checks for employees.
(a) Within 60 days after August 19, 2011 (the effective date of Public Act 97-441), the Department shall require all of its community developmental services agencies to conduct required registry checks on employees at the time of hire and annually thereafter during employment. The required registries to be checked are the Health Care Worker Registry, 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' State Central Register by the Department of Children and Family Services' standards for background checks in Part 385 of Title 89 of the Illinois Administrative Code. 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 the Department's standards for abuse and neglect investigations in Section 1-17 of the Department of Human Services Act.
(b) In collaboration with the Department of Children and Family Services and the Department of Public Health, the Department of Human Services shall establish a waiver process from the prohibition of employment or termination of employment requirements in subsection (a) of this Section for any applicant or employee listed under the Department of Children and Family Services' State Central Register seeking to be hired or maintain his or her employment with a community developmental services agency under this Act. The waiver process for applicants and employees outlined under Section 40 of the Health Care Worker Background Check Act shall remain in effect for individuals listed on the Health Care Worker Registry.
(c) In order to effectively and efficiently comply with subsection (a), the Department of Children and Family Services shall take immediate actions to streamline the process for checking the State Central Register for employees hired by community developmental services agencies referenced in this Act. These actions may include establishing a website for registry checks or establishing a registry check process similar to the Health Care Worker Registry.
(Source: P.A. 97-441, eff. 8-19-11; 97-813, eff. 7-13-12.)
210 ILCS 135/14
(210 ILCS 135/14)
Transparency for individuals and guardians.
By October 1, 2011, the Department shall make available to individuals and guardians upon enrollment a document listing telephone numbers and other contact information to report suspected cases of abuse, neglect, or exploitation. The information provided shall include a delineation of the individuals' rights. By July 1, 2012, the Department shall make available through its website information on each agency regarding licensure and quality assurance survey results; licensure and contract status; and substantiated findings of abuse, egregious neglect, and exploitation. The Department shall adopt rules regarding the posting of this information and shall inform individuals and guardians of its availability during the initial provider selection process.
(Source: P.A. 97-441, eff. 8-19-11.)
210 ILCS 135/15
(210 ILCS 135/15)
Designation of representative.
Any adult resident of a community-integrated living arrangement who does not have a legal guardian and has not been adjudicated incompetent may designate another adult of his or her choice to serve as the representative of the resident for the sole purpose of receiving notification from the agency or from the Department concerning any incident or condition regarding the health, safety, or well-being of the resident. The designation shall be made in writing and signed by the resident, the designated representative, and a representative of the agency. The agency shall inform the resident of his or her right to designate another adult as a representative for such purposes. The designation may be revoked in writing by the resident at any time. The agency shall provide a designation of representative form that is substantially the same as the following:
"DESIGNATION OF REPRESENTATIVE
I, (insert name), am ....... years old and reside at ........
I have not been adjudicated incompetent and do not have a legal guardian.
I hereby delegate (insert name, phone number, and e-mail address of designated representative), an adult who resides at .........., as my representative for the sole purpose of receiving notification of any incident that may affect my health, safety or well-being while a resident at .........., and hereby give my consent to (insert name of agency) to communicate with (insert name of designated representative) about any such incident.
I understand that I may revoke this Designation of Representative at any time by notifying (insert name of agency) in writing that I wish to do so.
I also understand that by executing this document I am waiving my right to confidentiality, but only to the extent of the authority conveyed in this document.
(Insert Name of Resident)
Signature of Resident
(Insert Name of Representative)
Signature of Representative
(Insert Name of Agency Representative)
Signature of Representative".
(Source: P.A. 97-441, eff. 8-19-11.)