Section 300.110  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 or skilled nursing care, pursuant to the terms and conditions of the Nursing Home Care 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 six 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 two-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 have distinct parts classified according to levels of services. The distinct part must meet the applicable physical plant standards of this Part, based on the level of service classification sought for that distinct part.  To protect the health, welfare, and safety of residents in a distinct part of the facility who require higher standards, the facility shall comply with whatever additional physical plant standards 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 to meet the health, welfare, and safety needs of the residents of the facility.

 

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 the Act, or willfully fail or refuse to file any required information;

 

2)         Open or operate a facility without a license.  (Section 3-318(a) 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 300.120(e) as to submission of false or misleading information in a license application.  (Section 3-318(b) of the Act)

 

g)         An intermediate care facility shall not use in its title or description "Hospital", "Sanitarium", "Sanatorium", "Skilled Nursing Facility", or any other word or description in its title or advertisements that indicates that a type of service is provided by the facility for which the facility is not licensed to provide or does not provide.  A skilled nursing facility may use in its title or advertisement the words or description "Nursing Home", "Intermediate Care", "Rehabilitation Center", or "Skilled Nursing Facility".

 

h)         Any person establishing, constructing, or modifying a health care facility or portion of a health care facility without obtaining a required permit from the Health Facilities and Services Review Board, or in violation of the terms of the required permit, 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)          The administrator of a facility licensed under the Act and this Part shall give 60 days' notice prior to voluntarily closing 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 the Office of State Long-Term Care Ombudsman, to any resident who must be transferred or discharged, to the resident's representative, and to a member of the resident's family, when practicable.  If the Department suspends, revokes, or denies renewal of the facility's license, then notice of the facility's closure shall be given no later than the date specified by the Department.  Notice shall state the proposed date of closing and the reason for closing.  The facility shall submit a closure plan to the Department for approval, which shall address the process for the safe and orderly transfer of residents.  The approved plan shall be included in the notice.  The facility shall offer to assist the resident in securing an alternative placement and shall advise the resident on available alternatives.  When 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.  A facility closing in its entirety shall not admit any new residents on or after the date the written notice is submitted to the Department as specified by the Act and this Part.  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 by Section 3-419 of the Act and Section 300.3300 of this Part.  (Section 3-423 of the Act)

 

j)          Licensure for More Than One Level of Care

 

1)         A facility may be licensed for more than one level of care.  Bedrooms of like-licensed levels of care must be contiguous to each other within each "nursing unit" as defined in Section 300.330.  Each nursing unit may have up to two levels of care and must meet the construction standards for the highest licensed level of care in the nursing unit.

 

2)         If a facility wishes to license a portion of its beds as an Intermediate Care for the Developmentally Disabled, Medically Complex for the Developmentally Disabled, or assisted living, licensed under the ID/DD Community Care Act, the MC/DD Act, and the Assisted Living and Shared Housing Act, respectively, the beds must be located in a distinct part (as defined in Section 300.330) of the facility.

 

k)         Each facility shall notify the Department via e-mail 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.

 

m)        A facility licensed under the Nursing Home Care Act may not refer a patient or the family of a patient to a home health agency, home nursing agency, or home services agency unless the agency is licensed under the Home Health, Home Services, and Home Nursing Agency Licensing Act.  (Section 3.8 of 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.

 

n)         A facility shall comply with the Alzheimer's Disease and Related Dementias Services Act and the Alzheimer's Disease and Related Dementias Services Code.

 

(Source:  Amended at 46 Ill. Reg. 14237, effective July 27, 2022)

 

Section 300.120  Application for License

 

a)         Any person acting individually or jointly with other persons who proposes to build, own, establish, or operate an intermediate care facility or skilled nursing facility shall submit application information on forms provided by the Department.  The applicant shall provide a written description of the proposed program, and other such information as the Department may require in order to determine the appropriate level of care for which the facility should be licensed. Application forms 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 [20 ILCS 3960].

 

c)         Application for a license to establish or operate an intermediate care facility or skilled nursing facility shall be made in writing and submitted to the Department, with other such information as the Department may require, on forms furnished by the Department. (Section 3-103(1) of the Act)

 

d)         All license applications shall be accompanied with an application fee of $1,990.  The fee for a 2-year license shall be double the fee for the annual license.  (Section 3-103(2) of the Act)

 

e)         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)         Such 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)

 

f)        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 in such cases.

 

g)         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 six months of any changes in the information originally provided in the application.  (Section 3-103(3) of the Act)

 

h)         The Department may issue licenses or renewals for periods of not less than six  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. The fees for such licenses shall be pro-rated on the basis of the portion of the year for which they are issued. (Section 3-110 of the Act)

 

(Source:  Amended at 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.130  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 18 years of age.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.140  Issuance of an Initial License for a New Facility

 

a)         Upon receipt and review of an application for a license made under the Act and inspection of the applicant facility under the Act, the Director will issue a probationary license if the Director finds that:

 

1)         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 five years;

 

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

 

b)         If the applicant has not been previously licensed or if the facility is not in operation at the time application is made, the Department will issue only a probationary license. A probationary license shall be valid for 120 days unless sooner suspended or revoked under Section 3-119 of the Act.  (Section 3-116 of the Act.

 

c)         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, will issue a license under Section 3-109 of the Act, except that, during a statewide public health emergency, as defined in the Illinois Emergency Management Agency Act, the Department will fully and completely inspect the facility within appropriate time frames to the extent feasible.  (Section 3-116 of the Act)  If the facility is not in compliance and satisfactory progress toward 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)  Under no condition will more than two successive probationary licenses be issued.

 

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 twenty-four consecutive months.

 

(Source:  Amended at 48 Ill. Reg. 3317, effective February 16, 2024)

 

Section 300.150  Issuance of an Initial License Due to a Change of Ownership

 

a)         Upon receipt and review of an application for a license made under the Act and inspection of the applicant facility under the Act, the Director will issue a probationary license if the Director finds:

 

1)         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 five years;

 

2)         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)         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 a license to any other person, the transferee shall 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.  (Section 3-112(a) 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 a license is issued to the transferee.  (Section 3-112(b) 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 license granted to a transferee for a facility that is in receivership shall be subject to any contractual obligations assumed by a grantee under the Equity in Long-term Care Quality Act and to the plan submitted by the receiver for continuing and increasing adherence to best practices in providing high-quality nursing home care, unless the grant is repaid under the Equity in Long-Term Care Quality Act.  (Section 3-113 of the Act)

 

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

 

g)         If the applicant has not been previously licensed or if the facility is not in operation at the time application is made, the Department will issue only a probationary license. A probationary license shall be valid for 120 days unless sooner suspended or revoked under Section 3-119.

 

h)         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, except that, during a statewide public health emergency, as defined in the Illinois Emergency Management Agency Act, the Department will fully and completely inspect the establishment within appropriate time frames to the extent feasible. (Section 3-116 of the Act)  If the facility is not in compliance and satisfactory progress toward compliance is not being made, the Department will allow the probationary license to expire.

 

i)          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)  Under no condition will more than two successive probationary licenses be issued.

 

j)          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.

 

k)         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 twenty-four consecutive months.

 

(Source:  Amended at 48 Ill. Reg. 3317, effective February 16, 2024)

 

Section 300.160  Issuance of a Renewal License

 

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.  The renewal application shall not be approved unless the applicant has provided to the Department an accurate disclosure document in accordance with the Alzheimer's Special Care Disclosure Act [220 ILCS 4] and Section 300.163 of this Part, if applicable. (Section 3-115 of the Act)

 

(Source:  Amended at 24 Ill. Reg. 17330, effective November 1, 2000)

 

Section 300.163  Alzheimer's Special Care Disclosure

 

A facility that offers to provide care for persons with Alzheimer's disease through an Alzheimer's special care unit or center shall disclose to the Department or to a potential or actual client of the facility the following information in writing on request of the Department or client:

 

a)         The form of care or treatment that distinguishes the facility as suitable for persons with Alzheimer's disease;

 

b)         The philosophy of the facility concerning the care or treatment of persons with Alzheimer's disease;

 

c)         The facility's pre-admission, admission, and discharge procedures;

 

d)         The facility's assessment, care planning, and implementation guidelines in the care and treatment of persons with Alzheimer's disease;

 

e)         The facility's minimum and maximum staffing ratios, specifying the general licensed health care provider to client ratio and the trainee health care provider to client ratio;

 

f)         The facility's physical environment;

 

g)         Activities available to clients at the facility;

 

h)         The role of family members in the care of clients at the facility; and

 

i)          The costs of care and treatment under the program or at the center. (Section 15 of the Alzheimer's Special Care Disclosure Act)

 

(Source:  Added at 23 Ill. Reg. 1103, effective January 15, 1999)

 

Section 300.165  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 or his or her designee to take adverse licensure action against a facility shall be based on a finding that one or more of the following criteria are met:

 

1)         A substantial failure to comply with the Act or this Part.  For purposes of this provision, substantial failure is a failure to meet the requirements of this Part that is other than a variance from strict and literal performance and that results only in unimportant omissions or defects given the particular circumstances involved.  A substantial failure by a facility shall include, but not 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 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

            any of the following crimes during the previous five years.  Such convictions shall be verified by a certified copy of the record of the court of conviction.

 

A)        A felony; or

 

B)        Two or more misdemeanors involving moral turpitude.  (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 verifiable statements by residents of a facility, law enforcement officials, or other persons with knowledge of the individual's character. 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)         The facility is operating (or, for an initial applicant, intends to operate) with personnel who are insufficient in number or unqualified by training or experience to properly care for the number and type of residents in the facility.  Standards in this Part concerning personnel, including Sections 300.810, 300.820, 300.830, 300.1220, 300.1230 and 300.1240, will be considered in making this determination.  (Section 3-119(a)(3) of the Act)

 

5)         Financial or other resources are insufficient  to operate the facility in accordance with the Act and this Part.  Financial information and changes in financial information provided by the facility under Section 300.120(f) 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 300.510.  (Section 3-119(a)(5) of the Act)

 

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

 

8)         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 the resident's written consent or the consent of his or her legal guardian.

 

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

 

9)         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.

 

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

 

c)         The Director or his or her designee shall 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 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.170  Denial of Initial License

 

a)         A determination by the Director or his or her designee to deny the issuance of an initial license shall be based on a finding that one or more of the criteria outlined in Section 300.165 or the following criteria are met:

 

1)         Conviction of the applicant, or if the applicant is a firm, partnership or association, or any of its members or if a corporation, the conviction of the corporation or any of its officers and stockholders, or of the person designated to manage or supervise the facility of any of the following crimes during the previous 5 years.  Such convictions shall be verified by a certified copy of the record of the court of conviction.

 

A)        A felony; or

 

B)        Two or more misdemeanors involving moral turpitude.  (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 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 such 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 300.165(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 with contractual obligations assumed by a recipient of a grant under the Equity in Long-term Care Quality Act and the plan (if applicable) submitted by a grantee for continuing and increasing adherence to best practices in providing high-quality nursing home care. (Section 3-117(4) of the Act)

 

5)         That the facility is not under the direct supervision of a full-time administrator, as defined by 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 this Part, 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)

 

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

 

1)         A clear and concise statement of the basis of the denial.  The statement shall include a citation to the provisions of 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 3-103 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 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.175  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 or his or her designee finds that a condition, occurrence, or situation in the facility meets any of the criteria specified in Section 300.165(b) and in Section 3-119(a) of the Act.  Pursuant to Section 10-65 of the Illinois Administrative Procedure Act  [5 ILCS 100/10-65], 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 or his or her designee 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 basis of the denial.  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) of this Section and Section 3-119(d) of the Act.

 

3)         A description of the right of the applicant to appeal the denial of the application for renewal and the right to a hearing.  (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.

 

d)         The current license of the facility shall be extended by the Department when it finds that such extension is necessary to permit orderly removal and relocation of residents.  (Section 3-119(d)(3) of the Act)

 

(Source:  Amended at 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.180  Revocation of License

 

a)         The license of a facility shall be revoked when the Director or his or her designee finds that a condition, occurrence or situation in the facility meets any of the criteria specified in Section 300.165(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 level A violation as provided in Section 300.282(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 or his or her designee 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 basis of the revocation.  The statement shall include a citation to the provisions of the Act and this Part on which the license is being revoked.

 

2)         A statement of the date on which the revocation will take effect as provided in subsection (c) of this Section 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 when it finds that such extension is necessary to permit orderly removal and relocation of residents.  (Section 3-119(d)(3) of the Act)

 

(Source:  Amended at 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.190  Experimental Program Conflicting With Requirements

 

a)         Any facility desiring to conduct an experimental program or do research which 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 which would violate residents rights under the Act.  Such approval will be granted only if the request will not create an unnecessary and unusual threat to the health, welfare, or safety of the residents or staff.  (A, B)

 

b)         The Department may grant to a facility special permission to provide day care when it has adequate facilities and staff to satisfactorily provide such services based on the requirements in Section 300.3710.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.200  Inspections, Surveys, Evaluations and Consultation

 

The terms survey, inspection and evaluation are synonymous.  These terms refer to the overall examination of compliance with the Act and this Part.

 

a)         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 to the representative of the Department access and entry to the premises or facility for obtaining information required to carry out the Act and this Part.  In addition, representatives of 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 the Freedom of Information Act.

 

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;

 

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;

 

3)         Intentionally prevent or interfere with the preservation of evidence pertaining to any violation of the Act or this Part;

 

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) 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 300.120(e) 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 will consider one or more of the following:

 

1)         previous inspection reports;

 

2)         the facility's history of compliance with the Act and this Part:

 

A)        correction of violations;

 

B)        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); or

 

8)         requirements pursuant to the "1864 Agreement" (42 U.S.C.A. 1395aa) between the Department and U.S. 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 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 determined 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 Type "B" violation if tested against the factors described in Sections 300.272 and 300.274.

 

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) of this Section.

 

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 their 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 after 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 resident care.

 

(Source:  Amended at 46 Ill. Reg. 14237, effective July 27, 2022)

 

Section 300.210  Filing an Annual Attested Financial Statement

 

a)         Each licensee shall submit an annual attested financial statement to the Department.  This financial statement shall be filed in a prescribed format on forms supplied by the Department.  The forms will be developed in conjunction with the Illinois Department of Public Aid.  The time period covered in the financial statement shall be a period determined by the Department for the initial filing, and shall thereafter coincide with the facility's fiscal year or the calendar year.  (Section 3-208 of the Act)

 

b)         The Department may require any facility to file an audited financial statement, if the Department determines that such a statement is needed. (Section 3-208 of the Act)

 

c)         The Department may require any or all facilities to submit attested or audited financial statements more frequently than annually, if the Department determines that more frequent financial statements are needed. The frequency and time period of such filings shall be as determined by the Department for each individual facility. (Section 3-208 of the Act)

 

d)         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.

 

e)         The information required to be submitted in the financial statement will include at a minimum 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, insurance, travel, clerical, 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 shop.

 

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.

 

f)         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.

 

1)         A facility which is licensed for the first time (a newly constructed facility) must file a projection of capital costs.

 

2)         Each of the above must file a full cost report within nine months after acquisition (covering the first six months of operation).  Each must also file a cost report within 90 days of the close of its first complete fiscal year.

 

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

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.220  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.  Section 2-206 of the Act 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 Sections 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 has been 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. (Section 2-205 of the 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 the Department's rules titled Access to Records of the Department of Public Health (2 Ill. Adm. Code 1127). The Department may, at its discretion, waive reproduction fees if the party requesting the material is involved in legal action with the Department.

 

(Source:  Amended at 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.230  Information to Be Made Available to the Public by the Licensee

 

a)         Every facility shall conspicuously post for 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;

 

4)         A list of the material available for public inspection under subsection (b) and Section 3-210 of the Act;

 

5)         Phone numbers and websites for rights protection services must be posted in common areas and at the main entrance and provided upon entry and at the request of resident's representatives; and

 

6)         The statement "The Illinois Long-Term Care Ombudsman Program is a free resident advocacy service available to the public."

 

b)         The administrator shall post for all residents and at the main entrance the name, address, and telephone number of the appropriate State governmental office where complaints may be lodged in language the resident can understand, which must include notice of the grievance procedure of the facility or program as well as addresses and phone numbers for the Office of Health Care Regulation and the Long-Term Care Ombudsman Program and website showing the information of a facility's ownership.  The facility shall include a link to the Long-Term Care Ombudsman Program's website on the home page of the facility's website.  (Section 3-209(a) of the Act)  If a facility does not have a facility-specific website, the link to the Long-Term Care Ombudsman Program's website shall be included on the facility's parent company website.

 

c)         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 five years;

 

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

 

d)         A facility that has received a notice of violation for a violation of the minimum staffing requirements under Section 3-202.05 of the Act and Section 300.1230 of this Part shall display, during the period of time the facility is out of compliance, a notice stating in Calibri (body) font and 26-point type in black letters on an 8.5 by 11 inch white paper the following:

 

"Notice Dated: ...................

This facility does not currently meet the minimum staffing ratios required by law. Posted at the direction of the Illinois Department of Public Health."

 

1)         The notice shall be posted, at a minimum, at all publicly used exterior entryways into the facility, inside the main entrance lobby, and next to any registration desk for easily accessible viewing. The notice shall also be posted on the main page of the facility's website.

 

2)         Pursuant to Section 300.1234(a)(5), the Department shall have the discretion to determine the gravity of any violation and, taking into account mitigating and aggravating circumstances and facts, may reduce the requirement of, and amount of time for, posting the notice.  (Section 3-209 of the Act)

 

e)         All Cook County facilities with Colbert Class Members shall conspicuously display, in a public and accessible location, a Department-provided poster informing residents of their right to explore or decline community transition, and their right to be free from retaliation, regardless of their decision on transition.  This poster shall include a telephone number for reporting retaliation to the Department and shall include the steps a resident should take if retaliation does occur.  The display of the poster will be included as a compliance measure in the Department's survey process. 

 

(Source:  Amended at 49 Ill. Reg. 760, effective December 31, 2024)

 

Section 300.240  Municipal Licensing

 

a)         Municipalities which 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 (Ill. Rev. Stat. 1987, ch. 24, pars. 1-3-1 et seq.).

 

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. During the 24 month period following the effective date of the Act, the municipality may issue renewal licenses for a period of less than one year in order to distribute the expiration date of such licenses throughout the calendar year.

 

c)         The municipality shall notify the Department within ten days from 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 will 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 will indicate reason for denial and the current status of licensee's (applicant's) application for municipal license.

 

d)         The municipality shall use the same licensing classifications as the Department; and a facility may not be licensed for a different classification by the Department than by the municipality.

 

e)         The Department and the municipality 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, this Part 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 insure 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.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.250  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 (Section 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 that 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 that 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 41 Ill. Reg. 14811, effective November 15, 2017)

 

Section 300.260  Issuance of Conditional Licenses

 

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 which 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 ten (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 such time as the applicant or licensee has had the opportunity to request a hearing pursuant to subsection (d) of this Section, 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) of this Section.  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 17 Ill. Reg. 15106, effective September 3, 1993)

 

Section 300.270  Monitor and Receivership

 

a)         The Department may place an employee or agent to serve as a monitor in a facility 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; or

 

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. (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;

 

2)         have an understanding of the needs of long-term care facility residents as evidenced by one year of experience in working, as appropriate, with elderly or developmentally disabled individuals in programs such as patient care, social work, or advocacy;

 

3)         have an understanding of the Act and this Part which 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 full-time work experience in the long-term care industry of the State of Illinois.

 

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 such monitor's placement under subsection (a) of this Section;

 

3)         provide to the Department written and oral reports 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 provisions of the Freedom of Information Act, subject to the confidentiality requirements of the Act.

 

e)         The assignment as monitor may be terminated at any time by the Department.

 

f)         Through consultation with the long-term care industry associations, professional organizations, consumer groups and health-care management corporations, the Department shall maintain a list of receivers. Preference on the list shall be given to individuals possessing a valid Illinois Nursing Home Administrator's License, experience in financial and operations management of a long-term care facility and individuals with access to consultative experts with the aforementioned experience.  To be placed on the list, individuals must meet the following minimum requirements:

 

1)         be in good physical health as evidenced by a physical examination by a physician within the last year;

 

2)         have an understanding of the needs of long-term care facility residents and the delivery of the highest possible quality of care as evidenced by one year of experience in working with elderly or 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 full-time working experience in the Illinois long-term care industry.

 

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

 

h)         The receiver may request that the Director of the Department 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, his medical records and his belongings if he 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 the selection of 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 the aforesaid powers and duties, the receiver shall be considered a public employee under the Local Governmental and Governmental Employees Tort Immunity Act  [745 ILCS 10]. 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 19 Ill. Reg. 11600, effective July 29, 1995)

 

Section 300.271  Presentation of Findings

 

a)         If it is probable that findings will be presented that could be issued as violations of regulations which 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 shall 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, the Department shall 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, in 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 shall so inform the facility in writing.  The facility shall then have an opportunity to submit additional comments addressing the different or additional Sections of the Act or this Part.  The surveyors will be advised of any code changes made after their recommendations are submitted.

 

g)         The facility shall have 5 (five) working days from receipt of the notice required by subsection (f) of this Section to submit its additional comments to the Department.  The Department shall consider such additional comments in determining the existence and level of violation of the Act and/or 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 such recording is provided, at facility expense, to the surveyors at the conclusion of the exit conference. No video-taped recording shall be allowed.

 

i)          Surveyors shall not conduct an exit conference for the following reason:

 

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

 

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

 

(Source:  Added at 17 Ill. Reg. 15106, effective September 3, 1993)

 

Section 300.272  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 or his or her designee will 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 will be considered findings or deficiencies.  (Section 3-212(c) of the Act)

 

b)         In making this determination, the Director or his or her designee will consider any comments and documentation provided by the licensee within 10 days after receipt of the copy of the report in accordance with Section 300.200(c). (Section 3-212(c) of the Act)

 

c)         In determining whether the findings warrant the issuance of a notice of violation, the Director or his or her designee will base his or her determination on the following factors:

 

1)         The severity of the finding.  The Director or his or her designee will consider whether the finding constitutes a technical non-substantial error or whether the finding is serious enough to constitute an actual violation of the intent and purpose of the Act or this Part.

 

2)         The danger posed to resident health and safety.  The Director or his or her designee 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.  The Director or his or her designee will consider comments and documentation provided by the facility evidencing that steps have been taken to correct reported 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 or his or her designee will consider whether the same finding or a similar finding relating to the same condition or occurrence has been included in previous reports and the facility has allowed the condition or occurrence to continue or to recur.  (Section 3-212(c) of the Act)

 

d)         If the Director or his or her designee determines that the report's findings constitute a violation or violations that do not directly threaten the health, safety, or welfare of a resident or residents, the Department shall issue an administrative warning as provided in Section 300.277 (Section 3-303.2(a) of the Act)

 

e)         Violations shall be determined under this Section no later than 75 days after completion of each inspection, survey, and evaluation. (Section 3-212(c) of the Act)

 

(Source:  Amended at 43 Ill. Reg. 3536, effective February 28, 2019)

 

Section 300.274  Determination of the Level of a Violation

 

a)         After determining that issuance of a notice of violation is warranted and prior to issuance of the notice, the Director or his or her designee 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 level AA, a level A, a level B, or a level C violation based on the criteria in this Section.

 

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

 

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

 

3)         A "level B violation" or "Type B violation" is a violation of the Act or this Part which 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. (Section 1-130 of the Act)

 

4)         A "level C violation" or "Type C violation" is a violation of the Act or this Part which 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 level of a violation, the Director or his or her designee 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 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 such 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 such notice.  Failure of the facility to notify residents of potentially harmful conditions or occurrences will be considered.  The adequacy of the method of such notification and the extent to which such 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 such 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 such 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 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.276  Notice of Violation

 

a)         Each notice of violation shall be 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 level of the violation as determined pursuant to Section 300.274.

 

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 or his designee 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 300.272.  (Section 3-301 of the Act)

 

(Source:  Amended at 46 Ill. Reg. 14237, effective July 27, 2022)

 

Section 300.277  Administrative Warning

 

a)         If the Department finds a situation, condition, or practice which violates the Act or this Part that 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 or his or her designee determines that issuance of an administrative warning is warranted under Section 300.272.

 

d)         The facility is not required to submit a plan of correction in response to an administrative warning.

 

e)         If the Department finds, during the next on-site inspection which occurs no earlier  than 90 days from the issuance of the administrative warning, that the facility has not corrected the situation, condition, or practice which 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 300.278.  The Department will consider the plan of correction and take any necessary action in accordance with Section 302.278.  (Section 3-303.2(b) of the Act)

 

(Source:  Amended at 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.278  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 300.277(d) 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 300.120(e) 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. Evidence of the assessment and evaluation shall be maintained by the facility.  Each plan of correction shall include:

 

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

 

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

 

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

 

f)         Submission of a plan of correction will 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.

 

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 Type "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 46 Ill. Reg. 14237, effective July 27, 2022)

 

Section 300.280  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 300.278 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 300.278(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 300.278.

 

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. 4684, effective March 24, 1989)

 

Section 300.282  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 up to $25,000 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. (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) of the Act, which is cited as a repeat violation, shall have its license revoked and shall be assessed a fine of 3 times the fine computed per resident per day under subsection (a) or (b) of this Section.  (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.  (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 pursuant to 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) of this Section 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 10 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 licensee who commits one or more Type "C" violations with a high risk designation shall be assessed a fine of up to $500 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), 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(7.5) of the Act)

 

h)         The minimum and maximum fines that may be assessed pursuant to Section 3-305 of the Act and this Section 300.282 shall be twice those otherwise specified for any facility that willfully makes a misstatement of fact to the Department, or willfully fails to make a required notification to the Department, if that misstatement or failure delays the start of a surveyor or impedes a survey.  (Section 3-305(8) 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(9) 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 300.615(b)

 

2)         Section 300.615(e)

 

3)         Section 300.615(f)

 

4)         Section 300.615(g)

 

5)         Section 300.625(a)

 

6)         Section 300.625(b)

 

7)         Section 300.625(c)

 

8)         Section 300.625(f)

 

9)         Section 300.625(j)

 

10)        Section 300.625(k)

 

11)        Section 300.625(l)

 

12)        Section 300.625(n)

 

13)        Section 300.625(o)

 

14)        Section 300.627(c)

 

15)        Section 300.627(d)

 

16)        Section 300.627(e)

 

17)        Section 300.661

 

18)        Section 300.680

 

19)        Section 300.686

 

20)        Section 300.690

 

21)        Section 300.695(b)

 

22)        Section 300.696

 

23)        Section 300.1210(b)

 

24)        Section 300.1210(d)(5)

 

25)        Section 300.1210(d)(6)

 

26)        Section 300.1230

 

27)        Section 300.1240

 

28)        Section 300.2900(d)(2)

 

29)        Section 300.3100(d)(2)

 

30)        Section 300.3240(a)

 

31)        Section 300.3240(d)

 

32)        Section 300.3240(e)

 

k)         If a licensee has paid a civil monetary penalty imposed pursuant to the Medicare and Medicaid Certification Program for the equivalent federal violation giving rise to a fine under Section 3-305 of the Act and this Section 300.282, or provides the Department with a copy of a letter to the Centers for Medicare and Medicaid Services (CMMS) of its binding intent to waive its right to a federal hearing to contest a civil monetary penalty for the equivalent federal violation, the Department shall offset the fine by the amount of the civil monetary penalty.  The offset may not reduce the fine by more than 75% of the original fine, however.  (Section 3-305(10) of the Act) The meaning of "equivalent federal violation" shall be determined by the Department. Upon request by the Department, the facility shall provide proof to the Department of the federal civil monetary penalty when the payment is due.

 

l)          When the Department finds that a provision of Article II 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 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 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.284  Calculation of Penalties (Repealed)

 

(Source:  Repealed at 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.286  Notice of Penalty Assessment; Response by Facility

 

a)         If the Director or his or her designee 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 300.282.

 

2)         The amount of any reduction or whether the penalty has been waived pursuant to Section 300.288.

 

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 that the facility has 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)

 

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 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. 14237, effective July 27, 2022)

 

Section 300.287  Consideration of Factors for Assessing Penalties

 

At any hearing requested by a facility that challenges the appropriateness of any penalty imposed by the Department, the facility may present evidence as to any or all of the following factors.  The Director or his or her designee will then consider any such evidence presented by the facility, or any evidence otherwise available to the Department, regarding the following factors 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.

 

a)         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 or his or her designee finds that death or serious physical or mental harm to a resident has occurred or that the facility has knowingly subjected residents to potential serious harm.

 

b)         The reasonable diligence exercised by the licensee and efforts to correct violations.  The Director or his or her designee will assess a monetary penalty if he or she finds that the violation recurred or continued, is widespread throughout the facility or evidences flagrant violation of the Act or this Part.

 

c)         Any previous violations committed by the licensee.  The Director or his or her designee will assess a penalty when he or she finds 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 or his or her designee will also consider any evidence that the violations constitute a pattern of deliberate action by the facility.  The extent of any change in the ownership and management of the facility will be considered in relation to the seriousness of previous violations.

 

d)         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)

 

(Source:  Added at 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.288  Reduction or Waiver of Penalties

 

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

 

1)         The Director or his designee shall consider the factors contained in Section 300.286(a) in determining whether to reduce the amount of the penalty to be assessed from the amount calculated pursuant to Section 300.284 and in determining the amount of such reduction.

 

2)         When the Director or his designee 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 level A violation to an amount less than $1000.

 

b)         Reductions and waivers for level B violations.

 

1)         Penalties resulting from level B violations may be reduced or waived only under one of the following conditions:

 

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

 

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

 

C)        The facility submits a plan of correction within ten days after the notice of violation is received, the plan provides for correction within not more than 30 days after submission of the plan of correction, and the plan is approved by the Department.

 

D)        Correction of the violation requires substantial capital improvements or repairs in the physical plant of the facility, the facility submits a plan or correction involving substantial capital costs, the plan of correction provides completion of the corrective action within 90 days after submission of the plan, and the plan is approved by the Department. (Section 3-308 of the Act)

 

2)         Under these conditions, the Director or his designee shall consider the factors outlined in Section 300.286(a) in determining whether to reduce or waive the penalty and in setting the amount of any reduction.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.290  Quarterly List of Violators (Repealed)

 

(Source:  Repealed at 24 Ill. Reg. 17330, effective November 1, 2000)

 

Section 300.300  Alcoholism Treatment Programs In Long-Term Care Facilities

 

a)         A long-term care facility that desires to provide an alcoholism treatment program must first receive written approval from the Department. Such approval will be granted only if it can be shown that such program will not interfere in any way with the residents in the other parts of the facility.

 

b)         Any alcoholism treatment program in a long-term care facility must meet the program standards of the rules for Alcoholism and Substance Abuse Treatment, Intervention and Research Programs (77 Ill. Adm. Code 2058), as promulgated by the Illinois Department of Alcoholism and Substance Abuse under the Illinois Alcoholism and Other Drug Dependency Act (Ill. Rev. Stat. 1987, ch. 111½, par. 6351-1 et seq.).

 

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

 

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

 

e)         The alcoholism treatment program staff will not be utilized in performing services in the long-term care area of the facility, nor will long-term care program staff be utilized to provide any services in the alcoholism treatment designated area.

 

f)         There may be joint use of laundry, food service, housekeeping and administrative services, provided written approval is obtained from the Department.  Such approval will be granted only if it can be shown that such joint usage will not interfere in any way with the residents in other parts of the facility.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.310  Department may Survey Facilities Formerly Licensed

 

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

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.315  Supported Congregate Living Arrangement Demonstration (Repealed)

 

(Source:  Repealed at 48 Ill. Reg. 3317, effective February 16, 2024)

 

Section 300.320  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;

 

2)         the continued validity of extending the waiver on the same basis;

 

3)         the effect upon the health and safety of residents;

 

4)         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);

 

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

 

6)         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 this Section at the time of the indicated reviews, unless it can show why such 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 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.330  Definitions

 

The terms defined in this Section are terms that are used in one or more of the sets of licensing standards established by the Department to license various levels of long-term care.  They are defined as follows:

 

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 refers to the infliction of injury on a resident that occurs other than by accidental means and that requires (whether or not actually given) medical attention.

 

Mental injury arises from the following types of conduct:

 

Verbal abuse refers to the use by a licensee, employee or agent of oral, written or gestured language that includes disparaging and derogatory terms to residents or within their hearing or seeing distance, regardless of their age, ability to comprehend or disability.

 

Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation, or offensive physical contact by a licensee, employee or agent.

 

Sexual harassment or sexual coercion perpetrated by a licensee, employee or agent.

 

Sexual assault.

 

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 − as used in this Part, the Nursing Home Care Act.

 

Activity Program − a specific planned program of varied group and individual activities geared to the individual resident's needs and available for a reasonable number of hours each day.

 

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 that may restrict freedom of movement or normal access to one'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 300.680 of this Part 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 300.277 of this Part and Section 3-303.2 of the Act that 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, in order 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)

 

Aide or Orderly − any person providing direct personal care, training or habilitation services to residents.

 

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.

 

Assessment − the use of an objective system with which to evaluate the physical, social, developmental, behavioral, and psychosocial aspects of an individual.

 

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

 

Autism − a syndrome described as consisting of withdrawal, very inadequate social relationships, exceptional object relationships, language disturbances and monotonously repetitive motor behavior.

 

Autoclave − an apparatus for sterilizing by superheated steam under pressure.

 

Basement − when used in this Part, any story or floor level below the main or street floor.  Where, due to grade difference, there are two levels that 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 Modification − treatment to be used to establish or change behavior patterns.

 

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, learning difficulty and behavior disorders.

 

Certification for Title XVIII and XIX − the issuance of a document by the Department to the U.S. Department of Health and Human Services or the Department of Healthcare and Family Services verifying compliance with applicable statutory or regulatory requirements for the purposes of 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.  Certified 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 of the Act)

 

Colbert Consent Decree – Colbert et al. v. Pritzker et al., Case No. 07 C 4737, United States District Court, N.D. Illinois, Eastern Division.

 

Colbert Consent Decree Class Members or Colbert Class Members – all Medicaid-eligible adults with disabilities in Cook County, Illinois, who are being, or may in the future be, unnecessarily confined to nursing facilities and who, with appropriate supports and services, may be able to live in a community setting.

 

Colbert Consent Decree Defendant Agencies – the Illinois Department of Human Services, the Illinois Department of Public Health, the Illinois Department on Aging, and the Illinois Department of Healthcare and Family Services, including any successor to these departments.

 

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

 

Continuing Care Contract − a contract through which a facility agrees to supplement all forms of financial support for a resident throughout the remainder of the resident's life.

 

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.

 

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 disability, cerebral palsy, epilepsy, 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, 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;

 

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.

 

Director − the Director of Public Health or the Director's 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 having facilities meeting the standards applicable to the levels of service to be provided.  Staff and services for a distinct part are established as set forth in the respective regulations governing the levels of services approved for the distinct part.

 

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 long-term care for which the license (new or renewal) is to be granted.

 

Exploitation − taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion.

 

Facility, Intermediate Care − a facility that provides basic nursing care and other restorative services under periodic medical direction.  Many of these services may require skill in administration.  These facilities are for residents who have long-term illnesses or disabilities that may have reached a relatively stable plateau.

 

Facility or Long-Term Care Facility − a private home, institution, building, residence, or any other place, whether operated for profit or not, or a county home for the infirm and chronically ill operated pursuant to Division 5-21 or 5-22 of the Counties Code, or any similar institution operated by a political subdivision of the State of Illinois, which provides, through its ownership or management, personal care, sheltered care or nursing for three or more persons, not related to the applicant or owner by blood or marriage.  It includes skilled nursing facilities and intermediate care facilities as those terms are defined in Title XVIII and Title XIX of the Federal Social Security Act (42 U.S.C. 1395 et seq. and 1936 et seq.).  It also includes homes, institutions, or other places operated by or under the authority of the Illinois Department of Veterans' Affairs. A "facility" may consist of more than one building as long as the buildings are on the same tract, or adjacent tracts of land.  However, there shall be no more than one "facility" in any one building. "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 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 Arrangements 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;

 

A facility licensed under the ID/DD Community Care Act;

 

A facility licensed under the Specialized Mental Health Rehabilitation Act of 2013;

 

A facility licensed under the MC/DD Act; or

 

A medical foster home, as defined in 38 CFR 17.73, that is under the oversight of the U.S. Department of Veterans Affairs.  (Section 1-113 of the Act)

 

Facility, Skilled Nursing − when used in this Part is synonymous with a skilled nursing facility.  A skilled nursing facility provides skilled nursing care, continuous skilled nursing observations, restorative nursing, and other services under professional direction with frequent medical supervision.  These facilities are provided for patients who need the type of care and treatment required during the post-acute phase of illness or during recurrences of symptoms in long-term illness.

 

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 − means on duty a minimum of 36 hours, four days per week.

 

Goal − an expected result or condition that involves a relatively long period of time to achieve, that is specified in behavioral terms in a statement of relatively broad scope, 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 the alleviation of a disability or 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, sheltered employment, protective services, counseling and other services.

 

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 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 300.282(i), of a provision that has been identified by the Department in Section 300.282(j) 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; or

 

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

 

Intellectual Disability – subaverage general intellectual functioning originating during the developmental period and associated with maladaptive behavior.

 

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.  This team shall include at least a physician, a social worker and other professionals. 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 his or her 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.

 

Lead Defendant Agency – State of Illinois Agency named in each fiscal year's Implementation Plan as the lead agency for the Williams and Colbert Consent Decrees on behalf of the Defendants. For the purposes of this definition, "Implementation Plan" refers to the plan set forth in the Consent Decree, created and implemented by the Defendants, with the input of the Monitor and Plaintiffs, to accomplish the obligations and objectives set forth in the Decree.

 

Licensed Nursing Home Administrator − see "Administrator".

 

Licensed Practical Nurse − a person with a valid Illinois license 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.

 

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

 

Maladaptive Behavior − impairment in adaptive behavior as determined by a clinical psychologist or by a physician. 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, 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 facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident.  (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 long-term care for which the license (new or renewal) is to be granted.

 

Nurse − a registered professional 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 procedures involving understanding of cause and effect to safeguard life and health.

 

Nursing Unit − a physically identifiable designated area of a facility consisting of all the beds within the designated area, but having no more than 75 beds, none of which are more than 120 feet from the nurse's station.

 

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, Registered or OTR − 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 − 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 person, whether or not a guardian has been appointed for such individual.  (Section 1-120 of the Act)

 

Pharmacist, Licensed − 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 a resident's body that the resident cannot remove easily and which restricts freedom of movement or normal access to one's body.  (Section 2-106 of the Act)

 

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

 

Physical Therapist Assistant − a person who has graduated from a two-year college level program approved by the American Physical Therapy Association.

 

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 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)

 

Psychiatric Services Rehabilitation Aide – an individual employed by a long-term care facility to provide, for mentally ill residents, at a minimum, crisis intervention, rehabilitation, and assistance with activities of daily living. (Section 1-120.7 of the Act)

 

Psychiatrist − a physician who has had at least three years of formal training or primary experience in the diagnosis and treatment of mental illness.

 

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

 

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 this criteria; and who is licensed, registered, or certified by the State of Illinois, if required.

 

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

 

Registered Professional 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. A repeat violation shall not be a new citation of the same rule, unless the licensee is not substantially addressing the issue routinely throughout the facility.  (Section 3-305(7) of the Act)

 

Reputable Moral Character − having no history of a conviction of the applicant, or if the applicant is a firm, partnership, or association, of any of its members, or of a corporation, of any of its officers, or directors, or of the person designated to manage or supervise the facility, of a felony, or of two or more misdemeanors involving moral turpitude, as shown by a certified copy of the record of the court of conviction, or in the case of the conviction of a misdemeanor by a court not of record, as shown by other evidence; or other satisfactory evidence that the moral character of the applicant, or manager, or supervisor of the facility is not reputable.

 

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

 

Resident Services Director − the full-time administrator, or an individual on the professional staff in the facility, who is directly responsible for the coordination and monitoring of the residents' overall plans of care in an intermediate care 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)

 

Restorative Services or Restorative Measures − services or measures designed to assist residents to attain and maintain the highest degree of function of which they are capable (physical, mental, and social).

 

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 Authorized Personnel – individuals who have a legal duty to provide specified services to residents of long-term care facilities, including, but not limited to, representatives of the Office of the State Long-Term Care Ombudsman Program, the Office of State Guardian, and community-service providers or third parties serving as agents of the State for purposes of providing telemedicine, transitional services to community-based living, in-person assessments and evaluations, legal services, and other supports related to existing consent decrees court-mandated actions.

 

State Fire Marshal − the Fire Marshal of the Office of the State Fire Marshal, Division of Fire Prevention.

 

Sterilization − the act or process of destroying completely all forms of microbial life, including viruses.

 

Stockholder of a Corporation − any person who, directly or indirectly, beneficially owns, holds or has the power to vote, at least 5% of any class of securities issued by the corporation. (Section 1-125 of the Act)

 

Story − when used in this Part, means 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 an academic credit requirement in a high school or undergraduate or graduate institution; or

 

immediately succeeds a full quarter, semester or trimester of academic enrollment in either a high school or undergraduate or graduate 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; or

 

immediately succeeds graduation from the high  school or undergraduate or graduate institution.  (Section 1-125.1 of the Act)

 

Substantial Compliance − meeting requirements except for variance from the strict and literal performance that results in unimportant omissions or defects given the particular circumstances involved.  This definition is limited to the term as used in Sections 300.140(a)(3) and 300.150(a)(3).

 

Substantial Failure − the failure to meet requirements other than a variance from the strict and literal performance that results in unimportant omissions or defects given the particular circumstances involved.  This definition is limited to the term as used in Section 300.165(b)(1).

 

Supervision − authoritative guidance by a qualified person for the accomplishment of a function or activity within his or her 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.

 

Title XVIII − Title XVIII of the federal Social Security Act as now or hereafter amended.  (Section 1-126 of the Act)

 

Title XIX − Title XIX of the federal Social Security Act as now or hereafter amended. (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 which 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. (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 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.

 

(Source:  Amended at 46 Ill. Reg. 16829, effective September 26, 2022)

 

Section 300.340  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 No. 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)        American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE), Handbook of Fundamentals (2001), Handbook of Applications (2007), and ASHRAE Guideline 12-2020, "Managing the Risk of Legionellosis Associated with Building Water Systems" (March 30, 2021), which may be obtained from the American Society of Heating, Refrigerating, and Air Conditioning Engineers, Inc., 1791 Tullie Circle, N.E., Atlanta, GA  30329.

 

C)        American Society for Testing and Materials (ASTM) International Standard No. 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.

 

D)        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.

 

E)        For existing facilities, National Fire Protection Association (NFPA) 101:  Life Safety Code, (2012) Chapter 19 and all appropriate references under Chapter 2, and the following additional standards, which may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA  02169:

 

i)          NFPA 20 (2010):  Installation of Stationary Pumps for Fire Protection

 

ii)         NFPA 22 (2008): Water Tanks for Private Fire Protection

 

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

 

F)         For new facilities, the standards of the NFPA 101, Life Safety Code (2012), Chapter 18 and all appropriate references under Chapter 2, and the following additional standards, which may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA  02169:

 

i)          NFPA 20 (2010): Standard for the Installation of Stationary Pumps for Fire Protection

 

ii)         NFPA 22 (2008), Standard for Water Tanks for Private Fire Protection

 

G)        For new and existing facilities, NFPA 99:  Health Care Facilities Code – 2012 Edition.

 

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

 

i)          Fire Resistance Directory (2015 Edition)

 

ii)         Building Material Directory (2015 Edition)  

 

I)         American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition DSM-5 (2022), available at:  https://appi.org/Products/dsm or from the American Psychiatric Association, 800 Maine Avenue, SW, Suite 900, Washington, DC  20024.

 

J)         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 300.3220.)

 

K)        The Prescribers' Digital Reference (PDR) database, which may be accessed at www.pdr.net.

 

L)        The Lexicomp-online database, which may be accessed at www.wolterskluwercdi.com/lexicomp-online.

 

M)       The American Society of Health-System Pharmacists (ASHP) database, which may be accessed at www.ashp.org.

 

2)         Federal guidelines:

The following guidelines and toolkits of the Centers for Disease Control and Prevention, United States Public Health Service, Department of Health and Human Services, Agency for Healthcare Research and Quality, and Occupational Safety and Health Administration:

 

A)        Guideline for Prevention of Catheter-Associated Urinary Tract Infections, available at:  https://www.cdc.gov/infection-control/media/pdfs/guideline-cauti-h.pdf?CDC_AAref_Val=https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf (June 6, 2019)

 

B)        Guideline for Hand Hygiene in Health-Care Settings, available at:  https://www.cdc.gov/infection-control/media/pdfs/Guideline-Hand-Hygiene-P.pdf (October 25, 2002)

 

C)        Guidelines for Prevention of Intravascular Catheter-Related Infections, 2011, available at:   https://www.cdc.gov/infection-control/media/pdfs/guideline-bsi-h.pdf?CDC_AAref_Val=https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf (October 2017)

 

D)        Guideline for Prevention of Surgical Site Infection, 2017, available at:  https://jamanetwork.com/journals/jamasurgery/fullarticle/2623725 (August 2017)

 

E)        Guideline for Preventing Healthcare-Associated Pneumonia, 2003, available at:  https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm (March 26, 2004)

 

F)         2007 Guideline for Isolation Precautions:  Preventing Transmission of Infectious Agents in Healthcare Settings, available at:  https://www.cdc.gov/infection-control/media/pdfs/Guideline-Isolation-H.pdf (September 2024)

 

G)        Infection Control in Healthcare Personnel, available in two parts: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services, available at:  https://www.cdc.gov/infection-control/media/pdfs/Guideline-Infection-Control-HCP-H.pdf (October 25, 2019) and Epidemiology and Control of Selected Infections Transmitted Among Healthcare Personnel and Patients, available at: https://www.cdc.gov/infection-control/media/pdfs/Guideline-IC-HCP-H.pdf (March 28, 2024)

 

H)        The Core Elements of Antibiotic Stewardship for Nursing Homes, available at:   https://www.cdc.gov/antibiotic-use/media/pdfs/core-elements-antibiotic-stewardship-508.pdf (March 18, 2024)

 

I)         The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A: Policy and Practice Actions to Improve Antibiotic Use, available at:  https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdf

 

J)         Nursing Home Antimicrobial Stewardship Guide, available at:  https://www.ahrq.gov/nhguide/index.html (March 2023)

 

K)        Toolkit 3.  Minimum Criteria for Common Infections Toolkit, available at: https://www.ahrq.gov/nhguide/toolkits/determine-whether-to-treat/toolkit3-minimum-criteria.html (September 2017)

 

L)        TB Prevention in Health Care Settings (December 15, 2023) available at:   https://www.cdc.gov/tb-healthcare-settings/hcp/infection-control/index.html

 

M)       Infection Control Guidance: SARS-CoV-2 (June 24, 2024) available at:  https://www.cdc.gov/covid/hcp/infection-control/?CDC_AAref_Val=https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html

 

N)        Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Novel or Targeted Multidrug-resistant Organisms (MDROs) (April 2, 2024) available at:   https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html

 

O)        Hospital Respiratory Protection Program Toolkit: Resources for Respirator Program Administrators (April 2022) available at: https://www.cdc.gov/niosh/docs/2015-117/default.html

 

P)         Respiratory Protection Guidance for the Employers of Those Working in Nursing Homes, Assisted Living, and Other Long-Term Care Facilities During the COVID-19 Pandemic available at: https://www.osha.gov/sites/default/files/respiratory-protection-covid19-long-term-care.pdf

 

Q)        Guidelines for Environmental Infection Control in Health-Care Facilities (July 2019) available at:  https://www.cdc.gov/infection-control/media/pdfs/Guideline-Environmental-H.pdf

 

R)          Toolkit for Controlling Legionella in Common Sources of Exposure (January 13, 2021), available at:   https://stacks.cdc.gov/view/cdc/104362

 

3)         Federal regulations:

 

A)        21 CFR 1306, Prescriptions (April 1, 2024)

 

B)        42 CFR 483, Requirements for States and Long-Term Care Facilities (October 1, 2023)

 

C)        38 CFR 17.73, Medical Foster Homes – General (July 1, 2023)

 

D)        42 CFR 483.80, Infection Control (October 1, 2023)

 

b)         All incorporations by reference of federal regulations 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)        Child Care Act of 1969 [225 ILCS 10]

 

C)        Court of Claims Act [705 ILCS 505]

 

D)        Illinois Dental Practice Act [225 ILCS 25]

 

E)        Election Code [10 ILCS 5]

 

F)         Freedom of Information Act [5 ILCS 140]

 

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

 

H)        Hospital Licensing Act [210 ILCS 85]

 

I)         Illinois Controlled Substances Act [720 ILCS 570]

 

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

 

K)        Illinois Municipal Code [65 ILCS 5]

 

L)        Nurse Practice Act [225 ILCS 65]

 

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

 

N)        Illinois Physical Therapy Act [225 ILCS 90]

 

O)        Life Care Facilities Act [210 ILCS 40]

 

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

 

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

 

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

 

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

 

T)         Nursing Home Care Act [210 ILCS 45]

 

U)        Pharmacy Practice Act [225 ILCS 85]

 

V)        Probate Act of 1975 [775 ILCS 5]

 

W)       Illinois Public Aid Code [305 ILCS 5]

 

X)        Illinois Administrative Procedure Act [5 ILCS 100]

 

Y)        Clinical Psychologist Licensing Act [225 ILCS 15]

 

Z)        Dietitian Nutritionist Practice Act [225 ILCS 30]

 

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

 

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

 

CC)     Illinois Living Will Act [755 ILCS 35]

 

DD)     Illinois Power of Attorney Act [755 ILCS 45/Art. IV]

 

EE)      Health Care Surrogate Act [755 ILCS 45]

 

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

 

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

 

HH)     Supportive Residences Licensing Act [210 ILCS 65]

 

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

 

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

 

KK)     Counties Code [55 ILCS 5]

 

LL)      Professional Counselor and Clinical Professional Counselor Licensing Act [225 ILCS 107]

 

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

 

NN)     Illinois Optometric Practice Act of 1987 [225 ILCS 80]

 

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

 

PP)      Alzheimer's Disease and Related Dementias Special Care Disclosure Act [210 ILCS 4]

 

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

 

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

 

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

 

TT)      Language Assistance Services Act [210 ILCS 87]

 

UU)     Alzheimer's Disease and Related Dementias Services Act [410 ILCS 406]

 

VV)     Illinois Uniform Conviction Information Act [20 ILCS 2635]

 

WW)   Specialized Mental Health Rehabilitation Act of 2013 [210 ILCS 49]

 

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

 

YY)     MC/DD Act [210 ILCS 46]

 

ZZ)      Home Health, Home Services, and Home Nursing Agency Licensing Act [210 ILCS 55]

 

AAA)  Methamphetamine Control and Community Protection Act [720 ILCS 646]

 

BBB)   Sex Offender Management Board Act [20 ILCS 4026]

 

CCC)   Illinois Emergency Management Agency Act [20 ILCS 3305]

 

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

 

EEE)   Latex Glove Ban Act [410 ILCS 180]

 

3)         State of Illinois rules:

 

A)        Office of the State Fire Marshal, Boiler and Pressure Vessel Safety (41 Ill. Adm. Code 2120)

 

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

 

C)        Department of Public Health:

 

i)          Control of Notifiable Diseases and Conditions 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 Public Records of the Department of Public Health (2 Ill. Adm. Code 1127)

 

x)         Intermediate Care for the Developmentally Disabled Facilities Code (77 Ill. Adm. Code 350)

 

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)      Alzheimer's Disease And Related Dementias Services Code (77 Ill. Adm. Code 973)

 

xvii)     Specialized Mental Health Rehabilitation Facilities Code (77 Ill. Adm. Code 380)

 

xviii)    Supportive Residences Licensing Code (77 Ill. Adm. Code 385)

 

xix)      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, Medical Payment (89 Ill. Adm. Code 140)

 

H)        Department on Aging, Community Care Program (89 Ill. Adm. Code 240)

 

(Source:  Amended at 49 Ill. Reg. 760, effective December 31, 2024)

SUBPART B: ADMINISTRATION

 

Section 300.510  Administrator

 

a)         There shall be an administrator licensed under the Nursing Home Administrators Licensing and Disciplinary Act (Ill. Rev. Stat. 1987, ch. 111, par. 3651 et seq.) full-time for each licensed facility.  The licensee will report any change in administrator to the Department, within five days.

 

b)         The administrator shall delegate in writing adequate authority to a person at least 18 years of age who is capable of acting in an emergency during his or her absence.  Such administrative assignment shall not interfere with resident care and supervision.  The administrator or the person designated by the administrator to be in charge of the facility in the administrator's absence, shall be deemed by the Department to be the agent of the license for the purpose of Section 3-212 of the Act, which requires Department staff to provide the licensee with a copy of their report before leaving the facility. (B)

 

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 applicable regulations are met in the facility and that employees are familiar with those regulations according to the level of their responsibilities.  (A, B)

 

f)         If the facility has an assistant administrator, the Department shall be informed 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 (Ill. Rev. Stat. 1987, ch. 111, par. 3651 et seq.).

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

SUBPART C: POLICIES

 

Section 300.610  Resident Care Policies

 

a)         The facility shall have written policies and procedures governing all services provided by the facility.  The written policies and procedures shall be formulated by a Resident Care Policy Committee consisting of at least the administrator, the advisory physician or the medical advisory committee, and representatives of nursing and other services in the facility.  The policies shall comply with the Act and this Part.  The written policies shall be followed in operating the facility and shall be reviewed at least annually by this committee, documented by written, signed and dated minutes of the meeting. 

 

b)         All of the information contained in the policies shall be available to the public, staff and residents, and for review by the Department.

 

c)         The written policies shall include, at a minimum the following provisions:

 

1)         Admission, transfer and discharge of residents, including categories of residents accepted and not accepted, residents that will be transferred or discharged, transfers within the facility from one room to another, and other types of transfers;

 

2)         Resident care services, including physician services, emergency services, personal care and nursing services, restorative services, activity services, pharmaceutical services, dietary services, social services, clinical records, dental services, and diagnostic services (including laboratory and x-ray);

 

3)         A policy prohibiting blood transfusions, unless the facility is hospital based and appropriate services are available in case of an adverse reaction to the transfusions; and

 

4)         A policy to identify, assess, and develop strategies to control risk of injury to residents and nurses and other health care workers associated with the lifting, transferring, repositioning, or movement of a resident. The policy shall establish a process that, at a minimum, includes all of the following:

 

A)        Analysis of the risk of injury to residents and nurses and other health care workers taking into account the resident handling needs of the resident populations served by the facility and the physical environment in which the resident handling and movement occurs;

 

B)        Education of nurses in the identification, assessment, and control of risks of injury to residents and nurses and other health care workers during resident handling;

 

C)        Evaluation of alternative ways to reduce risks associated with resident handling, including evaluation of equipment and the environment;

 

D)        Restriction, to the extent feasible with existing equipment and aids, of manual resident handling or movement of all or most of a resident's weight, except for emergency, life-threatening, or otherwise exceptional circumstances;

 

E)        Procedures for a nurse to refuse to perform or be involved in resident handling or movement that the nurse, in good faith, believes will expose a resident or nurse or other health care worker to an unacceptable risk of injury;

 

F)         Development of strategies to control risk of injury to residents and nurses and other health care workers associated with the lifting, transferring, repositioning, or movement of a resident; and

 

G)        Consideration of the feasibility of incorporating resident handling equipment or the physical space and construction design needed to incorporate that equipment when developing architectural plans for construction or remodeling of a facility or unit of a facility in which resident handling and movement occurs. (Section 3-206.05 of the Act)

 

d)         For the purposes of subsection (c)(4):

 

1)         "Health care worker" means an individual providing direct resident care services who may be required to lift, transfer, reposition, or move a resident.

 

2)         "Nurse" means an advanced practice nurse, a registered nurse, or a licensed practical nurse licensed under the Nurse Practice Act.  (Section 3-206.05 of the Act)

 

e)         The facility shall have a written agreement with one or more hospitals to provide diagnostic, emergency and acute care hospital services.  The Department will waive this requirement if the facility can document that it is unable to meet the requirement because of its remote location or refusal of local hospitals to enter an agreement. The services shall include:

 

1)         Emergency admissions;

 

2)         Admission of facility residents who are in need of hospital care;

 

3)         Diagnostic services; and

 

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

 

(Source:  Amended at 37 Ill. Reg. 4954, effective March 29, 2013)

 

Section 300.615  Determination of Need Screening and Request for Resident Criminal History Record Information

 

a)         For the purpose of this Section only, a nursing facility is any bed licensed as a skilled nursing or intermediate care facility bed, or a 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 nursing facility must be screened to determine the need for nursing 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 (89 Ill. Adm. Code 140.642(c)) 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 long-term care 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 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 on Aging is responsible for the screening required in subsection (b) of this Section for individuals 60 years of age or older who are not developmentally disabled or do not have a severe mental illness.  The Illinois Department of Human Services is responsible for the screening required in subsection (b) of this Section 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) of this Section.

 

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 18 or older seeking admission to the facility, unless a background check was initiated by a hospital pursuant to the Hospital Licensing Act.  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.idoc.state.il.us 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 background 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 to be taken on the premises of the facility.  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 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.620  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)         An individual who needs services that are not readily available in a particular facility, or through arrangement with a qualified outside resource, shall not be admitted to or kept in that facility.  The Department defines a "qualified outside source" as one recognized as meeting professional standards for services provided.

 

c)         Each facility shall have a policy concerning the admission of persons needing prenatal and/or maternity care, and a policy concerning the keeping of such persons who become pregnant while they are residents of the facility.  If these policies permit such 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 such individuals from in-house and/or outside resources.  (See Section 300.3220.)

 

d)         No person shall be admitted to or kept in the facility:

 

1)         Who is at risk because the person is reasonably expected to self-inflict serious physical harm or to inflict serious physical harm on another person in the near future, as determined by professional evaluation;

 

2)         Who is destructive of property, if the destruction jeopardizes the safety of him/herself or others; or

 

3)         Who is an identified offender, unless the requirements of Section 300.615 for new admissions and the requirements of Section 300.625 are met.

 

e)         No resident shall be admitted to the facility who is developmentally disabled and who needs programming for such conditions, as described in the rules governing intermediate care facilities for the developmentally disabled (77 Ill. Adm. Code 350).  Such persons shall be admitted only to facilities licensed as intermediate care facilities for the developmentally disabled under 77 Ill. Adm. Code 350 or, if the person is under 18, to a long-term care facility for persons under 22 years of age that is licensed under 77 Ill. Adm. Code 390.  Persons from 18 to 21 years of age in need of such care may be kept in either facility.

 

f)         Persons under 18 years of age may not be cared for in a facility for adults without prior written approval from the Department.

 

g)         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.

 

h)         If a resident insists on being discharged and is discharged against medical advice, the facts involved in the situation shall be fully documented in the resident's clinical record.

 

i)          Persons with communicable, contagious, or infectious diseases may be admitted under the conditions and in accordance with the procedures specified in Section 300.1020.

 

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

 

(Source:  Amended at 31 Ill. Reg. 6044, effective April 3, 2007)

 

Section 300.624  Criminal History Background Checks for Persons Who Were Residents on May 10, 2006 (Repealed)

 

(Source:  Repealed at 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.625  Identified Offenders

 

a)         The facility shall review the results of the criminal history background checks immediately upon receipt of these 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, 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, to verify compliance with the requirements of Public Act 94-163 and Public Act 94-752, 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 300.695 of this Part.

 

3)         Every licensed facility shall provide to every prospective and current resident and resident's guardian, and to every facility employee, a written notice, prescribed by the Department, advising the resident, guardian, or employee of his or her right to ask whether any residents of the facility are identified offenders.  The facility shall confirm whether identified offenders are residing in the facility.

 

A)        The notice shall also be prominently posted within every licensed facility.

 

B)        The notice shall include a statement that information regarding registered sex offenders may be obtained from the Illinois State Police website, www.isp.state.il.us, and that information regarding persons serving terms of parole or mandatory supervised release may be obtained from the Illinois Department of Corrections website, www.idoc.state.il.us.  (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 300.615 of this Part.

 

h)         Facilities shall annually complete all of the steps required in subsection (f) of this Section 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 care plan.  (Section 2-201.6(f) of the Act)

 

l)          If the identified offender is a convicted (see 730 ILCS 150/2) or registered (see 730 ILCS 150/3) sex offender  or if the Identified Offender Report and Recommendation prepared pursuant to Section 2-201.6(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 care plans at least quarterly for identified offenders for appropriateness and effectiveness of the portions specific to the identified offense and shall document such review.  The facility shall modify the care 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 care 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 300.690 of this Part.  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 300.3300 of this Part.

 

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 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.626  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 300.3300 of this Part.  (Section 2-201.6(g) of the Act)

 

b)         All discharges and transfers shall be pursuant to Section 300.3300 of this Part.

 

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 in place policies and procedures for the discharge of 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 300.625 of this Part and subsection (a) of this Section;

 

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 plan of care developed pursuant to Section 300.625(j).

 

(Source:  Amended at 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.627  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 300.3300 of this Part.  (Section 2-201.6(g) of the Act)

 

b)         All discharges and transfers shall be pursuant to Section 300.3300 of this Part.

 

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)         This notification shall include all of the documentation required under Section 300.625 of this Part and subsection (a) of this Section, and the transferring facility shall provide this information 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, 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 and/or regulated in their home state and would be authorized to receive this information if they were in Illinois.

 

(Source:  Amended at 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.630  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 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 that Section; provided that a petition for guardianship or for modification of guardianship is filed within 15 days of the person's admission to a facility, and provided further that such a contract is executed within ten days of the disposition of the petition. (Section 2-202(a) of the Act)

 

4)         No adult shall be admitted to a facility if he objects, orally or in writing, to such 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)

 

5)         If on the effective date of this Part, a person has not executed a contract as required by Section 2-202 of the Act, then such a contract shall be executed by, or on behalf of, the person, within ten days of the effective date of this Part, unless a petition has been filed for guardianship or modification of guardianship.  If a petition for guardianship or modification of guardianship has been filed, and there is no guardian, agent or a member of the person's immediate family available, able, or willing to execute the contract at that time, then a contract shall be executed within ten days of the disposition of such petition.

 

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

 

c)         Before a licensee (any facility licensed under the Act) enters a contract under Section 2-202 of the Act, it shall provide the prospective resident and his 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 guardian, if any, and any other person who executed the contract. (Section 2-220(c) of the Act)

 

f)         The contract shall be signed by the licensee or his agent.  The title of each person signing the contract for the facility shall be clearly indicated next to each such signature.  The nursing home 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) of this Section. 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 labelled "signature of responsible party" or "signature of guarantor."

 

h)         The contract shall include a definition of "responsible party" or "guarantor," which describes in full the liability incurred by any such 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 Public Aid.  (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 thirty (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 of the receipt of 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 which are not covered by the rate or fee established in subsection (m) of this Section.  If a separate rate or fee for any such supplemental service or product can be calculated with definiteness at the time the contract is executed, then such 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.  But the contract shall include a statement explaining the resident's liability for such itemized service or product and explaining that the resident will be receiving a bill for such 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 thirty (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 of the receipt of 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 payment due under the contract. (Section 2-202(g)(4) of the Act)

 

p)         The contract shall specify the amount of deposit paid.  (Section 2-202(g)(5) of the Act) Such amount shall be expressed in terms of a precise number of dollars and be clearly designated as a deposit.  The contract shall specify when such deposit shall be paid by the resident, and the contract shall specify when such deposit shall be returned by the facility.  The contract shall specify the conditions (if any) which must be satisfied by the resident before the facility shall return the deposit.  Upon the satisfaction of all such conditions, the deposit shall be returned to the resident.  If the deposit is nonrefundable, the contract shall provide express notice of such 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 which 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 which 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 the resident's 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 the resident's life.  (Section 2-202(i) of the Act)

 

t)          All facilities which 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 (Ill. Rev. Stat. 1991, ch. 111½, par. 4160-1 et seq.) [210 ILCS 40], including the obtaining of a permit from the Department, before they may enter into such 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 Public Aid.  (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 18 Ill. Reg. 15868, effective October 15, 1994)

 

Section 300.640  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, residents' representatives shall take the place of the required number of residents.  The administrator shall designate another 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)         the inclusion of community members such as volunteers, family members, residents' friends, residents' advocates, or community representatives, etc. on the council;

 

2)         the establishment of 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 nonresident 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 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 such assistance.

 

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

 

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.  Such 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 which 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;

 

3)         Early identification of problems;

 

4)         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, 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 31 Ill. Reg. 8813, effective June 6, 2007)

 

Section 300.650  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 following requirements.

 

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)         Facilities shall maintain a confidential medical file for each employee that shall contain health records, including the employee's vaccination and testing records, initial health evaluation and the results of the tuberculin skin test required under Section 300.655, and any other pertinent health records.

 

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

 

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 license 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.

 

e)         All personnel shall have either training or experience, or both, in the job assigned to them.

 

f)         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; infection prevention and control; and understanding and communicating with the type of residents being cared for in the facility.  In addition, all new direct care staff, including student interns, shall complete an orientation program covering the facility's policies and procedures for resident care services before being assigned to provide direct care to residents.  This orientation program shall include information on the prevention and treatment of decubitus ulcers and the importance of nutrition in general health care.

 

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, including infection prevention and control policies required in Section 300.696, skill training and ongoing education to enable all personnel to perform their duties effectively.  The in-service training sessions regarding personal care, nursing and restorative 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 of program content for each session and of personnel attending each session shall be kept.

 

3)         All facilities shall provide training and education on the requirements of Section 2-106.1 of the Act and Section 300.686 of this Part to all personnel involved in providing care to residents, and train and educate those personnel on the methods and procedures to effectively implement the facility's policies. Training and education provided under Section 2-106.1 of the Act and Section 300.686 shall be documented in each personnel file.  (Section 2-106.1(b-15) of the Act)

 

g)         Employees shall be assigned duties that are directly related to their functions, as identified in their job descriptions.  Exceptions may be made in emergencies.

 

h)         Personnel policies shall include a plan to provide personnel coverage for regular staff when they are absent.

 

(Source:  Amended at 46 Ill. Reg. 6033, effective April 1, 2022)

 

Section 300.651  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 300.651.  (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 and this Part.  (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 300.651 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 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.655  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 functions 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 300.1025.  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. 4684, effective March 24, 1989)

 

Section 300.660  Nursing Assistants

 

a)         A facility shall not employ an individual as a nursing assistant, home health aide, psychiatric services rehabilitation aide, 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, nurse aide unless the facility has inquired of 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.

 

b)         The facility shall not employ an individual as a nursing assistant if that individual is not on the Health Care Worker Registry unless the individual is enrolled in a training program as defined in Section 3-206(a)(5) of the Act. (Section 3-206.01(a) of the Act)

 

c)         The facility shall ensure that each nursing assistant complies with one of the following conditions:

 

1)         Is approved on the Department's Health Care Worker Registry.  "Approved" means that the nurse aide has met the training or equivalency requirements of Section 300.663 of this Part and does not have a disqualifying criminal background check without a waiver.

 

2)         Within 120 days after initial employment, submits documentation to the Department in accordance with Section 300.663 of this Part to be registered on the Health Care Worker Registry.

 

d)         The facility shall ensure that each person employed by the facility as a nursing assistant has met each of the following requirements:

 

1)         Is at least sixteen years of age, of temperate habits and good moral character, honest, reliable and trustworthy (Section 3-206 (a)(1) of the Act);

 

2)         Is 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)         Has provided 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)         Has completed at least eight years of grade school or has provided proof of equivalent knowledge (Section 3-206(a)(4) of the Act);

 

5)         Has completed the training or equivalency requirements for certified nursing assistants, or has begun a current course of training for certified nursing assistants, approved by the Department, within 45 days of initial employment in the capacity of a certified nursing assistant at any facility. Such courses of training shall be successfully completed within 120 days of initial employment in the capacity of certified nursing assistant at a facility, except as follows:

 

A)        Nursing assistants 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.  During a statewide public health emergency, as defined in the Illinois Emergency Management Agency Act, all nursing assistants shall, to the extent feasible, complete the training. (Section 3-206(a)(5) of the Act)

 

B)        The Department may accept comparable training in lieu of the 120-hour course for student nurses, foreign nurses, military personnel, or employees of the Department of Human Services. (Section 3-206(a)(5) of the Act)

 

6)         Is familiar with and has general skills related to resident care.

 

e)         The facility shall develop and implement procedures, which shall be approved by the Department, for an ongoing competency review process, which shall take place within the facility, for certified nursing assistants.

 

f)         At the time of each regularly scheduled licensure survey, or at the time of a complaint investigation, the Department may require any certified nursing assistant to demonstrate, either through written examination or action, or both, sufficient knowledge in all areas of required training and competency in the principles, techniques, and procedures covered by the certified nursing assistant training program curriculum described in 77 Ill. Adm. Code 395 when possible problems in the care provided by aides or other evidences of inadequate training are observed. The State- approved manual skills evaluation testing format and forms will be used to determine competency of a certified nursing assistant when appropriate. If such knowledge or competency is inadequate the Department shall require the certified nursing assistant to complete in-service training and review in the facility until the certified nursing assistant demonstrates to the Department, either through written examination or action, or both, sufficient knowledge in all areas of required training. The in-service training shall address the certified nursing assistant training principles and techniques relative to the procedures in which the certified nursing assistants are found to be deficient during inspection (see 77 Ill. Adm. Code 395). (Section 3-206(a)(5) of the Act)

 

g)         The facility shall certify that each nursing assistant employed by the facility meets the requirements of this Section.  Such certification shall be retained by the facility as part of the employee's personnel record.

 

(Source:  Amended at 48 Ill. Reg. 3317, effective February 16, 2024)

 

Section 300.661  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 45 Ill. Reg. 11096, effective August 27, 2021)

 

Section 300.662  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 nursing assistant; or

 

4)         performs any nursing or nursing-related services for residents of a facility. (Section 3-206.03(b) of the Act)

 

c)         A facility may employ resident attendants to assist the nurse aides with the activities authorized under subsection (a) of this Section.  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 (see Section 300.1220), 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.  Such 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 deemed 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 at least five hours in length and 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; handwashing; 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 at least 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; handwashing; and resident privacy;

 

3)         A personal hygiene unit that is at least 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; handwashing; use of disposable gloves; hair combing and brushing; face and handwashing 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 dietician concerning the specific feeding, hydration, and/or personal hygiene care needs of the resident whom he or she will be assigned to assist.

 

m)        Training programs shall 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 (h) of this Section 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 revision, 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 reason for the finding.

 

s)         If the Department finds that any conditions stated in the written notice of non-compliance issued under subsection (r) of this Section have not been corrected within 30 days after the date of issuance of such 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 300.661 of this Part.

 

(Source:  Added at 24 Ill. Reg. 17330, effective November 1, 2000)

 

Section 300.663  Registry of Certified Nursing Assistants

 

a)         An individual will be included on the Health Care Worker Registry as a certified nursing assistant when the individual has successfully completed a training program approved in accordance with the Long-Term Care Assistants and Aides Training Programs Code, successfully completes the required competency examination, and meets background check information required in Section 300.661 of this Part, and when there are no findings of abuse, neglect, or misappropriation of property in accordance with Section 955.310 of the Health Care Worker Background Check Code.

 

b)         An individual who has not completed a Department-approved nurse aide training program in Illinois will be included on the Health Care Worker Registry as a certified nursing assistant if the individual has met background check information required in Section 300.661 of this Part and submits documentation supporting one of the following equivalencies:

 

1)         Documentation of current registration from another state indicating that the requirements of 42 CFR 483.151 − 483.156 have been met and that there are no documented findings of abuse, neglect, or misappropriation of property.

 

2)         Documentation of successful completion of a nursing arts course (e.g., Basics in Nursing, Fundamentals of Nursing, Nursing 101) with at least 40 hours of supervised clinical experience in an accredited nurse training program as evidenced by a diploma, certificate or other written verification from the school and, within 120 days after employment, successful completion of the written portion of the Department-established certified nursing assistant competency test.

 

3)         Documentation of successful completion of a United States military training program that includes the content of a Department-approved nurse aide training program as provided in 77 Ill. Adm. Code 395; at least 40 hours of supervised clinical experience, as evidenced by a diploma, certification, DD-214, or other written verification, and, within 120 days after employment, successful completion of the written portion of the Department-established certified nursing assistant competency test.

 

4)         Documentation of completion of a nursing program in a foreign country, including the following, and, within 120 days after employment, successful completion of the written portion of the Department-established certified nursing assistant competency test:

 

A)        A copy of the license, diploma, registration or other proof of completion of the program;

 

B)        A copy of the Social Security card; and

 

C)        Visa or proof of citizenship.

 

c)         An individual shall notify the Health Care Worker Registry of any change of address within 30 days and of any name change within 30 days and shall submit proof of any name change to the Department. (Section 26 of the Health Care Worker Background Check Act)

 

d)         An individual may satisfy the supervised clinical experience requirement for placement on the Health Care Worker Registry through supervised clinical experience at an assisted living establishment licensed under the Assisted Living and Shared Housing Act. (Section 3-206(5) of the Act)

 

(Source:  Amended at 45 Ill. Reg. 11096, effective August 27, 2021)

 

Section 300.664  Certified Nursing Assistant Interns

 

a)         A certified nursing assistant intern shall report to a facility's charge nurse or nursing supervisor and may only be assigned duties authorized in Section 2310-434 of the Department of Public Health Powers and Duties Law of the Civil Administrative Code of Illinois by a supervising nurse.  (Section 3-614(a) of the Act)

 

b)         A facility shall notify its certified and licensed staff members, in writing, that a certified nursing assistant intern may only provide the services and perform the procedures permitted under Section 2310-434 of the Department of Public Health Powers and Duties Law of the Civil Administrative Code of Illinois.

 

1)         The notification shall detail which duties may be delegated to a certified nursing assistant intern.

 

2)         The facility shall establish a policy describing the authorized duties, supervision, and evaluation of certified nursing assistant interns available upon request of the Department and any surveyor.  (Section 3-614(b) of the Act)

 

c)         If a facility learns that a certified nursing assistant intern is performing work outside the scope of the duties authorized in Section 2310-434 of the Department of Public Health Powers and Duties Law of the Civil Administrative Code of Illinois, the facility shall:

 

1)         Stop the certified nursing assistant intern from performing the work;

 

2)         Inspect the work and correct mistakes, if the work performed was done improperly;

 

3)         Assign the work to the appropriate personnel; and

 

4)         Ensure that a thorough assessment of any resident involved in the work performed is completed by a registered nurse. (Section 3-614(c) of the Act)

 

d)         A facility that employs a certified nursing assistant intern in violation of this Section shall be subject to civil penalties or fines under Section 3-305 of the Act.  (Section 3-614(d) of the Act)

 

e)         A minimum of 50% of nursing and personal care time shall be provided by a certified nursing assistant, but no more than 15% of nursing and personal care time may be provided by a certified nursing assistant intern.  (Section 3-614(e) of the Act)

 

f)         This Section will be repealed effective November 1, 2027.

 

(Source:  Added at 48 Ill. Reg. 13796, effective August 28, 2024)

 

Section 300.665  Student Interns

 

a)         No person who meets the definition of student intern in Section 300.330 shall be required to complete a current course of training for nursing assistants.

 

b)         The facility may utilize student interns to perform basic nursing assistant skills for which they have been evaluated and deemed competent by an approved evaluator using the State approved manual skills competency evaluation testing format and forms (see 77 Ill. Adm. Code 395.300), but shall not allow interns to provide rehabilitation nursing (see Section 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 nursing assistant staff positions held by student interns.

 

(Source:  Amended at 17 Ill. Reg. 19279, effective October 26, 1993)

 

Section 300.670  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 actions 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 (see Section 300.Table D), as established by the National Oceanic and Atmospheric Administration, 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 300.2620(d), to the local health authority and local emergency management agency having jurisdiction.

 

3)         Each facility shall provide a description of its emergency source of electrical power, including the services connected to the source, to the local health authority and local emergency management agency having jurisdiction.  The facility shall inform the local health authority and local emergency management agency at any time that the emergency source of power or services connected to the source are changed.

 

4)         When requested by the local health authority and the local emergency management agency, the facility shall participate in emergency planning activities.

 

(Source:  Amended at 37 Ill. Reg. 2298, effective February 4, 2013)

 

Section 300.680  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. These policies shall be developed by the medical advisory committee or the advisory physician with participation by nursing and administrative personnel.

 

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:  Amended at 20 Ill. Reg. 12208, effective September 10, 1996)

 

Section 300.682  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 rehabilitation 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 physical 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 5 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) 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. 12208, effective September 10, 1996)

 

Section 300.684  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 proved 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 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 is 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 restraints.

 

e)         The facility's emergency use of physical restraints shall comply with Sections 300.682(e), (f), (g), and (j).

 

(Source:  Added at 20 Ill. Reg. 12208, effective September 10, 1996)

 

Section 300.686  Unnecessary, Psychotropic, and Antipsychotic Medications

 

a)         For the purposes of this Section, the following definitions shall apply:

 

1)         "Adverse consequence" – unwanted, uncomfortable, or dangerous effects that a medication may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. It may include, but is not limited to, various types of adverse medication reactions and interactions (e.g., medication-medication, medication-food, and medication-disease).

 

2)         "Antipsychotic medication" – a medication that is used to treat symptoms of psychosis such as delusions, hearing voices, hallucinations, paranoia, or confused thoughts. Antipsychotic medications are used in the treatment of schizophrenia, severe depression, and severe anxiety. Older antipsychotic medications tend to be called typical antipsychotics. Those developed more recently are called atypical antipsychotics.

 

3)         "Dose" – the total amount/strength/concentration of a medication given at one time or over a period of time. The individual dose is the amount/strength/concentration received at each administration. The amount received over a 24-hour period may be referred to as the daily dose.

 

4)         "Duplicative therapy" – multiple medications of the same pharmacological class or category or any medication therapy that substantially duplicates a particular effect of another medication that the individual is taking.

 

5)         "Emergency" – has the same meaning as in Section 1-112 of the Act and Section 300.330 of this Part.  (Section 2-106.1(b-3) of the Act)

 

6)         "Excessive dose" – the total amount of any medication (including duplicative therapy) given at one time or over a period of time that is greater than the amount recommended by the manufacturer's label, package or insert, and the accepted standards of practice for a resident's age and condition.

 

7)         "Gradual dose reduction" – the stepwise tapering of a dose to determine if symptoms, conditions or risks can be managed by a lower dose or if the dose or medication can be discontinued.

 

8)         "Informed consent" – documented, written permission for specific medications, given freely, without coercion or deceit, by a capable resident, or by a resident's surrogate decision maker, after the resident, or the resident's surrogate decision maker, has been fully informed of, and had an opportunity to consider, the nature of the medications, the likely benefits and most common risks to the resident of receiving the medications, any other likely and most common consequences of receiving or not receiving the medications, and possible alternatives to the proposed medications.

 

9)         "Licensed nurse" – an advanced practice registered nurse, a registered nurse, or a licensed practical nurse, as defined in the Nurse Practice Act.  (Section 2-106.1(d) of the Act)

 

10)        "Psychotropic medication" – medication that is used for or listed as used for psychotropic, antidepressant, antimanic or antianxiety behavior modification or behavior management purposes in the Prescribers Digital Reference database, the Lexicomp-online database, or the American Society of Health-System Pharmacists database.  Psychotropic medication also includes any medication listed in 42 CFR 483.45(c)(3).  (Section 2-106.1(b-3) of the Act)

 

11)        "Surrogate decision maker" – an individual representing the resident's interests in regard to consent to receive psychotropic medications, as permitted by Section 2-106.1(b-3) of the Act and this Section.  (Section 2-106.1(b-3) of the Act)

 

b)         State laws, regulations, and policies related to psychotropic medication are intended to ensure psychotropic medications are used only when the medication is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication.  (Section 2-106.1(b) of the Act)

 

c)         Psychotropic medication shall only be given in both emergency and nonemergency situations if the diagnosis of the resident supports the benefit of the medication and clinical documentation in the resident's medical record supports the benefit of the medication over the contraindications related to other prescribed medications.  (Section 2-106.1(b-3) of the Act)

 

d)         A resident shall not be given unnecessary drugs.  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;

 

5)         In the presence of adverse consequences that indicate the medications should be reduced or discontinued (Section 2-106.1(a) of the Act); or

 

6)         Any combination of the circumstances stated in subsections (d)(1) through (5).

 

e)         Residents shall not be given antipsychotic medications unless antipsychotic medication therapy is ordered by a physician or an authorized prescribing professional, as documented in the resident's comprehensive assessment, to treat a specific symptom 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 Appendix F.

 

f)         Residents who use antipsychotic medications shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue these medications in accordance with Appendix F.  In compliance with subsection 2-106.1(b-3) of the Act and this Section, the facility shall obtain informed consent for each dose reduction.

 

g)         Except in the case of an emergency, psychotropic medication shall not be administered without the informed consent of the resident or the resident's surrogate decision maker.  (Section 2-106.1(b-3) of the Act) Additional informed consent is not required for changes in the prescription so long as those changes are described in the original written informed consent form, as required by subsection (h)(12)(A).  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, pursuant to subsection (h)(12)(A).  The most common side effects of the medications shall be described.  In an emergency, a facility shall:

 

1)         Document the alleged emergency in detail, including the facts surrounding the medication's need, pursuant to the requirements of Section 300.1820; and

 

2)         Present this documentation to the resident and the resident's representative or other surrogate decision maker no later than 24 hours after the administration of emergency psychotropic medication.  (Section 2-106.1(b-3) of the Act)

 

h)         Protocol for Securing Informed Consent for Psychotropic Medication

 

1)         Except in the case of an emergency as described in subsection (g), a facility shall obtain voluntary informed consent, in writing, from a resident or the resident's surrogate decision maker before administering or dispensing a psychotropic medication to that resident.  When informed consent is not required for a change in dosage as described in subsection (h)(12)(A), the facility shall note in the resident's file that the resident was informed of the dosage change prior to the administration of the medication or that verbal, written, or electronic notice has been communicated to the resident's surrogate decision maker that a change in dosage has occurred.  (Section 2-106.1(b-3) of the Act)

 

2)         No resident shall be administered psychotropic medication prior to a discussion between the resident or the resident's surrogate decision maker, or both, and the resident's physician or a physician the resident was referred to, a registered pharmacist, or a licensed nurse about the most common possible risks and benefits of a recommended medication and the use of standardized consent forms designated by the Department.  (Section 2-106.1(b-3) of the Act)

 

3)         Prior to initiating any detailed discussion designed to secure informed consent, a licensed health care professional shall inform the resident or the resident's surrogate decision maker that the resident's physician has prescribed a psychotropic medication for the resident, and that informed consent is required from the resident or the resident's surrogate decision maker before the resident may be given the medication.

 

4)         The discussion shall include information about:

 

A)        The name of the medication;

 

B)        The condition or symptoms that the medication is intended to treat, and how the medication is expected to treat those symptoms;

 

C)        How the medication is intended to affect those symptoms;

 

D)        Other common effects or side effects of the medication, and any reasons (e.g., age, health status, other medications) that the resident is more or less likely to experience side effects;

 

E)        Dosage information, including how much medication would be administered, how often, and the method of administration (e.g., orally or by injection; with, before, or after food);

 

F)         Any tests and related procedures that are required for the safe and effective administration of the medication;

 

G)        Any food or activities the resident should avoid while taking the medication;

 

H)        Any possible alternatives to taking the medication that could accomplish the same purpose; and

 

I)         Any possible consequences to the resident of not taking the medication.

 

5)         Pursuant to Section 2-105 of the Act, the discussion designed to secure informed consent shall be private, between the resident or the resident's surrogate decision maker and the resident's physician, or a physician the resident was referred to, or a registered pharmacist, or a licensed nurse. 

 

6)         In addition to the oral discussion, the resident or his or her surrogate decision maker shall be given the information in subsection (h)(4) in writing, in a form designated or developed by the Department.  Each form shall be written in plain language understandable to the resident or the resident's surrogate decision maker, be able to be downloaded from the Department's official website or another website designated by the Department, shall include information specific to the psychotropic medication for which consent is being sought, and will be used for every resident for whom psychotropic drugs are prescribed.  (Section 2-106.1(b-3) of the Act)

 

7)         If the written information is in a language not understood by the resident or his or her surrogate decision maker, the facility, in compliance with the Language Assistance Services Act and the Language Assistance Services Code, shall provide, at no cost to the resident or the resident's surrogate decision maker, an interpreter capable of communicating with the resident or his or her surrogate decision maker and the authorized prescribing professional conducting the discussion. 

 

8)         The authorized prescribing professional shall guide the resident through the written information.  The written information shall include a place for the resident or his or her surrogate decision maker to give, or to refuse to give, informed consent.  The written information shall be placed in the resident's record. Informed consent is not secured until the resident or surrogate decision maker has given written informed consent.  If the resident has dementia and the facility is unable to contact the resident's surrogate decision maker, the facility shall not administer psychotropic medication to the resident except in an emergency as provided by subsection (g).

 

9)         Informed consent shall be sought first from a resident, then from a surrogate decision maker, in the following order or priority:

 

A)        The resident's guardian of the person if one has been named by a court of competent jurisdiction.

 

B)        In the absence of a court-ordered guardian, informed consent shall be sought from a health care agent under the Illinois Power of Attorney Act who has authority to give consent.

 

C)        If neither a court-ordered guardian of the person, nor a health care agent under the Power of Attorney Act, is available, and the attending physician determines that the resident lacks capacity to make decisions, informed consent shall be sought from the resident's attorney-in-fact designated under the Mental Health Treatment Preference Declaration Act, if applicable, or the resident's representative.  (Section 2-106.1(b-3) of the Act)

 

10)       Regardless of the availability of a surrogate decision maker, the resident may be notified and present at any discussion required by this Section.  Upon request, the resident or the resident's surrogate decision maker shall be given, at a minimum, written information about the medication and an oral explanation of common side effects of the medication to facilitate the resident in identifying the medication and in communicating the existence of side effects to the direct care staff. 

 

11)       The facility shall inform the resident, surrogate decision maker, or both of the existence of a copy of:

 

A)        The resident's care plan;

 

B)        The facility policies and procedures adopted in compliance with Section 2-106.1(b-15) of the Act, and this Section; and

 

C)        A notification that the most recent of the resident's care plans and the facility's policies are available to the resident or surrogate decision maker upon request.

 

12)       The maximum possible period for informed consent shall be until:

 

A)        A change in the prescription occurs, either as to type of psychotropic medication or an increase or decrease in dosage, dosage range, or titration schedule of the prescribed medication that was not included in the original informed consent; or

 

B)        A resident's care plan changes in a way that affects the prescription or dosage of the psychotropic medication.  (Section 2-106.1(b-3) of the Act).

 

13)       A resident or their surrogate decision maker shall not be asked to consent to the administration of a new psychotropic medication in a dosage or frequency that exceeds the maximum recommended daily dosage as found in the Prescribers Digital Reference database, the Lexicomp-online database, or the American Society of Health-System Pharmacists database unless the reason for exceeding the recommended daily dosage is explained to the resident or their surrogate decision maker by a licensed medical professional, and the reason for exceeding the recommended daily dosage is justified by the prescribing professional in the clinical record.  The dosage and frequency shall be reviewed and re-justified by the licensed prescriber on a weekly basis and reviewed by a consulting pharmacist.  The justification for exceeding the recommended daily dosage shall be recorded in the resident's record and shall be approved within seven calendar days after obtaining informed consent, in writing, by the medical director of the facility.

 

14)       Pursuant to Section 2-104(c) of the Act, the resident or the resident's surrogate decision maker shall be informed, at the time of the discussion required by subsection (h)(2), that their informed consent may be withdrawn at any time, and that, even with informed consent, the resident may refuse to take the medication. 

 

15)       The facility shall obtain informed consent using forms provided by the Department on its official website, or on forms approved by the Department, pursuant to Section 2-106.1(b-3) of the Act.  The facility shall document on the consent form whether the resident is capable of giving informed consent for medication therapy, including for receiving psychotropic medications. If the resident is not capable of giving informed consent, the identity of the resident's surrogate decision maker shall be placed in the resident's record.

 

16)       No facility shall deny continued residency to a person on the basis of the person's or resident's, or the person's or resident's surrogate decision maker's, refusal of the administration of psychotropic medication, unless the facility can demonstrate that the resident's refusal would place the health and safety of the resident, the facility staff, other residents, or visitors at risk.  A facility that alleges that the resident's refusal to consent to the administration of psychotropic medication will place the health and safety of the resident, the facility staff, other residents, or visitors at risk shall:

 

A)        Document the alleged risk in detail, along with a description of all nonpharmacological or alternative care options attempted and why they were unsuccessful;

 

B)        Present this documentation to the resident or the resident's surrogate decision maker, to the Department, and to the Office of the State Long Term Care Ombudsman; and

 

C)        Inform the resident or their surrogate decision maker of their right to appeal an involuntary transfer or discharge to the Department as provided in the Act and this Part.  (Section 2-106.1(b-10) of the Act)

 

i)          All facilities shall implement written policies and procedures for compliance with Section 2-106.1 of the Act and this Section.  A facility's failure to make available to the Department the documentation required under this subsection is sufficient to demonstrate its intent to not comply with Section 2-106.1 of the Act and this Section and shall be grounds for review by the Department.  (Section 2-106.1(b-15) of the Act)

 

j)          Upon the receipt of a report of any violation of Section 2-106.1 of the Act and this Section, the Department will investigate and, upon finding sufficient evidence of a violation of Section 2-106.1 of the Act and this Section, may proceed with disciplinary action against the licensee of the facility. In any administrative disciplinary action under this subsection, the Department will have the discretion to determine the gravity of the violation and, taking into account mitigating and aggravating circumstances and facts, may adjust the disciplinary action accordingly.  (Section 2-106.1(b-20) of the Act)

 

k)         A violation of informed consent that, for an individual resident, lasts for seven days or more under this Section is, at a minimum, a Type "B" violation. A second violation of informed consent within a year from a previous violation in the same facility regardless of the duration of the second violation is, at a minimum, a Type "B" violation.  (Section 2-106.1(b-25) of the Act)

 

l)          Any violation of Section 2-106.1 of the Act and this Section by a facility may be enforced by an action brought by the Department in the name of the People of Illinois for injunctive relief, civil penalties, or both injunctive relief and civil penalties. The Department may initiate the action upon its own complaint or the complaint of any other interested party.  (Section 2-106.1(b-30) of the Act)

 

m)        Any resident who has been administered a psychotropic medication in violation of Section 2-106.1 of the Act and this Section may bring an action for injunctive relief, civil damages, and costs and attorney's fees against any facility responsible for the violation.  (Section 2-106.1(b-35) of the Act)

 

n)         An action under this Section shall be filed within two years after either the date of discovery of the violation that gave rise to the claim or the last date of an instance of a noncompliant administration of psychotropic medication to the resident, whichever is later.  (Section 2-106.1(b-40) of the Act)

 

o)         A facility subject to action under Section 2-106.1 of the Act and this Section shall be liable for damages of up to $500 for each day, after discovery of a violation, that the facility violates the requirements of Section 2-106.1 of the Act and this Section.  (Section 2-106.1(b-45) of the Act)

 

p)         The rights provided for in Section 2-106.1 of the Act and this Section are cumulative to existing resident rights. No part of this Section shall be interpreted as abridging, abrogating, or otherwise diminishing existing resident rights or causes of action at law or equity.  (Section 2-106.1(b-55) of the Act)

 

q)         In addition to the penalties described in this Section and any other penalty prescribed by law, a facility that is found to have violated Section 2-106.1 of the Act and this Section, or the federal certification requirement that informed consent be obtained before administering a psychotropic medication, shall thereafter be required to obtain the signatures of two licensed health care professionals on every form purporting to give informed consent for the administration of a psychotropic medication, certifying the personal knowledge of each health care professional that the consent was obtained in compliance with the requirements of Section 2-106.1 of the Act and this Section.  (Section 2-106.1(b-3) of the Act)

 

(Source:  Amended at 48 Ill. Reg. 3317, effective February 16, 2024)

 

Section 300.690  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 a reportable incident or accident results in the death of a resident, the facility shall, after contacting local law enforcement pursuant to Section 300.695, notify the Regional Office by phone only.  For the purposes of this Section, "notify the Regional Office by phone only" means talk with a Department representative who confirms over the phone that the requirement to notify the Regional Office by phone has been met.  If the facility is unable to 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 37 Ill. Reg. 2298, effective February 4, 2013)

 

Section 300.695  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 300.30.

 

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. 4846, effective April 1, 2002)

 

Section 300.696  Infection Prevention and Control

 

a)         A facility shall have an infection prevention and control program for the surveillance, investigation, prevention, and control of healthcare-associated infections and other infectious diseases. The program shall be under the management of the facility’s infection preventionist who is qualified through education, training, experience, or certification in infection prevention and control.

 

b)         Written policies and procedures for surveillance, investigation, prevention, and control of infectious agents and healthcare-associated infections in the facility shall be established and followed, including for the appropriate use of personal protective equipment as provided in the Centers for Disease Control and Prevention’s Guideline for Isolation Precautions, Hospital Respiratory Protection Program Toolkit, and the Occupational Safety and Health Administration’s Respiratory Protection Guidance.  The policies and procedures must be consistent with and include the requirements of the Control of Communicable Diseases Code, and the Control of Sexually Transmissible Infections Code.

 

1)         All staff shall be trained at least annually on basic infection prevention and control practices based on job responsibilities.  Training records shall be maintained for three years.  For the purposes of this Section, “staff” means those individuals who work in the facility on a regular (that is, at least once a week) basis, including individuals who may not be physically in the facility for a period of time due to illness, disability, or scheduled time off, but who are expected to return to work.  This also includes individuals under contract or arrangement, including hospice and dialysis staff, physical therapists, occupational therapists, mental health professionals, or volunteers, who are in the facility on a regular basis.

 

2)         Students enrolled in accredited health care training programs who are providing direct care during internships or clinical rotations must have completed infection prevention and control training prior to working in the facility.  The facility shall ensure access to documentation of completed infection prevention and control training for all interns and students and provide a copy of this record upon request by the Department.

 

3)         Facility activities shall be monitored on an ongoing basis by the Infection Preventionist to ensure adherence to all infection prevention and control policies and procedures. 

 

4)         Infection prevention and control policies and procedures shall be maintained in the facility and made available upon request to facility staff, the resident and the resident’s family or resident’s representative, the Department, the certified local health department, and the public.

 

c)         A group, e.g., an infection prevention and control committee, quality assurance committee, or other facility entity, shall periodically, but no less than annually, review the measures and outcomes of investigations and activities to prevent and control infections, documented by written, signed, and dated minutes of the meeting. 

 

d)         Each facility shall adhere to the following guidelines and toolkits of the Centers for Disease Control and Prevention, United States Public Health Service, Department of Health and Human Services, Agency for Healthcare Research and Quality, and Occupational Safety and Health Administration (see Section 300.340):

 

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)         Guidelines for Preventing Healthcare-Associated Pneumonia

 

6)         Guideline for Isolation Precautions:  Preventing Transmission of Infectious Agents in Healthcare Settings

 

7)         Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services

 

8)         The Core Elements of Antibiotic Stewardship for Nursing Homes

 

9)         The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A: Policy and Practice Actions to Improve Antibiotic Use

 

10)       Nursing Home Antimicrobial Stewardship Guide

 

11)       Toolkit 3.  Minimum Criteria for Common Infections Toolkit

 

12)       TB Infection Control in Health Care Settings

 

13)       Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes

 

14)       Implementation of Personal Protective Equipment (PPE) in Nursing Homes to Prevent Spread of Novel or Targeted Multidrug-resistant Organisms (MDROs)

 

15)       Hospital Respiratory Protection Program Toolkit: Resources for Respirator Program Administrators

 

16)       Respiratory Protection Guidance for the Employers of Those Working in Nursing Homes, Assisted Living, and Other Long-Term Care Facilities During the COVID-19 Pandemic 

 

17)       Guidelines for Environmental Infection Control in Health-Care Facilities

 

e)         The facility shall establish an infection prevention and control program (IPCP) that includes, at a minimum, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

 

f)         Infectious Disease Surveillance Testing and Outbreak Response

 

1)         The facility shall have a testing plan and response strategy in place to address infectious disease outbreaks.  Pursuant to the plan and response strategy, the facility shall test residents and facility staff for infectious diseases listed in Section 690.100 of the Control of Communicable Diseases Code in a manner that is consistent with current guidelines and standards of practice.

 

2)         Each facility shall conduct testing of residents and staff for the control or detection of infectious diseases when:

 

A)        The facility is experiencing an outbreak; or

 

B)        Directed by the Department or the certified local health department where the chance of transmission is high, including, but not limited to, regional outbreaks, epidemics, or pandemics.  For the purposes of this Section, “outbreak” has the same meaning as defined in the Control of Communicable Diseases Code.

 

3)         Documentation

 

A)        For residents, document in each resident’s record any time a test was completed, including the result of the test, or whether testing was refused or contraindicated.

 

B)        For facility staff and volunteers, maintain a testing log documenting any time a test was completed, including the result of the test, or whether testing was refused or contraindicated.  The testing log shall include all facility staff and volunteers.

 

4)         Upon confirmation that a resident, staff member, volunteer, student, or student intern tests positive with an infectious disease, or displays symptoms consistent with an infectious disease, each facility shall take immediate steps to prevent the transmission by implementing practices that include but are not limited to cohorting, isolation and quarantine, environmental cleaning and disinfecting, hand hygiene, and use of appropriate personal protective equipment.

 

5)         Each facility shall have written procedures for addressing residents, staff members, volunteers, students, and student interns who refuse testing or are unable to be tested.

 

6)         Each facility shall make arrangements with a testing laboratory to process any specimens collected under subsection (f) and shall ensure complete information for the individual being tested is submitted with each specimen as required by the laboratory requisition form.

 

7)         For testing done under subsection (f), each facility shall report to the Department, on a form and manner as prescribed by the Department, the number of residents, staff members, volunteers, students, and student interns tested, and the number of positive, negative, and indeterminate cases.

 

g)         Certified facilities shall comply with 42 CFR 483.80(h).

 

h)         Facilities shall not restrict visitation without a reasonable clinical or safety cause and shall facilitate in-person visitation whenever feasible, in accordance with Department and CDC guidance for infection prevention.

 

(Source:  Amended at 46 Ill. Reg. 6033, effective April 1, 2022)

 

Section 300.697  Infection Preventionists

 

A facility shall designate a person or persons as Infection Preventionists (IP) to develop and implement policies governing control of infections and communicable diseases.  The IPs shall be qualified through education, training, experience, or certification or a combination of such qualifications. The IP's qualifications shall be documented and shall be made available for inspection by the Department. (Section 2-213(d) of the Act). The facility’s infection prevention and control program as required by Section 300.696(e) shall be under the management of an IP.

 

a)         IPs shall complete, or provide proof of completion of, initial infection control and prevention training, provided by CDC or equivalent training, covering topics listed in subsection (b)(1) to the facility, within 30 days after accepting an IP position.  Documentation of required initial infection control and prevention training shall be maintained in the employee file.

 

b)         Effective July 1, 2022, a qualified IP candidate shall:

 

1)         Have completed at least 19 hours of training in infection prevention and control including, but not limited to, training in the following areas:

 

A)        Principles of Standard Precautions

 

B)        Principles of Transmission-Based Precautions

 

C)        Prevention of Healthcare-Associated Infections

 

D)        Hand Hygiene

 

E)        Environmental Cleaning, Sterilization, Disinfection, and Asepsis

 

F)         Environment of Care and Water Management

 

G)        Employee/Occupational Health

 

H)        Surveillance and Epidemiological Investigations

 

I)         Antimicrobial Stewardship

 

2)         Have clinical work experience related to infection prevention and control in health care settings including, but not limited to, hospitals or long-term care settings.

 

c)         A facility shall have at least one IP on-site for a minimum of 20 hours per week to develop and implement policies governing prevention and control of infectious diseases.

 

d)         Facilities with more than 100 licensed beds or facilities that offer high-acuity services, including but not limited to on-site dialysis, infusion therapy, or ventilator care shall have at least one IP on-site for a minimum of 40 hours per week to develop and implement policies governing control of infectious diseases.  For the purposes of this subsection (d), "infusion therapy" refers to parenteral, infusion, or intravenous therapies that require ongoing monitoring and maintenance of the infusion site (e.g. central, percutaneously inserted central catheter, epidural, and venous access devices).

 

e)         A facility’s IP shall coordinate with the facility group listed in Section 300.696(c) to ensure compliance with Section 300.696.

 

(Source:  Added at 46 Ill. Reg. 6033, effective April 1, 2022)

 

Section 300.699  Electronic Monitoring

 

A facility shall comply with Section 2-115 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:  Amended at 48 Ill. Reg. 3317, effective February 16, 2024)

 

Section 300.700  Testing for Legionella Bacteria

 

a)         A facility shall develop a policy for testing its water supply for Legionella bacteria.  The policy shall include the frequency with which testing is conducted.  The policy and the results of any tests and corrective actions taken shall be made available to the Department upon request.  (Section 3-206.06 of the Act) 

 

b)         The policy shall be based on the ASHRAE Guideline "Managing the Risk of Legionellosis Associated with Building Water Systems" and the Centers for Disease Control and Prevention's" Toolkit for Controlling Legionella in Common Sources of Exposure".  The policy shall include, at a minimum:

 

1)         A procedure to conduct a facility risk assessment to identify potential Legionella and other waterborne pathogens in the facility water system;

 

2)         A water management program that identifies specific testing protocols and acceptable ranges for control measures; and

 

3)         A system to document the results of testing and corrective actions taken.

 

(Source:  Added at 46 Ill. Reg. 10460, effective May 31, 2022)

SUBPART D: PERSONNEL

 

Section 300.810  General

 

a)         Sufficient staff in numbers and qualifications shall be on duty all hours of each day to provide services that meet the total needs of the residents.  As a minimum, there shall be at least one staff member awake, dressed, and on duty at all times.  (A, B)

 

b)         The number and categories of personnel to be provided shall be based on the following:

 

1)         Number of residents.

 

2)         Amount and  kind of personal care, nursing care, supervision, and program 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.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.820  Categories of Personnel

 

a)         The facility shall provide an administrator as set forth in Subpart B.  (B)

 

b)         The facility shall provide a Resident Services Director who is assigned responsibility for the coordination and monitoring of the resident's overall plan of care.  The director of nurses or an individual on the professional staff of the facility may fill this assignment to assure that residents' plans of care are individualized, written in terms of short and long-range goals, understandable and utilized; their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible, in the preparation of their plan of care.  (B,)

 

c)         The facility shall provide activity personnel as set forth in Section 300.1410(b).  (B)

 

d)         The facility shall provide dietary personnel as set forth in Sections 300.2010 and 300.2020.  (B)

 

e)         The facility shall designate a staff member(s) to provide social services to residents. (B)

 

f)         The facility shall provide nursing personnel as set forth in Subpart F.  (B)

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.830  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)         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 service consultation. Skilled nursing facilities must provide a social worker to meet this requirement.

 

c)         The facility shall have a written agreement for activity program consultation if required under Section 300.1410(c).

 

d)         Specific restorative services (physical therapy, occupational therapy, etc.) provided by the facility shall include consultation as set forth in Section 300.1420(a).

 

e)         The facility shall arrange for an advisory physician or medical advisory committee as set forth in Section 300.1010.

 

f)         The facility shall arrange for an advisory dentist and dental hygienist if desired, as set forth in Section 300.1050.

 

g)         The facility shall arrange for a consultant pharmacist as set forth in Section 300.1610.

 

h)         Skilled Nursing Facilities shall arrange for consultation from a health information management consultant as set forth in Section 300.1860.

 

i)          Facilities shall arrange for a dietary consultant as set forth in Section 300.2010(b).

 

(Source:  Amended at 26 Ill. Reg. 10523, effective July 1, 2002)

 

Section 300.840  Personnel Policies

 

The personnel policies required in Section 300.650, Section 300.651, and other personnel policies established by the facility, shall be followed in the operation of the facility.

 

(Source:  Amended at 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.850  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 PA 102-1007)

 

(Source:  Added at 48 Ill. Reg. 3317, effective February 16, 2024)

SUBPART E: MEDICAL AND DENTAL CARE OF RESIDENTS

 

Section 300.1010  Medical Care Policies

 

a)         Advisory Physician or Medical Advisory Committee

 

1)         There shall be an advisory physician, or a medical advisory committee composed of physicians, who shall be responsible for advising the administrator on the overall medical management of the residents and the staff of the facility.  If the facility employs a house physician, he may be the advisory physician.  (B)

 

2)         Additional for Skilled Nursing Facilities. There shall be a medical advisory committee composed of two (2) or more physicians who shall be responsible for advising the administrator on the overall medical management of the residents and the staff in the facility.  If the facility employs a house physician, the house physician may be one member of this committee.

 

b)         The facility shall have and follow a written program of medical services which sets forth the following:  the philosophy of care and policies and procedures to implement it; the structure and function of the medical advisory committee, if the facility has one; the health services provided; arrangements for transfer when medically indicated; and procedures for securing the cooperation of residents' personal physicians.  The medical program shall be approved in writing by the advisory physician or the medical advisory committee.  (B)

 

c)         Every resident shall be under the care of a physician.

 

d)         All residents, or their guardians, shall be permitted their choice of a physician.

 

e)         All resident shall be seen by their physician as often as necessary to assure adequate health care.  (Medicare/Medicaid requires certification visits.)

 

f)         Physician treatment plans, orders and similar documentation shall have an original written signature of the physician.  A stamp signature, with or without initials, is not sufficient.

 

g)         Each resident admitted shall have a physical examination, within five days prior to admission or within 72 hours after admission.  The examination report shall include at a minimum each of the following:

 

1)         An evaluation of the resident's condition, including height and weight, diagnoses, plan of treatment, recommendations, treatment orders, personal care needs, and permission for participation in activity programs as appropriate.

 

2)         Documentation of the presence or absence of tuberculosis infection by tuberculin skin test in accordance with Section 300.1025.

 

3)         Documentation of 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.  (A photograph of incipient or manifest decubitus ulcers is recommended on admission.)

 

4)         Orders from the  physician regarding weighting of the resident, and the frequency of such weighing, if ordered.

 

h)         The facility shall notify the resident's physician of any accident, injury, or significant 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.  The facility shall obtain and record the physician's plan of care for the care or treatment of such accident, injury or change in condition at the time of notification.  (B)

 

i)          At the time of an accident or injury, immediate treatment shall be provided by personnel trained in first aid procedures. (B)

 

(Source:  Amended at 16 Ill. Reg. 17089, effective November 3, 1992)

 

Section 300.1020  Communicable Disease Policies

 

a)         The facility shall comply with the Control of Communicable Diseases Code (77 Ill. Adm. Code 690).

 

b)         A resident who is suspected of or diagnosed as having any communicable, contagious or infectious disease, as defined in the Control of Communicable Diseases Code, 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 300.620 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 inform the Department of all incidents of scabies and other skin infestations.

 

(Source:  Amended at 29 Ill. Reg. 12852, effective August 2, 2005)

 

Section 300.1025  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. 8106, effective July 15, 1999)

 

Section 300.1030  Medical Emergencies

 

a)         The advisory physician or medical advisory committee shall develop policies and procedures to be followed during the various medical emergencies that may occur from time to time in long-term care facilities.  These medical emergencies include, but are not limited to, such things as:

 

1)         Pulmonary emergencies (for example, airway obstruction, foreign body aspiration, and acute respiratory distress, failure, or arrest).

 

2)         Cardiac emergencies (for example, ischemic pain, cardiac failure, or cardiac arrest).

 

3)         Traumatic injuries (for example, fractures, burns, and lacerations).

 

4)         Toxicologic emergencies (for example, untoward drug reactions and overdoses).

 

5)         Other medical emergencies (for example, convulsions and shock).  (A, B)

 

b)         The facility shall maintain in a suitable location the equipment to be used during these emergencies.  This equipment shall include at a minimum the following:  a portable oxygen kit, including a face mask and/or cannula; an airway; and bag-valve mask manual ventilating device. (B)

 

c)         There shall be at least one staff person on duty at all times who has been properly trained to handle the medical emergencies in subsection (a) of this Section.  This staff person may also be conducted in fulfilling the requirement of subsection (d) of this Section, if the staff person meets the specified certification requirements.  (B)

 

d)         When two or more staff are on duty in the facility, at least two staff people on duty in the facility shall have current certification in the provision of basic life support by an American Heart Association or American Red Cross certified training program.  When there is only one person on duty in the facility, that person needs to be certified. Any facility employee who is on duty in the facility may be utilized to meet this requirement.

 

(Source:  Amended at 18 Ill. Reg. 15868, effective October 15, 1994)

 

Section 300.1035  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 such rights.  Included within this policy shall be:

 

1)         implementation of Living Wills or Powers of Attorney for Health Care in accordance with the Living Will Act (Ill. Rev. Stat. 1991, ch. 110½, pars. 701 et seq.) [755 ILCS 35] and the Powers of Attorney for Health Care Law (Ill. Rev. Stat. 1991, ch. 110½, pars. 804-1 et seq.) [755 ILCS 45];

 

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 failed or has not yet been given the opportunity to make these choices;

 

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 (Ill. Rev. Stat. 1991, ch. 110½, par. 851-1 et seq.) [755 ILCS 40].

 

c)         Within 30 days of admission for new residents, and within one year of the effective date of this Section for all residents who were admitted prior to the effective date of this Section, 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/or

 

2)         decline consent to any or all of the life-sustaining treatment available at the facility.

 

d)         Any decision made by a resident, an agent, or a surrogate pursuant to subsection (c) of this Section must be recorded in the resident's medical record.  Any subsequent changes or modifications must 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) of this Section and may not discriminate in the provision of health care on the basis of such 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 (Ill. Rev. Stat. 1991, ch. 111½, pars. 5301 et seq.) [745 ILCS 70]

 

f)         The resident, agent, or surrogate may change his or her decision regarding life-sustaining treatment 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) of this Section, 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 such a decision is made by the resident, agent, or surrogate in accordance with the requirements of the Health Care Surrogate Act.

 

(Source:  Added at 17 Ill. Reg. 16194, effective January 1, 1994)

 

Section 300.1040  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 12-12 of the Criminal Code of 1961, including, without limitation, acts prohibited under Sections 12-13 through 12-16 of the Criminal Code of 1961.

 

b)         The facility shall adhere to the following protocol for the care and treatment of residents who are suspected of having been sexually assaulted in a long term care facility or elsewhere (Section 3-808 of the Act):

 

1)         Notify local law enforcement pursuant to the requirements of Section 300.695;

 

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)         Offer to call a friend or family member and a sexual assault crisis advocate, when available, to accompany the survivor.

 

c)         The facility shall take all reasonable steps to preserve evidence of the alleged sexual assault, and not to launder or dispose of the resident's clothing or bed linens until local law enforcement can determine whether they have evidentiary value, including encouraging the survivor not to change clothes or bathe, if he or she 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 300.690.

 

(Source:  Old Section repealed at 20 Ill. Reg. 12160, effective September 10, 1996; new Section added at 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.1050  Dental Standards

 

a)         Each long-term care facility shall have a dental program which will provide for in-service education to residents and staff under direction of dental personnel including at a minimum the following:  (B)

 

1)         Information regarding nutrition and diet control measures which are dental health oriented.

 

2)         Instruction in proper oral hygiene methods.

 

3)         Instruction concerning the importance of maintenance of proper oral hygiene and where appropriate including family members (as in the case of residents leaving the long-term care facility).

 

b)         The direct care staff shall receive in-service education annually.  This will be provided by a dentist or a dental hygienist.  (B)

 

1)         Direct care staff shall be educated in ultrasonic or manual denture and partial denture cleaning techniques.

 

2)         Direct care staff shall be educated in proper brushing and oral health care for residents who are unable to care for their own health.

 

3)         Direct care staff shall be educated in examining the mouth in order to recognize abnormal conditions for necessary referral.

 

4)         Direct care staff shall be educated regarding nutrition and diet control measures and the effect on dental health.

 

5)         Supplemental dental training films shall be included with any other health training films seen on a rotating basis.

 

c)         The long-term care facility's dental program shall provide for each resident having proper daily personal dental hygiene attention, with the nursing staff responsible for continuity of care which includes, but is not limited to, the following:  (B)

 

1)         Assistance in cleaning mouth with electric or hand brush if resident is unable to do so.

 

2)         Weekly ultrasonic cleaning of dentures and partials is strongly recommended.

 

d)         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 by a qualified dentist

 

e)         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 facility's 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. 4684, effective March 24, 1989)

 

Section 300.1060  Vaccinations

 

a)         A facility shall annually administer or arrange for administration of 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(a) of the Act)

 

b)         A facility shall document in the resident's medical record that an annual vaccination against influenza was administered, arranged, refused or medically contraindicated.  (Section 2-213(a) of the Act)

 

c)         A facility shall administer 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(b) 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(b) of the Act)

 

e)         A facility shall distribute educational information provided by the Department on all vaccines recommended by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (available at:  https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf), including, but not limited to the risks associated with shingles and how to protect oneself against the varicella-zoster virus. The facility shall provide the information to each resident who requests the information and each newly admitted resident. The facility may distribute the information to residents electronically. (Section 2-213(e) of the Act)

 

f)         A facility shall document in the resident's medical record that he or she was verbally screened for risk factors associated with hepatitis B, hepatitis C, and HIV, and whether or not the resident was immunized against hepatitis B. (Section 2-213(c) of the Act)

 

g)         All persons determined to be susceptible to the hepatitis B virus shall be offered immunization within 10 days after admission to any nursing facility.  (Section 2-213(c) of the Act)

 

(Source:  Amended at 45 Ill. Reg. 11096, effective August 27, 2021)

SUBPART F: NURSING AND PERSONAL CARE

 

Section 300.1210  General Requirements for Nursing and Personal Care

 

a)         Comprehensive Resident Care Plan.  A facility, with the participation of the resident and the resident's guardian or 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, and mental and psychosocial needs that are identified in the resident's comprehensive assessment, which allow 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 representative, as applicable. (Section 3-202.2a of the Act)

 

b)         The facility shall provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being of the resident, in accordance with each resident's comprehensive resident care plan. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.  Restorative measures shall include, at a minimum, the following procedures:

 

1)         The licensed nurse in charge of the restorative/rehabilitative nursing program shall have successfully completed a course or other training program that includes at least 60 hours of classroom/lab training in restorative/rehabilitative nursing as evidenced by a transcript, certificate, diploma, or other written documentation from an accredited school or recognized accrediting agency such as a State or National organization of nurses or a State licensing authority.  Such training shall address each of the measures outlined in subsections (b)(2) through (5) of this Section. This person may be the Director of Nursing, Assistant Director of Nursing or another nurse designated by the Director of Nursing to be in charge of the restorative/rehabilitative nursing program.

 

2)         All nursing personnel shall assist and encourage residents so that a resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable.  All nursing personnel shall assist and encourage residents so that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

 

3)         All nursing personnel shall assist and encourage residents so that a resident who is incontinent of bowel and/or bladder receives the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.  All nursing personnel shall assist residents so that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary.

 

4)         All nursing personnel shall assist and encourage residents so that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable.  This includes the resident's abilities to bathe, dress, and groom; transfer and ambulate; toilet; eat; and use speech, language, or other functional communication systems.  A resident who is unable to carry out activities of daily living shall receive the services necessary to maintain good nutrition, grooming, and personal hygiene.

 

5)         All nursing personnel shall assist and encourage residents with ambulation and safe transfer activities as often as necessary in an effort to help them retain or maintain their highest practicable level of functioning.

 

c)         Each direct care-giving staff shall review and be knowledgeable about his or her residents' respective resident care plan.

 

d)         Pursuant to subsection (a), general nursing care shall include, at a minimum, the following and shall be practiced on a 24-hour, seven-day-a-week basis:

 

1)         Medications, including oral, rectal, hypodermic, intravenous and intramuscular, shall be properly administered.

 

2)         All treatments and procedures shall be administered as ordered by the physician.

 

3)         Objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident's medical record.

 

4)         Personal care shall be provided on a 24-hour, seven-day-a-week basis.  This shall include, but not be limited to, the following:

 

A)        Each resident shall have proper daily personal attention, including skin, nails, hair, and oral hygiene, in addition to treatment ordered by the physician.

 

B)        Each resident shall have at least one complete bath and hair wash weekly and as many additional baths and hair washes as necessary for satisfactory personal hygiene.

 

C)        Each resident shall have clean, suitable clothing in order to be comfortable, sanitary, free of odors, and decent in appearance.  Unless otherwise indicated by his/her physician, this should be street clothes and shoes.

 

D)        Each resident shall have clean bed linens at least once weekly and more often if necessary.

 

5)         A regular program to prevent and treat pressure sores, heat rashes or other skin breakdown shall be practiced on a 24-hour, seven-day-a-week basis so that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that the pressure sores were unavoidable.  A resident having pressure sores shall receive treatment and services to promote healing, prevent infection, and prevent new pressure sores from developing.

 

6)         All necessary precautions shall be taken to assure that the residents' environment remains as free of accident hazards as possible.  All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.

 

(Source:  Amended at 35 Ill. Reg. 11419, effective June 29, 2011)

 

Section 300.1220  Supervision of Nursing Services

 

a)         Each facility shall have a director of nursing services (DON) who shall be a registered nurse.

 

1)         This person shall have knowledge and training in nursing service administration and restorative/rehabilitative nursing.  This person shall also have some knowledge and training in the care of the type of residents the facility cares for (e.g., geriatric or psychiatric residents).  This does not mean that the director of nursing must have completed a specific course or a specific number of hours of training in restorative/rehabilitative nursing unless this person is in charge of the restorative/rehabilitative nursing program. (See Section 300.1210(a).)

 

2)         This person shall be a full-time employee who is 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.

 

A)        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 approved 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 numbers and availability of licensed 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 nurses available in the area cannot be expected to produce, in the near future, a qualified person who is willing to work full time.

 

B)        In facilities with a capacity of fewer than 50 beds, this person may also provide direct patient care, and this person's time may be included in meeting the staff-to-resident ratio requirements.

 

3)         In skilled nursing facilities of l00 or more occupied beds, there shall be an assistant director of nursing (ADON) who is a registered nurse.  This person shall also meet the qualifications specified in subsection (a)(1) of this Section for the director of nursing service.

 

4)         In intermediate care facilities of 150 or more occupied beds, a licensed nurse shall be designated as the ADON.   The assistant may provide direct patient care and be included in staff-to-resident ratio calculations.

 

5)         The assistant shall be a full-time employee who is on duty a minimum of 36 hours, four days per week.  The assistant may be assigned to work hours any time of the day or night.

 

6)         The assistant shall assist the DON in carrying out his/her responsibilities.

 

7)         If other duties interfere with the proper performance of the DON's or ADON's duties, another nurse shall be assigned to perform the duties of the DON or assistant for that period of time.

 

b)         The DON shall supervise and oversee the nursing services of the facility, including:

 

1)         Assigning and directing the activities of nursing service personnel.

 

2)         Overseeing the comprehensive assessment of the residents' needs, which include medically defined conditions and medical functional status, sensory and physical impairments, nutritional status and requirements, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy.

 

3)         Developing an up-to-date resident care plan for each resident based on the resident's comprehensive assessment, individual needs and goals to be accomplished, physician's orders, and personal care and nursing needs.  Personnel, representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician, shall be involved in the preparation of the resident care plan.  The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the resident's condition.  The plan shall be reviewed at least every three months.

 

4)         Recommending to the administrator the number and levels of nursing personnel to be employed, participating in their recruitment and selection and recommending termination of employment when necessary.

 

5)         Participating in planning and budgeting for nursing services, including purchasing necessary equipment and supplies.

 

6)         Developing and maintaining nursing service objectives, standards of nursing practice, written policies and procedures, and written job descriptions for each level of nursing personnel.

 

7)         Coordinating the care and services provided to residents in the nursing facility.

 

8)         Supervising and overseeing in-service education, embracing orientation, skill training, and on-going education for all personnel and covering all aspects of resident care and programming. The educational program shall include training and practice in activities and restorative/rehabilitative nursing techniques through out-of-facility or in-facility training programs.  This person may conduct these programs personally or see that they are carried out.

 

9)         Participating in the development and implementation of resident care policies and bringing resident care problems, requiring changes in policy, to the attention of the facility's policy development group.  (See Section 300.610(a).)

 

10)         Participating in the screening of prospective residents and their placement in terms of services they need and nursing competencies available.

 

(Source:  Amended at 26 Ill. Reg. 10523, effective July 1, 2002)

 

Section 300.1230  Direct Care Staffing

 

a)         For purposes of the minimum staffing ratios in Section 3-202.05 of the Act and this Section, all residents shall be classified as requiring either skilled care or intermediate care.  (Section 3-202.05(b-5) of the Act)

 

b)         For the purposes of this Section, the following definitions shall apply:

 

1)         "Direct care" − the provision of nursing care or personal care as defined in Section 300.330, therapies, and care provided by staff listed in subsection (i).  Direct care staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental and psychosocial well-being. Direct care staff does not include individuals whose primary duty is maintaining the physical environment of the facility (e.g., housekeeping).

 

2)         "Skilled care" – skilled nursing care, continuous skilled nursing observations, restorative nursing, and other services under professional direction with frequent medical supervision.  (Section 3-202.05(b-5) of the Act)  Skilled nursing services are either nursing or therapy care services, furnished pursuant to physician orders, that require the skills of a licensed nurse to treat, manage, and observe a resident's condition and evaluate a resident's care. The skilled nursing services may be provided by a CNA, under the supervision of a licensed nurse to ensure the safety of the patient and to achieve the medically desired result. A resident in a skilled nursing facility is classified as receiving skilled care if:

 

A)        The resident is receiving care covered by Medicare under any arrangement allowed by Title XVIII of the Social Security Act;

 

B)        The resident is receiving care that would be covered by Medicare, but the resident has exhausted his or her Medicare benefits; or

 

C)        The resident is not Medicare eligible, but is receiving care that would be covered by Medicare if the resident were eligible.

 

3)         "Intermediate care" – basic nursing care and other restorative services under periodic medical direction.  (Section 3-202.05(b-5) of the Act)  Services not classified as skilled care will be classified as intermediate care.

 

c)         A minimum of 25% of nursing and personal care time shall be provided by licensed nurses, with at least 10% of nursing and personal care time provided by registered nurses. Registered nurses and licensed practical nurses employed by a facility in excess of these requirements may be used to satisfy the remaining 75% of the nursing and personal care time requirements. (Section 3-202.05(e) of the Act)

 

d)         The minimum staffing ratios shall be 3.8 hours of nursing and personal care each day for a resident needing skilled care and 2.5 hours of nursing and personal care each day for a resident needing intermediate care.  (Section 3-202.05(d) of the Act)  For the purpose of this subsection, "nursing care" and "personal care" mean direct care provided by staff listed in subsection (i).

 

e)         The facility shall schedule nursing personnel so that the nursing needs of all residents are met.

 

f)         The number of staff who provide direct care who are needed at any time in the facility shall be based on the needs of the residents, and shall be determined by figuring the number of hours of direct care each resident needs per day. 

 

g)         Each facility shall provide minimum direct care staff by complying with subsection (f) and meeting the minimum direct care staffing ratios set forth in this Section.

 

h)         The direct care staffing calculations in this Section shall include only the number of staff actually on duty on site.  The following shall not be included in direct care staffing calculations:

 

1)         Meal and break times (paid or unpaid);

 

2)         Scheduled training; and

 

3)         When a facility is utilized as a clinical site for nurse aide training, if the facility is not paying the employee for the services provided.

 

i)          For the purpose of computing staff to resident ratios, direct care staff shall include the following:

 

1)         Registered professional nurses;

 

2)         Licensed practical nurses;

 

3)         Certified nurse assistants;

 

4)         Psychiatric services rehabilitation aides;

 

5)         Rehabilitation and therapy aides;

 

6)         Psychiatric services rehabilitation coordinators;

 

7)         Assistant directors of nursing;

 

8)         50% of the Director of Nurses' time;

 

9)         30% of the Social Services Directors' time (Section 3-202.05 of the Act); and

 

10)         Licensed physical, occupational, speech and respiratory therapists.

 

j)          Facilities subject to Subpart S may utilize specialized clinical staff, as defined in Section 300.4090(c) and (f), to count towards the staffing ratios. (Section 3-202.05(a) of the Act)

 

k)         To determine the direct care staffing required to meet daily minimum staffing ratios for skilled care and intermediate care, the following staffing formula shall be used:

 

1)         Determine the number of residents requiring skilled care and the number of residents requiring intermediate care.

 

2)         Calculate the total daily required nursing and personal care hours for each level of care:

 

A)        The number of residents requiring skilled care shall be multiplied by the required number of hours (3.8) per resident.

 

B)        The number of residents requiring intermediate care shall be multiplied by the required number of hours (2.5) per resident.

 

3)         Add the total number of hours of direct care required for each level of care to determine the total number of hours required to provide direct care for all residents in the facility.

 

4)         Multiplying the total minimum hours of direct care hours required for all residents, determined under subsection (k)(3), by 25% results in the minimum amount of licensed nurse hours that shall be provided during a 24-hour period.

 

5)         Multiplying the total minimum hours of direct care time required for all residents, determined under subsection (k)(3), by 10% results in the minimum amount of registered nurse hours that shall be provided during a 24-hour period.

 

6)         The remaining 75% of the minimum required direct care hours may also be fulfilled by other staff identified in subsection (i) as long as it can be documented that those staff provide direct care, and that nursing care and nursing delegation is in accordance with the Nurse Practice Act.

 

7)         The amount of time determined in subsections (k)(4), (5) and (6) is expressed in hours.

 

8)         See Appendix A for an example of staffing calculations. 

 

l)          A written work schedule shall be posted at least 10 days prior to the first day on the schedule. The work schedule shall be posted in a location conspicuous and accessible only to employees.

 

1)         This work schedule shall contain the employee's name, job title, (identifying the job title or titles listed in subsection (i), if applicable), shift assignment, hours of work, and days off.

 

2)         If an employee works in more than one job during the same week, specifically including those job duties listed in subsection (i), if applicable, the facility shall separately state the hours of work for each job duty.

 

3)         The work schedule, whether a hard copy or in an electronic format, shall be kept on file in the facility in the administrator's office for a minimum of three years after the week for which the schedule was used.

 

m)        Time spent in scheduled breaks and mealtimes, and scheduled training, when staff are not providing direct care shall be documented.

 

n)         A facility operating under a waiver from the minimum registered professional nurse staffing requirements (see Section 300.1232) shall provide written documentation of the waiver to the Department upon request.

 

(Source:  Amended at 45 Ill. Reg. 1134, effective January 8, 2021)

 

Section 300.1231  Calculation of Direct Care Staffing During Inspections, Surveys and Evaluations

 

a)         Calculation of direct care staffing during inspections, surveys and evaluations will be based on the finalized working schedule and daily census report totals for the two-week period preceding the first day of the inspection.  The work schedule shall be determined as outlined in Section 300.1230(k) and shall be provided upon request.

 

b)         For certified facilities, copies of nurse staffing information required by 42 CFR 483.35(g) for the two-week period preceding the first day of the inspection shall be provided upon request. 

 

(Source:  Added at 45 Ill. Reg. 1134, effective January 8, 2021)

 

Section 300.1232  Waiver of Registered Professional Nurse Staffing Requirements

 

a)         Upon application by a facility, the Director may grant or renew a waiver, in whole or in part, of the registered professional nurse staffing requirements contained in Section 3-202.05(e) of the Act and Section 300.1230(c) of this Part, considering the criteria in Section 300.320, if the facility demonstrates to the Director's satisfaction that the facility is unable, despite diligent efforts, including offering wages at a competitive rate for registered professional nurses in the community, to employ the required number of registered professional nurses and that the waivers will not endanger the health or safety of residents of the facility.

 

b)         A facility in compliance with the terms of a waiver granted under Section 3-303.1(c) of the Act and this Section will not be subject to fines or penalties imposed by the Department for violating the registered professional nurse staffing requirements of Section 3-202.05(e) of the Act and Section 300.1230(c). Nothing in the Act or this Section allows the Director to grant or renew a waiver of the minimum registered professional nurse staffing requirements provided in 42 CFR 483.35(b) to a facility that is Medicare-certified or to a facility that is both Medicare-certified and Medicaid-certified.

 

c)         Waivers granted under the Act and this Section will be reviewed quarterly by the Department, including requiring a demonstration by the facility that it has continued to make diligent efforts to employ the required number of registered professional nurses, and shall be revoked for noncompliance with any of the following requirements:

 

1)         For periods in which the number of registered professional nurses required by law is not in the facility, a physician or registered professional nurse shall respond immediately to a telephone call from the facility.

 

2)         The facility to notify the following of the waiver: the Office of the State Long Term Care Ombudsman, the residents of the facility, the residents' guardians, and the residents' representatives.  (Section 3-303.1(c) of the Act)

 

d)         A copy of each waiver application and each waiver granted or renewed by the Department will be on file with the Department and available for public inspection. The Director will annually review the file and recommend to the Long-Term Care Facility Advisory Board any modification in this Part suggested by the number and nature of waivers requested and granted and the difficulties faced in compliance by similarly situated facilities. (Section 3-303.1(d) of the Act)

 

e)         If the Department grants a waiver to a facility under this Section, the facility shall immediately notify the following of the waiver:

 

1)         The Office of the State Long Term Care Ombudsman;

 

2)         The residents of the facility;

 

3)         The residents' guardians;

 

4)         The residents' representatives (Section 3-303.1(c)(2) of the Act);

 

5)         Individuals seeking information from the facility prior to admission to the facility; and

 

6)         The Illinois Department of Healthcare and Family Services Bureau of Long-Term Care.

 

f)         A request for a waiver from the registered professional nurse staffing requirements shall be made in writing to the Department, specifying the following:

 

1)         A detailed explanation of why the facility is unable, despite diligent efforts, including offering wages at a competitive rate for registered professional nurses in the community, to employ the required number of registered professional nurses (Section 3-303.1(c) of the Act);

 

2)         A detailed description of the programs or services offered by the facility for which the waiver is requested;

 

3)         A detailed explanation of why the waiver will not endanger the health or safety of residents of the facility (Section 3-303.1(c) of the Act);

 

4)         The number of residents in the facility and the level of care they require, the location and number of ambulatory and non-ambulatory residents, and residents' decision making capacity; and

 

5)         The time period for which the waiver is requested.

 

g)         The Department may revoke a waiver granted to a facility if the facility fails to comply with any of the requirements in the Act and this Section.

 

h)         A facility operating under an initial license shall not be eligible for a waiver of registered professional nurse staffing requirements.

 

i)          A facility that has been subject to any of the following actions by the Department in the three years prior to application shall not be eligible for a waiver of registered professional nurse staffing requirements:

 

1)         Issuance of one or more Type "AA" violations if operated by the same owner at the time of the waiver application; 

 

2)         Issuance of two or more Type "A" violations if operated by the same owner at the time of the waiver application; or

 

3)         Issuance of two consecutive annual or bi-annual certification surveys with substantiated substandard quality of care deficiencies.

 

j)          No waiver shall 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(a) of the Act)  For facilities with two-year licenses, no waiver shall be granted for a period that exceeds one year.  Waivers shall not be transferable.

 

k)         The Department will post on its website a list of facilities with approved waivers by no later than June 30 of each year.

 

(Source:  Added at 45 Ill. Reg. 1134, effective January 8, 2021)

 

Section 300.1233  Quarterly Administrative Staffing Compliance Review

 

a)         The Department will determine compliance quarterly by comparing the number of hours provided per resident per day using the Centers for Medicare and Medicaid Services' payroll-based journal (PBJ) and the facility's daily census.  (Section 3-202.05(f) of the Act) PBJ data that is utilized for compliance shall not be contested.  For a crosswalk of job titles from Section 300.1230(i) versus PBJ job titles, see Appendix B.

 

b)         The quarterly deadlines for submitting PBJ data to the Department are as follows:

 

1)         For the first fiscal quarter reporting period of October 1 through December 31, quarterly PBJ data is due to the Department on March 1.

 

2)         For the second fiscal quarter reporting period of January 1 through March 31, quarterly PBJ data is due to the Department on June 1.

 

3)         For the third fiscal quarter reporting period of April 1 through June 30, quarterly PBJ data is due to the Department on September 1.

 

4)         For the fourth fiscal quarter reporting period of July 1 through September 30, quarterly PBJ data is due to the Department on December 1.

 

c)         Licensed-only facilities are not required to submit PBJ data to the Department but shall submit quarterly staffing data to the Department in a format and manner determined by the Department, adhering to the same deadlines as in subsection (b).

 

d)         The facility's daily census report shall be broken down by intermediate and skilled care.  (Section 3-202.05(f) of the Act) Required information for each day listed on the report is as follows:

 

1)         The date;

 

2)         The total number of residents requiring skilled care for the date;

 

3)         The total number of residents requiring intermediate care for the date; and

 

4)         The total census for the date.

 

e)         Facilities shall submit to DPH.LTCDailyCensus@illinois.gov a separate daily census report for each day of the month of the quarter, adhering to the same deadlines as in subsection (b).

 

f)         Failure to submit a required daily census report by the submission deadline shall result in calculations based on skilled care direct care staffing requirements for any of the missing information.

 

(Source:  Added at 45 Ill. Reg. 1134, effective January 8, 2021)

 

Section 300.1234  Penalties and Notice of Violation

 

a)         Notwithstanding any other provision of the Act or this Part, the Department will impose penalties for violations of the minimum staffing requirements of the Act and Section 300.1230, as follows:

 

1)         No monetary penalty will be issued for noncompliance during the implementation period, which will be July 1, 2020 through September 30, 2020. If a facility is found to be noncompliant during the implementation period, the Department will provide a written notice identifying the staffing deficiencies. The facility shall provide a sufficiently detailed correction plan to meet the statutory minimum staffing levels. 

 

2)         Monetary penalties will be imposed by the Department beginning no later than January 1, 2021, and quarterly thereafter, and shall be based on the latest quarter for which the Department has data.

 

3)         Monetary penalties shall be established based on a formula that calculates, on a daily basis, the cost of wages and benefits for the missing staffing hours.  All notices of noncompliance issued by the Department will include the computations used to determine noncompliance and establishing the variance between minimum staffing ratios and the Department's computations.

 

4)         The penalty for the first offense shall be 125% of the cost of wages and benefits for the missing staffing hours. The penalty will increase to 150% of the cost of wages and benefits for the missing staffing hours for the second offense and 200% of the cost of wages and benefits for the missing staffing hours for the third and all subsequent offenses.

 

5)         The penalty shall be imposed regardless of whether the facility has committed other violations of the Act and this Part during the same period that the staffing offense occurred.

 

6)         The penalty may not be waived, but the Department may determine the gravity of the violation in situations in which there is no more than a 10% deviation from the staffing requirements and make appropriate adjustments to the penalty.  

 

A)        A facility shall have 30 days from the receipt of the notice of violation to request an adjustment to the penalty pursuant to this subsection (a)(6).

 

B)        This subsection does not apply to deviations due to a waiver granted under Section 300.1232.

 

7)         The Department may waive the penalty when unforeseen circumstances have occurred that resulted in call-offs of scheduled staff.  This provision will be applied no more than 6 times per quarter.  (Section 3-202.05(g) of the Act)  A facility shall have 30 days from the receipt of the notice of violation to request a waiver of the penalty pursuant to this subsection (a)(7).  If the Department declines to waive the penalty, it will inform the facility of the reasons why.  For the purposes of this Section:

 

A)        An unforeseen circumstance includes, but is not limited to, a disaster as defined in Section 300.670(a), labor unrest, civil unrest, a viral epidemic or pandemic, family emergency, or any cause beyond the reasonable control of the facility.

 

B)        "Six Times" means 6 unforeseen circumstances.  If an unforeseen circumstance occurs, the facility shall document the type of unforeseen circumstance, the beginning and end dates of the unforeseen circumstance, and how many scheduled staff called off during the unforeseen circumstance.  The facility shall submit the report to the Department within 24 hours after the end of the unforeseen circumstance.  If the unforeseen circumstance is a viral epidemic or pandemic, the facility shall submit regular reports to the Department pursuant to Section 300.696.

 

b)         Nothing in the Act or this Section diminishes a facility's right to appeal a Department finding of non-compliance with the minimum staffing requirements of Section 300.1230.  (Section 3-202.05(g) of the Act)  A facility shall have 30 days from the receipt of the notice of violation to file an appeal on a Department finding of non-compliance.

 

c)         The Department will notify the facility of non-compliance with the minimum staffing requirements within 30 days after the latest quarter for which the Department has complete staffing data.  The notice shall contain, at a minimum:

 

1)         The year and quarter the staffing shortfall occurred;

 

2)         A summary breakdown of the total penalty showing results of calculations made pursuant to subsection (d);

 

3)         Citations to the Act and this Part relative to the violation;

 

4)         The total amount of the fine, if any, the date by which payment is due to be paid, and accepted forms of payment;

 

5)         An explanation of consequences for nonpayment, incomplete payment, or late payment (see subsection (e));

 

6)         A statement of the facility's right to file an appeal of the violation, to request an adjustment of the penalty when there is no more than a 10% deviation from the staffing requirements, or request a waiver of the penalty for an unforeseen circumstance; and

 

7)         The process for filing an appeal or requesting an adjustment or a waiver of the penalty.

 

d)         The Department will use the following procedures to determine penalties for facilities that fail to meet minimum direct care staffing ratios:

 

1)         The Department will calculate penalties for unmet direct care staffing hours using the most current median hourly wage data reported by U.S. Department of Labor Bureau of Labor Statistics (BLS) in the BLS' Occupational Employment Statistics' metropolitan and nonmetropolitan Area Occupational Employment and Wage Estimates for the State of Illinois, which is published at https://www.bls.gov/oes/current/ oessrcma.htm.

 

A)        The hourly wage for unmet registered professional nurse hours will be determined by the most current median hourly wage available for RNs (defined as "registered nurses" with the BLS occupational code 29-1141) in the metropolitan area in which the nursing facility is located.

 

B)        The hourly wage for unmet licensed practical nurse hours will be determined by the most recent median hourly wage available for LPNs (defined as "licensed practical and licensed vocational nurses" with the BLS occupational code 29-2061) in the metropolitan area in which the nursing facility is located.

 

C)        The hourly wage for unmet hours of direct care staff who are not registered nurses or licensed practical nurses will be determined by the most recent median hourly wage available for CNAs (defined as "nursing assistants" with the BLS occupational code 31-1014) in the metropolitan area in which the nursing facility is located.

 

2)         The Department will use the following formulas to determine the wage cost for each day's unmet direct care staffing hours when a staffing-hours shortfall is greater than zero.  For the purposes of this Section, "median wage" refers to the BLS wage rate for the metropolitan or non-metropolitan area in which the facility is located.

 

A)        The cost of RN hours shortfall = the RN hours shortfall x the median RN wage.

 

B)        The cost of LPN hours shortfall = the LPN hours shortfall x the median LPN wage.

 

C)        The cost of direct care hours shortfall = the direct care hours shortfall x the median CNA wage.

 

3)         The Department will use the following procedures to add the cost of benefits to the cost of hourly wages identified in subsection (d)(2):

 

A)        The Department will use a multiplier of 120% of the hourly wage that would have been paid for each hour of deficiency in skilled, intermediate or direct care. When calculating, under this subsection (d)(3), the combined wage and benefit value basis to determine a penalty for each violation, the wage per hour values shall be determined by the most recent cost reports filed with the Department of Healthcare and Family Services by facilities licensed under the Nursing Home Care Act.

 

B)        The Department will calculate the total compensation costs (employee wages and benefits) of unmet direct care staffing hours using the following formula, which applies a multiplier based on the percentage identified in subsection (d)(3)(A) to the total direct care staffing hour shortfalls identified in subsections (d)(2)(A), (B), and (C):

 

Total Compensation Cost of Unmet Direct Care Staffing Hours = (1.0 + (the Cost of Benefits Per Hour Worked/the Cost of Wages Per Hour Worked)) X (Cost of RN Hours Shortfall + Cost of LPN Hours Shortfall + Cost of Direct Care Hours Shortfall)

 

4)         The total penalty amount will be calculated based on the total compensation cost of unmet direct care staffing hours calculated in subsection (d)(3)(B), as follows:

 

A)        If the violation is the facility's first violation for unmet direct care staffing hours, the Total Compensation Cost for Unmet Direct Care Staffing Hours will be multiplied by 125%.

 

B)        If the violation is the facility's second violation for unmet direct care staffing hours, the Total Compensation Cost for Unmet Direct Care Staffing Hours will be multiplied by 150%.

 

C)        If the violation is the facility's third violation or any violation beyond the third, the Total Compensation Cost for Unmet Direct Care Staffing Hours will be multiplied by 200%.

 

D)        Any shortfall of hours within a quarter, regardless of whether the shortfall is in all or only one direct care staff category, constitutes one violation.

 

e)         If the person or facility against whom a penalty has been assessed does not comply with a written demand for payment within 30 days after receiving a notice of violation, the Department will issue an order to do any of the following:

 

1)         Direct the State Treasurer or Comptroller to deduct the amount of the fine from amounts otherwise due from the State for the penalty and remit that amount to the Department;

 

2)         Add the amount of the penalty to the facility's licensing fee. If the licensee refuses to make the payment at the time of application for renewal of its license, the license shall not be renewed; or

 

3)         Bring an action in circuit court to recover the amount of the penalty.  (Section 3-310 of the Act)

 

(Source:  Added at 45 Ill. Reg. 1134, effective January 8, 2021)

 

Section 300.1240  Additional Requirements

 

In addition to the staffing requirements, in Section 300.1230, the following staffing requirements also apply to all Skilled Nursing Facilities and Intermediate Care Facilities:

 

a)         There shall be a licensed nurse designated as being in charge of nursing services on all shifts when neither the director of nursing or assistant director of nursing are on duty.  If registered nurses and licensed practical nurses are on duty on the same shift, this person shall be a registered nurse. This person may be a charge nurse on one of the nursing units.   (A, B)

 

b)         There shall be at least one person awake, dressed and on duty at all times in each separate nursing unit.  (A, B)

 

c)         There shall be at least one registered nurse on duty seven days per week, 8 consecutive hours, in a skilled nursing facility.  (A, B)

 

d)         There shall be at least one registered nurse or licensed practical nurse on duty at all times in an intermediate care facility or a skilled nursing facility.  (A, B)

 

e)         There shall be at least one registered nurse or licensed practical nurse on duty on each floor housing residents in a skilled nursing facility.  (A, B)

 

f)         The need for licensed nurses on each nursing unit in a skilled nursing facility and each floor or nursing unit in an intermediate care facility will be determined on an individual case basis, dependent upon the individual situation.  If such additional staffing is required, the Department will inform the facility in writing of the kind and amount of additional staff time required, and the reason why it is needed.

 

g)         The need for an additional licensed nurse to serve as a "house supervisor" will be determined on an individual case basis.  If the Department determines that there is a need for a registered nurse in a skilled nursing facility or a licensed practical nurse in an intermediate care facility on certain shifts whose sole duties will consist of supervising the nursing services of the facility, the Department shall notify the facility in writing when and why such a person is needed.  This person shall not perform the duties of a charge nurse while serving as the "house supervisor".

 

(Source:  Amended at 16 Ill. Reg. 17089, effective November 3, 1992)

SUBPART G: RESIDENT CARE SERVICES

 

Section 300.1410  Activity Program

 

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 activities shall be coordinated with other services and programs to make use of both community and facility resources and to benefit the residents.

 

b)         Activity personnel shall be provided to meet the needs of the residents and the program.  Activity staff time each week shall total not less than 45 minutes multiplied by the number of residents in the facility. This time shall be spent in providing activity programming as well as planning and directing the program.  The time spent in the performance of other duties not related to the activity program shall not be counted as part of the required activity staff time.

 

1)         In a facility whose residents participate in regularly scheduled therapeutic programs outside the facility, such as school, employment or sheltered workshop, the minimum hours per week of activity staff time may be reduced.  The reduction shall be calculated by multiplying the number of residents in the facility who participate in such programs by the percentage of the day that these residents spend in such programs.

 

2)         Activity personnel working under the direction of the activity director shall have a minimum of 10 hours of in-service training per calendar or employment year, directly related to recreation/activities.  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.

 

c)         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 on duty in the facility at least four days per week.

 

2)         If the activity director is not a Certified Therapeutic Recreation Specialist (CTRS), Occupational Therapist Registered and Licensed (OTR/L), 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 December 24, 1987, 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 (c)(2) of this Section, any person hired as an activity director afer November 1, 2000 shall have taken 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 shall 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 assessment 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.

 

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)         Activity program staff shall participate in the assessment of each resident, 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 plan of care addressing needs and interests of the residents, including activity/recreational goals and/or 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 designed in accordance with the individual resident's needs, based on past and present lifestyle, cultural/ethnic background, interests, capabilities, and tolerance.  Activities shall be 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/or 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, reminiscence, 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 and/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 24 Ill. Reg. 17330, effective November 1, 2000)

 

Section 300.1420  Specialized Rehabilitation Services

 

If physical therapy, occupational therapy, speech therapy or any other specialized rehabilitative service is offered, it shall be provided by, or supervised by, a qualified professional in that specialty and upon the written order of the physician.  (B)

 

a)         In addition to the provision of direct services, any such qualified professional personnel shall be used as consultants to the total restorative program and shall assist with resident evaluation, resident care planning, and in-service education.

 

b)         Appropriate records shall be maintained by these personnel.  Direct service to individual residents shall be documented on the individual clinical record as set forth in Section 300.1810(c).  A summary of program consultation and recommendations as set forth in Section 300.1810(h) shall be documented.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.1430  Work Programs

 

a)         Work programs for individual residents in facilities shall be allowed only if they are oriented toward resident adjustment and therapeutic benefits and if they are approved in writing by the Department.  Such programs should be a rarity in skilled nursing facilities.

 

b)         Permission for each such program shall be secured from the Department.  Each program shall be presented in writing indicating such things as objectives, possible work assignment,  duties, policies governing the program, agency involvement (where appropriate), and supervision.

 

c)         Residents involved in such programs shall meet all requirements of the Department for persons functioning in these positions.

 

d)         Residents shall not be used to replace employed staff.  (B)

 

e)         Appropriate records shall be maintained for each resident functioning in these programs. These shall show appropriateness of the program for the individual, resident's response to the program and any other pertinent observations and shall  become a part of the resident's record.  (See Section 300.1810(c).)

 

f)         All such programs shall be in full compliance with all applicable regulations of both the State and Federal Departments of Labor.  Any program found by the Department not to be in compliance with State and Federal Departments of Labor regulations shall be terminated immediately.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.1440  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. 17330, effective November 1, 2000)

 

Section 300.1450  Language Assistance Services

 

A facility shall provide language assistance services in accordance with the Language Assistance Services Act and the Language Assistance Services Code.

 

(Source:  Amended at 45 Ill. Reg. 11096, effective August 27, 2021)

SUBPART H: MEDICATIONS

 

Section 300.1610  Medication Policies and Procedures

 

a)         Development of Medication Policies

 

1)         Every facility shall adopt written policies and procedures for properly and promptly obtaining, dispensing, administering, returning, and disposing of drugs and medications.  These policies and procedures shall be consistent with the Act and this Part and shall be followed by the facility.  These policies and procedures shall be in compliance with all applicable federal, State and local laws. 

 

2)         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 300.1640.  A licensed prescriber who dispenses medication from his or her personal office supply shall comply with Sections 33 and 54.5 of the Medical Practice Act of 1987; or Section 51 of the Illinois Dental Practice Act; or the Podiatric Medical Practice Act of 1987; or Section 15.1 of the Illinois Optometric Practice Act of 1987; or Section 15-20 of the Nurse Practice Act; or Section 7.5 of the Physician Assistant Practice Act of 1987. 

 

d)         All medications administered shall be recorded as set forth in Section 300.1810. 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 service.

 

f)         A pharmacist shall obtain a Division III license to operate an on-premises pharmacy in accordance with the Pharmacy Practice Act and68 Ill. Adm. Code 1330.

 

g)         No facility shall maintain a stock supply of controlled drugs or legend drugs, except for those in the emergency medication kits and 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 the order of a licensed prescriber (see Section 300.1620).  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)          The contents and number of 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 also 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 a locked container within a refrigerator, as appropriate) and labeled with a list of the substances and a statement that they are part of the emergency medication kit.  The label of the emergency medication kit shall list the substances and the specific location where they are stored.  

 

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 shall be administered only by persons licensed to administer medications, in compliance with 21 CFR 1306.11 and 1306.21 and the Illinois Controlled Substances Act.

 

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 afterward.  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 document each check 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 the regulations.  This is in addition to the usual methods of corrective action available to the Department, such as fines and other penalties.

 

l)          Oxygen may be administered in a facility.  The oxygen supply shall be stored and handled in accordance with NFPA 99 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 101. 

 

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 an identical 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 45 Ill. Reg. 11096, effective August 27, 2021)

 

Section 300.1620 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 300.1810.  All 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 telephone 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 10 calendar days. 

 

c)         Review of medication orders:  The staff pharmacist or consultant pharmacist shall review the medical record, including licensed prescribers' orders and laboratory test results, at least monthly and, based on their clinical experience and judgment, and Section 300.Appendix F, determine if there are irregularities that may cause potential adverse reactions, allergies, contraindications, medication errors, or ineffectiveness.  This review shall be documented in the clinical record.  Portions of this review may be done outside the facility.  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 policies 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 45 Ill. Reg. 11096, effective August 27, 2021)

 

Section 300.1630  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 300.1810.) 

 

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 as per Sections 300.2860 or 300.3060 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. 5862, effective April 01, 2003)

 

Section 300.1640  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, a locked medication room, or 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, and 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 medicine cabinet, medicine room, or 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 medications, 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 dispensed 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 licensed prescriber 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. 5862, effective April 01, 2003)

 

Section 300.1650  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 established by the facility in accordance with Section 300.1610.  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)         Inventory Controls

 

1)         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 prescriber's name, signature of person administering dose, and number of doses remaining.

 

2)         The pharmaceutical advisory committee may also require that other medications shall be subject to such inventory records.

 

(Source:  Amended at 27 Ill. Reg. 5862, effective April 01, 2003)

SUBPART I: RESIDENT AND FACILITY RECORDS

 

Section 300.1810  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.

 

6)         A user may terminate authorization for use of electronic or computer-generated signature upon written notice to the individual responsible for medical records or other person designated by the facility's policy.

 

7)         Each report generated by a user must be separately authenticated.

 

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)         The record shall include medically defined conditions and prior medical history, medical status, physical and mental functional status, sensory and physical impairments, nutritional status and requirements, special treatments and procedures, mental and psychosocial status, discharge potential, rehabilitation potential, cognitive status and drug therapy.

 

f)         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 rehabilitation services shall be included in the resident's progress record when the recommendations pertain to an individual resident.

 

g)         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.

 

h)         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.

 

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 300.1840 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)          All Cook County facilities with Colbert Class Members shall submit to the Colbert Lead Defendant Agency, or successor Colbert Lead Defendant Agency, on a monthly basis, an accurate census of all Medicaid-eligible residents, the previous month’s voluntary and involuntary discharges conducted under Section 300.3300, including any voluntary and involuntary discharges scheduled to be conducted within 48 hours after the end of the reporting month. This monthly census must be submitted on the form prescribed by the Colbert Lead Defendant Agency using secure (encrypted) email, no later than the fifth business day of each month.

 

m)        All Cook County facilities with Colbert Class Members shall provide educational materials and information to all Colbert Class Members voluntarily or involuntarily discharging from the facility at the time of completing the discharge paperwork, informing them of their rights and services under the Colbert Consent Decree, as prescribed by the Colbert Lead Defendant Agency.  All Cook County facilities shall provide written verification of educational materials and information given to the Colbert Class Members, as requested by a Colbert Defendant Agency.

 

n)         All Cook County facilities shall notify any agency providing transition services to a Colbert Class Member of such Class Member’s discharge at least 48 hours prior to the discharge taking place.

 

(Source:  Amended at 46 Ill. Reg. 16829, effective September 26, 2022)

 

Section 300.1820  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,

 

15)         Name, address and telephone number of the resident's dentist, and

 

16)         The diagnosis applicable at the time of admission.

 

b)         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)         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 activity programs, social services, dietary services and work 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 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 300.1010(g) 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, 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.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.1830  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. 4684, effective March 24, 1989)

 

Section 300.1840  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 discharged 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. 4684, effective March 24, 1989)

 

Section 300.1850  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 300.620(f) of this Part.

 

b)         The resident's record shall identify the reasons for any order and use of safety devices or restraints, as required by Sections 300.680(c) and 300.1040(d), respectively, of this Part.

 

c)         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 300.1010(h) of this Part.

 

d)         The resident's record shall contain the physician's permission, with contraindications noted, for participation in the activity program, as required by Section 300.1410(d) of this Part.

 

e)         The records of residents participating in work programs shall document the appropriateness of the program for the resident and the resident's response to the program, as described in Section 300.1430(e) 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 300.1620(a)(2) of this Part.

 

g)         Documentation of the review of medication order shall be entered in the resident's medical record as described in Section 300.1620(b) of this Part.

 

h)         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 300.1620(e) of this Part.

 

i)          Instances of inability to implement a physician's medication order shall be noted in the resident's medical record, as described in Section 300.1630(d) of this part.

 

j)          Medication errors and drug reactions shall be noted in the resident's medical record as described in Section 300.1630(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 describe in Section 300.2040 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 300.3210(b) of this Part.

 

m)        The facility shall comply with Section 300.3210(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 300.3220(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 300.3300(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 300.3300(j) of this Part.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.1860  Staff Responsibility for Medical Records

 

a)         Each skilled nursing facility shall have a health information management consultant.

 

1)         Each skilled nursing facility that has a full-time or part-time health information management consultant shall designate that employee as the person responsible for ensuring that the facility's medical records are completed, maintained and preserved in accordance with this Subpart.

 

2)         Each skilled nursing facility that does not have a full-time or part-time health information management consultant shall designate an employee to be responsible for completing, maintaining and preserving the facility's medical records. This individual shall be trained by, and receive regular consultation from, a health information management consultant in order to meet the requirements of this Subpart.

 

b)         Each intermediate care facility that does not have a full-time or part-time health information management consultant shall designate an employee to be responsible for completing, maintaining and preserving the medical records in accordance with the requirements of this Subpart.

 

(Source:  Amended at 26 Ill. Reg. 10523, effective July 1, 2002)

 

Section 300.1870  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 300.210 of this Part.

 

b)         The minutes of resident advisory council meetings required by Section 300.640(k) of this Part.

 

c)         The records of in-service training required by Section 300.650(b) (3) of this Part.

 

d)         Copies of reports of serious incidents or accidents involving residents required by Section 300.690 of this Part.

 

e)         Records of the emergency medication kit review by the pharmaceutical advisory committee required by Section 300.1610(i)(3) of this Part.

 

f)         The reports of findings and recommendations from consultants required in Section 300.1880(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 300.1880(d) of this Part.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.1880  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 300.210 of this Part.

 

2)         Records and daily time schedules shall be kept on each employee as set forth in Section 300.650(a) and (b) of this Part.

 

3)         The facility shall maintain a controlled substances record as described in Section 300.1650(d) of this Part.

 

4)         Menu and food purchase records shall be maintained as set forth in Section 300.2080(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 300.690 of this Part.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

SUBPART J: FOOD SERVICE

 

Section 300.2010  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 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)        If the person responsible for food service is not a dietitian, the person shall have frequent and regularly scheduled consultation from a dietitian. Consultation, given in the facility, shall include training, as needed, in areas such as menu planning and review, food preparation, food storage, food service, safety, food sanitation, and use of food equipment.  Clinical management of therapeutic diets shall also be included in consulting, covering areas such as tube feeding; nutritional status and requirements of residents, including weight, height, hematologic and biochemical assessments; physical limitations; adaptive eating equipment; and clinical observations of nutrition, nutritional intake, resident's eating habits and preferences, and dietary restrictions.

 

1)         Intermediate care facilities:  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.

 

2)         Skilled nursing facilities:  A minimum of eight hours of consulting time per month shall be provided for facilities with 50 or fewer residents.  An additional five 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. 8106, effective July 15, 1999)

 

Section 300.2020  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. 4684, effective March 24, 1989)

 

Section 300.2030  Hygiene of Dietary Staff

 

Food service personnel shall be in good health, shall practice hygienic food handling techniques, and good personal grooming.  (B)

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.2040  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 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 must be available in the kitchen.  If separate menus are not planned for each specific diet, information for each specific type, in a form easily understood by staff, shall be available 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 45 Ill. Reg. 11096, effective August 27, 2021)

 

Section 300.2050  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 eight ounces of milk:

 

1)         1½ ounces natural cheese,

 

2)         Two ounces processed cheese,

 

3)         One cup yogurt, or one cup frozen yogurt,

 

4)         One cup cottage cheese, or

 

5)         1½ 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 ½ cup canned fish.

 

3)         Three ounces of natural or processed cheese or ¾ cup cottage cheese.

 

4)         Three eggs (minimum weight 21 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)         1½ cups cooked dried peas or beans, six tablespoons of peanut butter, or one cup nuts, not more than twice a week and provided that eggs, milk or lean meat is 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 standard 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. 8106, effective July 15, 1999)

 

Section 300.2060  Therapeutic Diets (Repealed)

 

(Source:  Repealed at 23 Ill. Reg. 8106, effective July 15, 1999)

 

Section 300.2070  Scheduling Meals

 

a)         A minimum of three meals or their equivalent shall be served daily at regular times with no more than a l4 hour span between a substantial evening meal and breakfast.  The l4 hour span shall not apply to facilities using the "four or five meal-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 substitutes shall be served.

 

(Source:  Amended at 16 Ill. Reg. 17089, effective November 3, 1992)

 

Section 300.2080  Menus and Food Records

 

a)         Menus, including menus for "sack" lunches and 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)         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.

 

f)         Supplies of staple foods 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.

 

g)         Records of all food purchased shall be kept on file for not less than 30 days.

 

(Source:  Amended at 23 Ill. Reg. 8106, effective July 15, 1999)

 

Section 300.2090  Food Preparation and Service

 

a)         Foods 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 multi-purpose room except for an individual with a temporary illness, who is too ill, or for other valid reasons.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.2100  Food Handling Sanitation

 

Every facility shall comply with the Department's rules entitled "Food Code."

 

(Source:  Amended at 49 Ill. Reg. 760, effective December 31, 2024)

 

Section 300.2110  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. 14950, effective October 1, 1990)

SUBPART K: MAINTENANCE, HOUSEKEEPING, AND LAUNDRY

 

Section 300.2210  Maintenance

 

a)         Every facility shall have an effective written plan for maintenance, including sufficient staff, appropriate equipment, and adequate supplies.

 

b)         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, 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 screen to the inch and repair of any breaks in construction.  (B)

 

9)         Maintain all plumbing fixtures and piping in good repair and properly functioning.  (B)

 

10)         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. 14950, effective October 1, 1990)

 

Section 300.2220  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, as nonslip as possible, and free from tripping hazards including throw or scatter rugs.

 

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. 4684, effective March 24 1989)

 

Section 300.2230  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 the time involved for laundering and transporting soiled linens.

 

2)         If an in-house laundry service is provided then the following conditions shall exist:

 

A)        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.

 

B)        Written operating procedures shall be developed, posted and implemented which provide for the handling, transport and storage of clean and soiled linens.

 

C)        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.

 

D)        Clean linen shall be protected from contamination during handling, transport and storage.

 

E)        Soiled linen shall be handled, transported and stored in a manner that protects facility residents and personnel.

 

F)         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. 14950, effective October 1, 1990)

SUBPART L: FURNISHINGS, EQUIPMENT, AND SUPPLIES

 

Section 300.2410  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 be in good repair.  A double bed shall be provided for married couples if they request this arrangement and if there are no medical contraindications.

 

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, that are in good repair.

 

d)         A satisfactory reading lamp, or equivalent, shall be provided for each bed.

 

e)         Pillows

 

1)         Each bed shall be provided with a minimum of one clean, comfortable pillow.

 

2)         Additional pillows shall be available in the facility to satisfactorily serve the needs of the residents.

 

f)         Each bedroom shall be provided with a mirror unless there is a mirror in an adjoining bathroom.  Each lavatory shall be provided with a mirror.

 

g)         Each living room provided for residents' use shall have 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 that are well constructed, comfortable, in good repair, and of satisfactory design for the residents.  The facility shall provide a sufficient number of tables of a type that can accommodate residents who require the use of a wheelchair.

 

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 the facility shall provide:

 

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; and

 

6)         A satisfactory bedside cabinet.

 

k)         A sufficient number of tables that can be either rolled over the resident's bed or that can be placed next to bed shall be provided to serve every resident who cannot, or does not, eat in a dining room or area.

 

l)          Proper storage in each resident's room, either within the bedside cabinet or in a separate cabinet, for individual equipment such as an emesis basin, bedpan, urinal, and washbasin shall be provided.  This storage need not be provided in the resident's room if it is satisfactorily provided in a connecting bath or toilet room.

 

m)        A facility shall permit a resident to bring their own furnishings so long as those furnishings do not impede access into or out of the resident's room.

 

n)         A facility shall make reasonable efforts to have activated at all times the closed captioning feature on a television in a common area provided for use by the general public or in a resident's room, or enable the closed captioning feature when requested to do so by a member of the general public or a resident, if the television includes a closed captioning feature.  As used in this subsection (n), "closed captioning" means a text display of spoken words presented on a television that allows a deaf or hard of hearing viewer to follow the dialogue and the action of a program simultaneously.

 

1)         It is not a violation of this subsection if the closed captioning feature is deactivated by a member of the facility's staff after the feature is enabled in a common area or in a resident's room unless the deactivation of the closed captioning feature is knowing or intentional.  It is not a violation of this subsection if the closed captioning feature is deactivated by a member of the general public, a resident, or a member of the facility's staff at the request of a resident of the facility.  Facilities shall ensure that staff are trained on the requirements of this subsection (n) and that staff, prior to deactivating a television's closed captioning feature, confirm with others within the television viewing area of the intention to deactivate the closed captioning feature.  If residents are not in agreement on deactivating the closed captioning feature, then the closed captioning feature shall not be deactivated.

 

2)         If a facility does not have a television in a common area that includes a closed captioning feature, then the facility shall ensure that all televisions subsequently obtained for common areas include a closed captioning feature.  This subsection does not affect any other provision of law relating to disability discrimination or providing reasonable accommodations or diminish the rights of a person with a disability under any other law.  Nothing in this subsection shall apply to televisions that are privately owned by a resident or third party and not owned by the facility.  (Section 3-801.2 of the Act)

 

3)         A facility shall post information regarding the availability of closed captioning on televisions in the facility and shall provide residents with information on how to activate the closed caption feature.

 

(Source:  Amended at 49 Ill. Reg. 760, effective December 31, 2024)

 

Section 300.2420  Equipment and Supplies

 

a)         Equipment

 

1)         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.

 

2)         If the facility has residents who need the services of a suction machine, a sufficient quantity of such machines shall be provided to meet the needs of all such residents.

 

b)         Privacy Screens and Curtains

 

1)         At least one privacy screen shall be available in the facility for emergency use when resident privacy is needed.

 

2)         Each multiple-bed resident room shall be designed or equipped to assure full visual privacy for each resident. Full visual privacy means that residents have a means of completely withdrawing from view while occupying their beds (e.g., curtains, movable screens).

 

c)         A sufficient supply of clean linen and bedding in good condition to provide proper care and comfort to the residents shall be maintained.

 

d)         A first-aid kit or emergency box shall be maintained in every facility.  The first aid kit or emergency box 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.

 

e)         Activity program supplies shall be provided to maintain an ongoing program to meet the varied interests and needs of the residents.  These supplies shall include, but are not limited to, games, craft supplies, current magazines, books, radio, television, and a device for playing music, which shall include but is not limited to a record player or CD player.

 

f)         Kitchen equipment shall be provided as set forth in Sections 300.2100 and 300.2110.

 

g)         Cleaning equipment and supplies shall be provided as set forth in Sections 300.2210 through 300.2220.

 

h)         Each resident shall have a satisfactory nurse call device.  (See Sections 300.2940(g) and 300.3140(e).)

 

i)          Special equipment, implements, or utensils shall be provided to residents as needed to assist them when eating.

 

j)          A sufficient quantity of resident care equipment of satisfactory design and in good condition to carry out established resident care procedures shall be provided.  Resident care equipment shall include at a minimum the following: wheelchairs with brakes, walkers, metal bedside rails, bedpans, urinals, emesis basins, wash basins, footstools, metal commodes, over-the-lap tables, foot cradles, footboards, under-the-mattress bed boards, trapeze frames, transfer boards, parallel bars, and reciprocal pulleys.

 

k)         The use of latex gloves by facility food service and direct care personnel is prohibited.  If a crisis exists that interrupts a facility's ability to reliably source nonlatex gloves, facility personnel may use latex gloves upon a resident.  However, during the crisis, facility personnel shall prioritize, to the extent possible, using nonlatex gloves for the preparation and handling of food or for treatment of any resident with a self-identified allergy to latex and, for direct care personnel, the treatment of any resident upon whom the latex gloves are to be used who is unconscious or otherwise physically unable to communicate, and whose medical history lacks sufficient information to indicate whether or not the resident has a latex allergy.  (Sections 10(a), 10(c), and 15 of the Latex Glove Ban Act)

 

(Source:  Amended at 49 Ill. Reg. 760, effective December 31, 2024)

 

Section 300.2430  Sterilization of Equipment and Supplies

 

a)         Every facility shall follow an acceptable plan to provide for sterile equipment and supplies, such as needles, syringes, catheters, and dressing.  There shall be an autoclave available for sterilizing this type of equipment and supplies.  The autoclave should be located in a central sterilization area, or clean utility area. It may be located at the nurses' station. An autoclave will not be required in a facility when other acceptable arrangements have been made, such as:  (A, B)

 

1)         Use of individually wrapped sterile dressings, disposable syringes, needles, catheters, and gloves which shall be disposed of after a single use.

 

2)         Formal plan with another facility for the autoclaving of equipment and supplies.

 

3)         Other alternative methods when approved on an individual basis in writing from the Department based on a written request from the facility giving in detail the method proposed to be used and which method meets equivalent criteria for proper sterilization for these items to be sterilized.

 

b)         Every facility shall sanitize bed pans, urinals, wash basins, emesis basins, enema equipment, and similar patient care utensils as follows:

 

1)         Individual bed pans, urinals, wash basins, and similar equipment shall be washed and rinsed after each use, and be sanitized at least weekly.  If individual equipment is not provided, the equipment shall be washed, rinsed, and sanitized after each use.  (B)

 

2)         Utensils shall be pre-flushed prior to washing.  Utensils shall be washed in a hot detergent solution that is maintained clean.  After washing, utensils shall be rinsed free of detergents with clean water.

 

3)         Utensils shall be sanitized, either mechanically or manually, through the use of steam, hot water, or chemicals approved by the U.S. Environmental Protection Agency and formulated for the sanitization of patient care utensils.  Chemical sanitizers shall be used in accordance with label instructions.

 

4)         Patient care utensils sanitization shall be completed in the soiled utility room.  (B)

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

SUBPART M: WATER SUPPLY AND SEWAGE DISPOSAL

 

Section 300.2610  Codes

 

Water supply, sewage disposal and plumbing systems shall comply with all applicable State and local codes and ordinances. (B)

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.2620  Water Supply

 

a)         Each facility shall be served by water from a municipal public water supply when available.  (B)

 

b)         When a municipal public 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. 4684, effective March 24, 1989)

 

Section 300.2630  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. 4684, effective March 24, 1989)

 

Section 300.2640  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. 4684, effective March 24, 1989)

SUBPART N: DESIGN AND CONSTRUCTION STANDARDS FOR NEW INTERMEDIATE CARE AND SKILLED NURSING FACILITIES

 

Section 300.2810  Applicability of this Subpart N

 

a)         Applicability of New Construction Requirements

 

This Subpart N shall apply to all new facilities and major alterations and additions to existing facilities.  (Major alterations are those that are not defined as minor alterations in subsection (h).) Facilities contemplating construction shall contact the Health Facilities and Services Review Board for information concerning the current requirements.

 

b)         Before commencing construction of a new facility or specified types of alteration or additions to an existing long term care facility involving major construction, as defined in subsection (h), architectural drawings and specifications for the facility shall comply with Section 300.2830 and shall be submitted to the Department for review and approval. The Department will not assess a plan review fee on projects with an estimated construction cost of $100,000 or less.  (Section 3-202.5(a) of the Act)

 

c)         The 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 shall be signed within one year after the date of final approval.

 

1)         The Department will inform an applicant in writing within 10 working days after receiving drawings and specifications and the required fee, if any, from the applicant whether the applicant's submission is complete or incomplete. Failure to provide the applicant with this notice within 10 working days will result in the submission being deemed complete for purposes of initiating the 60-day review period under the Act and this Part.

 

2)         If the submission is complete and the required fee, if any, has been paid, the Department will approve or disapprove drawings and specifications submitted to the Department no later than 60 days following receipt by the Department. (Section 3-202.5(b) of the Act) 

 

d)         The drawings and specifications shall be of sufficient detail, pursuant to Section 300.2830, to enable the Department to render a determination of compliance with design and construction standards under the Act and this Part.  If the Department finds that the drawings are not of sufficient detail to render a determination of compliance, the plans will be determined to be incomplete and will not be considered for purposes of initiating the 60-day review period.

 

1)         If a submission of drawings and specifications is incomplete, the applicant may submit additional information.  The 60-day review period will not commence until the Department determines that a submission of drawings and specifications is complete or the submission is deemed complete.

 

2)         If the Department has not approved or disapproved the drawings and specifications within 60 days, the construction, major alteration, or addition will be deemed approved.  If the drawings and specifications are disapproved, the Department will state in writing, with specificity, the reasons for the disapproval.

 

3)         The entity submitting the drawings and specifications may submit additional information in response to the written comments from the Department or request a reconsideration of the disapproval.  A final decision of approval or disapproval will be made within 45 days after the receipt of the additional information or reconsideration request.  If denied, the Department will state the specific reasons for the denial.  (Section 3-202.5(b) of the Act)

 

e)         Any contract modifications that affect or change the function, design, or purpose of a facility shall be submitted to the Department for approval prior to authorizing the modifications.  The approval will be based upon compliance with Section 300.2830.  Comments or approval will be provided within 30 days after receipt by the Department.

 

f)         The Department will conduct an on-site inspection of the completed project no later than 30 days after notification from the applicant that the project has been completed and all certifications required by the Department have been received and accepted by the Department, except that, during a statewide public health emergency, as defined in the Illinois Emergency Management Agency Act, the Department will conduct an on-site inspection of the completed project to the extent feasible.  The Department will provide written approval for occupancy to the applicant within 5 working days after the Department's final inspection, provided the applicant has demonstrated substantial compliance as defined in subsection (k).  (Section 3-202.5(g) of the Act)

 

g)         The Department will provide written approval for occupancy pursuant to the Act and this Section and will not issue a violation to a facility as a result of a licensure or complaint survey based upon the facility's physical structure if:

 

1)         The Department reviewed and approved or is deemed to have approved the drawings and specifications for compliance with design and construction standards;

 

2)         The construction, major alteration, or addition was built as submitted;

 

3)         The Act or this Part have not been amended since the original approval; and

 

4)         The conditions at the facility indicate that there is a reasonable degree of safety provided for the residents.  (Section 3-202.5(c) of the Act)

 

h)         Minor alterations or remodeling changes that do not affect the structural integrity of the building, that do not change functional operation, that do not affect fire or life safety, and that do not add beds or facilities over those for which the facility is licensed do not need to be submitted for drawing approval.  However, the Health Facilities and Services Review Board requirements shall be met for all alterations and remodeling projects.

 

i)          No system of water supply, plumbing, sewage, garbage or refuse disposal shall be installed, nor any existing system 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.  The approval will be based upon compliance with Section 300.2820.

 

j)          Nothing in this Section shall be construed to apply to maintenance, upkeep, or renovation that does not affect the structural integrity of the building, does not affect fire or life safety, or does not add beds or services over the number for which the long-term care facility is licensed, and provides a reasonable degree of safety for the residents.  (Section 3-202.5(j) of the Act)

 

k)         A facility shall be deemed in substantial compliance if all life and fire safety systems and features are installed and operating in accordance with manufacturer's recommendations and all referenced standards in subsections 300.340(a)(1)(F) and (G).  All areas shall be complete and ready for their intended use and shall not pose a fire or safety hazard for the intended occupants of the facility.

 

(Source:  Amended at 48 Ill. Reg. 3317, effective February 16, 2024)

 

Section 300.2820  Compliance with Local Codes and Standards

 

a)         In addition to compliance with the standards set forth in this Part, 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.

 

b)         If no local building code exists, the recommendations of the International Building Code shall apply.

 

c)         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 45 Ill. Reg. 11096, effective August 27, 2021)

 

Section 300.2830  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, and the outline specifications.

 

c)         The plans shall be drawn at a scale sufficiently large to clearly present the proposed design.

 

d)         The drawings 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 the outline specifications, working drawings and specifications shall be submitted.  All working drawings shall be well prepared and clean and distinct prints shall be 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 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 including 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)         Gas, oxygen 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)        Nurses' call systems with outlets for beds, duty stations, corridor signal lights, annunciators and wiring diagrams.

 

F)         Fire alarm system with stations, signal devices, control board and wiring diagrams.

 

G)        Emergency electrical system with outlets, transfer switch, source of supply, feeders, and circuits.

 

H)        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, depending upon the extent of the modification.

 

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. 4684, effective March 24, 1989)

 

Section 300.2840  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.  These additional requirements shall include, but are not limited to fences, stairs, and other types of barriers to prevent residents from injury.

 

c)         The facility shall be served by a potable water supply with water pressure and volume that is acceptable to the Department. (B)

 

d)         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)

 

e)         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)

 

f)         Plans showing the proposed building location must be submitted to the Illinois Department of Transportation, Division of Water Resources to determine compliance with the State Flood Plain Regulations and Executive Order IV, l979.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.2850  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 Illinois Plumbing Code for drinking fountains 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 (Director of Nursing, Food Service Supervisor, Activity Director, Social Service Director), and Professional Consultants (Medical Director, Pharmacist, Dietitian, 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. 4684, effective March 24, 1989)

 

Section 300.2860  Nursing Unit

 

a)         The number of resident beds in a nursing unit shall not exceed 75 beds.

 

1)         Not less than 60 percent of the resident beds shall be in one or two bed rooms.

 

2)         Not less than three percent of the total number of the beds in the facility shall be located in single bed rooms with a private bath, water closet and lavatory.

 

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 300.2940(a)2) and (e)(1).

 

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 four 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)         A nurses' call system shall be provided in accordance with Section 300.2940(g).  (B)

 

8)         Complete visual privacy shall be provided for each resident in multibed rooms.  Design for privacy shall not restrict resident access to the entry, lavatory, nor toilet.

 

9)         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 bedrooms 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 nursing unit.

 

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. (B)

 

3)         This room shall be located to allow direct visual supervision from the nurses' station.

 

4)         This room shall be included in the authorized maximum bed capacity for the facility.

 

5)         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  (B)

 

1)         The facility shall provide a minimum of one nursing station per unit with direct access to the corridor for each nursing unit.  The location of this station shall allow visual control without the use of mirrors of each resident sleeping corridor.  Separation shall be provided from the utility rooms.

 

2)         One or more nursing units may be combined at a central nursing station if sufficient space is provided for all nursing functions.

 

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.

 

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)         Wheelchair resident toilet rooms are not required when all resident toilet rooms can accommodate wheelchair residents.

 

4)         The facility shall provide one training toilet room on each nursing floor, which 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)         The facility shall 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, storage cabinets, and a clinical rim flush sink.  The room shall also contain a three compartment sink with integral drainboard if chemical sanitizing procedures are used, or a double compartment sink with integral drainboard if a utensil sanitizer is used (See Section 300.2430).

 

4)         The charging room for a linen chute shall be large enough to unload the collecting cart with the door closed.

 

h)         Medication Facilities

 

1)         A medication station shall be provided for convenient and prompt 24 hour distribution of medicine to residents.  The medicine preparation room 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 medication preparation room.

 

2)         If medicine dispensing carts are used, a specific storage space for the cart shall be provided, which may be located in the nurses' station or in an alcove or other space under the direct control of the nursing staff.  A sink for handwashing and preparation of medication shall be provided in the nurses' 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)         An equipment storage room 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. 1491, effective January 14, 1994)

 

Section 300.2870  Dining, Living, Activities Rooms

 

a)         The combined area of these rooms shall not be less than 25 square feet per resident bed.

 

b)         Provide a minimum of one dining room with at least ten square feet per resident bed.  Provide facilities to allow individual feeding of residents on their sleeping floor if they are not able to feed themselves.  Dining area provided for this function may be included in the required area.

 

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. 4684, effective March 24, 1989)

 

Section 300.2880  Therapy and Personal Care

 

a)         Physical and occupational therapy facilities shall be provided as may be required by Section 300.1420.

 

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. 4684, effective March 24, 1989)

 

Section 300.2890  Service Departments

 

a)         Dietary facilities shall comply with 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 require space 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)

 

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)         An office or desk space shall be provided for the dietitian or 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 of the 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' bedroom.

 

3)         Provide storage rooms for maintenance supplies, and yard equipment.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.2900  General Building Requirements

 

a)         Elevators

 

1)         Have a minimum of one elevator in all buildings of two or more stories in height.  The basement shall be considered as one story if it is used by residents. (B)

 

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 in accordance with Capital Development Board rules entitled "Illinois Accessibility Code" (77 Ill. Adm. Code 400).

 

7)         Elevator call buttons, controls, and door safety stops shall be of a type that will not be activated by heat or smoke.  (B)

 

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.  (B)

 

9)         Fireman's emergency operations shall be furnished in accordance with American National Standards Institute Standard A17.1 Elevator Safety Code.  (B)

 

10)         Inspections and tests shall be made and written certification be furnished that the installation meets the requirements set forth in this section and all applicable safety regulations and codes.  (B)

 

b)         Handrails and Grab Bars

 

1)         Handrails shall be provided on both sides of all corridors and ramps used by residents. (B)

 

2)         Handrails shall be provided on all sides of an elevator cab not provided with a door. (B)

 

3)         Handrails on stairs used by residents shall be provided on both sides of the stairs including the platforms and landings.  (B)

 

4)         Handrail dimensions and details shall conform to the Capital Development Board rules entitled "Illinois Accessibility Code" (71 Ill. Adm. Code 400).  It is recommended that handrails be installed at a height of 32 inches measured vertically from the floor surface. (B)

 

5)         Grab bars shall be provided for all resident use toilets, showers, and tubs.  (B)

 

6)         The ends of handrails and grab bars shall return to the wall.  (B)

 

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 no less than six feet eight inches above the floor.

 

4)         Boiler room shall have ceiling clearances not less than two feet six inches above the main boiler header and connecting piping.

 

d)         Doors and Windows

 

1)         Main entrance and all 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 keys are carried by the staff at all times.  (B)

 

4)         Resident toilet rooms shall open directly into a corridor or into a resident bedroom. (B)

 

5)         The doors for the toilet rooms used by residents shall have a minimum door width of three feet.  (B)

 

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 egress to the room.  (B)

 

7)         Doors and windows shall fit snugly and be weather tight, yet open and close easily.

 

8)         Outside doors, other than required exits, and operable windows shall be equipped with tight-fitting, 16 mesh screens. Screen doors shall be equipped with self-closing devices.

 

9)         All doors to resident's 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 will be activated only when its own detector annunciates a fire.  In addition, a centrally located monitor shall contain signals which identify the resident room in which the smoke detector has signaled the alarm. The system shall be wired into the fire alarm system.  (B)

 

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, kitchens, utility rooms.  (B)

 

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 nurses handwashing sink.

 

g)         Provide paper towel dispensers and waste receptacles or electric hand dryers 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 l0°F 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)          Hazardous Areas, Fire Extinguishers and Miscellaneous

 

1)         Interior finish flame spread ratings shall be in accordance with the National Fire Protection Association, Life Safety Code Standard 101, Standards for Flame Spread and Smoke Emission Ratings.  (B)

 

2)         There shall be at least one approved fire extinguisher in all basements, furnace rooms, and kitchens, laundry rooms and beauty shops.  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)

 

3)         Approved containers with proper covers shall be provided for daily storage of rubbish. (B)

 

4)         Housekeeping throughout the building, including basements, attics, and unoccupied rooms shall be adequately performed to minimize all fire hazards.  (B)

 

5)         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.  Additional fire protection measures shall include, but are not limited to the institution of a fire watch, installation of a sprinkler system, and installation of smoke detectors.  (B)

 

k)         Have no other business not related to health care conducted in the building that constitutes a hazard or annoyance to the residents.  In any case, the business shall be in a segregated portion of the building and shall have a separate entrance.  (A, B)

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.2910  Structural

 

a)         General Design 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.  (B)

 

2)         Special provision shall be made for loads which have a greater load than the specified minimum live load, including partitions which are subject to change of location.  (B)

 

b)         Construction shall be in accordance with the requirements of National Fire Protection Association Standard 101, Life Safety Code, and the minimum requirements contained herein.  (A, B)

 

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.  It is recommended that soil test borings 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 International Conference Building Officials Uniform Building Code.

 

3)         The fire resistance rating of the structural members shall be as established by National Fire Protection Association Standard 220 (Standard Types of Building Construction).

 

c)         Provisions for Natural Disasters  (B)

 

1)         Earthquakes:  In regions where local experience shows that earthquakes have caused loss of life or extensive property damage, buildings and structures shall be designed to withstand the force assumptions specified in the International Conference Building Officials Uniform Building Code. Seismic zones are identified on the attached map.  (B)

 

2)         Tornadoes and Floods:  Special provisions shall be made in the design of buildings, including structural design, in regions where local experience shows loss of life or damage to buildings resulting from hurricanes, tornadoes, or floods.  (B)

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.2920  Mechanical Systems

 

a)         General Requirements

 

1)         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.

 

2)         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.

 

3)         The owner shall be provided with instructions in the operational use of the systems and equipment.

 

b)         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 180 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, and 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, 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 300.670(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 300.670(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 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, 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)         The ventilation of the medical gas storage and manifold rooms shall comply with the requirements of NFPA 99, as applicable, including the gravity option system.  If a concentrator is used to simultaneously fill a portable container and as a patient breathing device, the standards in NFPA 99 governing the use of medical gases in resident rooms shall be observed.

 

9)         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. 

 

10)         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.

 

11)         Access for filter changing shall be provided within equipment rooms.

 

(Source:  Amended at 45 Ill. Reg. 11096, effective August 27, 2021)

 

Section 300.2930  Plumbing Systems

 

a)         General Requirements.  All plumbing systems shall be designed and installed in accordance with the requirements of the Illinois Plumbing Code (77 Ill. Adm. Code 890) except that the number of resident required water closets, lavatories, bathtubs, showers, and other fixtures shall be as required by this Part 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 14 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 degrees Fahrenheit water 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)         Nonflammable Gas Systems. Nonflammable medical gas systems if installed shall be in accordance with the requirements of National Fire Protection Association Standards 56A and 56F.  (B)

 

g)         Clinical Vacuum (Suction) Systems. Clinical vacuum systems if installed shall be in accordance with the requirements of the Compressed Gas Association Pamphlet P-2.l.  (B)

 

h)         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 101 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. 14950, effective October 1, 1990)

 

Section 300.2940  Electrical Systems

 

a)         General 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 standards.

 

3)         The installation shall meet all the requirements of NFPA 70, NFPA 99, and NFPA 110, as applicable.

 

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 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 duplex grounding type receptacles as follows:  One located on each side of the head of each bed; one for a television if used; and one on another wall.  Receptacles shall be located between 12 and 30 inches above the finished floor.

 

2)         Resident bathrooms shall have at least one duplex receptacle.

 

3)         Duplex receptacles shall be installed approximately 50 feet apart in all corridors and within 25 feet of 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 24-hour-a-day supervision of the door, a signal is not required.

 

g)         Nurses' Calling System

 

1)         Each resident room shall be served by at least one calling station and each bed shall be provided with a call station.  One call station may serve two adjacent beds.  A nurse call shall register at the nurses' station and shall activate a visible signal in the corridor at the resident's door, and in the nurse's station.  In multicorridor nursing units, additional visible signals shall be installed at corridor intersections.  In rooms containing two or more calling stations, identifying lights shall be provided at the nurses' station.

 

2)         A nurses' call station shall be provided for residents' use at each resident's toilet, bath, and shower location.  The cord shall extend to within six inches of the floor.

 

h)         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. 

 

i)          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 45 Ill. Reg. 11096, effective August 27, 2021)

SUBPART O: DESIGN AND CONSTRUCTION STANDARDS FOR EXISTING INTERMEDIATE CARE AND SKILLED NURSING FACILITIES

 

Section 300.3010  Applicability

 

a)         These standards shall apply to all existing Long-Term Care Facilities and all minor alterations or remodeling changes to existing facilities.  See Subpart N for New Construction and Major Additions and Alterations.

 

b)         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.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.3020  Compliance with Local Codes and Standards

 

a)         Each facility shall comply with the applicable provisions of the following codes and standards. Any incorporation by reference in this Section of federal regulations or of any standards of a nationally recognized organization or association refers to the regulations and standards on the date specified in Section 300.340 and does not include any editions or amendments subsequent to the date specified.

 

b)         NFPA 101, Chapter 19, for existing structures and all appropriate references under Chapter 2 apply to and is part of the Subpart. In addition to the publications referenced in Chapter 2, the following standards shall be applicable for all existing facilities:

 

1)         NFPA 20, Standard for the Installation of Stationary Pumps for Fire Protection;

 

2)         NFPA 22, Water Tanks for Private Fire Protection; and

 

3)         NFPA 101A, Guide on Alternative Approaches to Life Safety.

 

c)         Nothing in this Section shall relieve the facility from compliance with building codes, ordinances and regulations that are enforced by city, county or other local jurisdictions.

 

(Source:  Amended at 45 Ill. Reg. 11096, effective August 27, 2021)

 

Section 300.3030  Preparation of Drawings and Specifications

 

Drawings and specifications prepared for work which is required by these Standards shall be prepared in accordance with Section 300.2830 of the Construction Standards for New Facilities.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.3040  Site

 

a)         Each facility shall comply with all applicable zoning ordinances 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, 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.  (B)

 

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.  (B)

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.3050  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 and for discussion with relatives.

 

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. 4684, effective March 24, 1989)

 

Section 300.3060  Nursing Unit

 

a)         General Requirements for Bedrooms

 

1)         Resident bedrooms shall have an entrance directly off of 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 subsection (a)(1).  However, no additional such rooms will be permitted to be established after December 24, 1987.

 

2)         Resident bedrooms shall have adequate and satisfactory artificial light and be equipped in accordance with Section 300.3140(c).

 

3)         Resident toilet rooms shall open directly into a corridor or into a resident's bedroom.  (B)

 

4)         A closet or wardrobe at least four square feet shall be provided for each resident.

 

5)         No bedroom floor shall be 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.

 

7)         Nurses' call system shall be provided in accordance with Section 300.3140(e).  (B)

 

8)         Visual privacy shall be provided for each resident in multi-bedrooms.  Methods for privacy shall not restrict resident access to entry, lavatory, or toilet.

 

b)         Resident Bedroom.

 

1)         Single resident bedrooms shall contain at least 100 square feet of usable floor area. Multiple resident bedrooms 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 multi-bedrooms, continue to be subject to waiver procedures on an annual basis (See Section 300.320).

 

2)         Maximum room capacity shall be four residents.  Beds shall be at least three feet apart, and no more than three beds 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)         In Intermediate Care Facilities, provide a special care room for each 150 beds.  In Skilled Nursing Facilities, provide a special care room for each 50 beds or portion thereof.

 

2)         Provide this room with a water closet, 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)         This room shall be included in the authorized maximum bed capacity for the facility.

 

5)         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. (In skilled nursing facilities there shall be a station for each nursing unit.)  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 one nurses' station serving two floors housing residents is acceptable if there are less than 15 beds on an adjacent 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. (In skilled nursing facilities each nurses' station shall be so equipped.)

 

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 may not be 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)         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. (In Skilled Nursing Facilities there shall be one for each sex on each floor.)  Provide a lavatory usable by wheelchair residents in this room.

 

5)         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.

 

f)         Utility Rooms

 

1)         Every facility shall have clean and soiled utility functions in separate rooms.  There shall be at least one each of these rooms in the facility. (In Skilled Nursing Facilities there shall be at least one each of these rooms on each floor having resident bedrooms.)

 

2)         Clean Utility Room

 

A)        The clean utility room shall be large enough to contain:

 

i)          a work counter or table;

 

ii)         a sink with drainboard;

 

iii)        ample storage cabinets for clean and sterile supplies and equipment; and

 

iv)        an autoclave, if required, for sterilizing needles, syringes, catheters, dressings, and similar items.

 

B)        The autoclave may be located in the nurses' station area.  The autoclave may be waived in lieu of other methods of sterilization approved by the Department.

 

3)         Soiled Utility Room

 

A)        The soiled utility room shall be large enough to contain:

 

i)          a two compartment sink with drainboards;

 

ii)         ample storage cabinets;

 

iii)        a clinical rim flush sink for: rinsing bed pans, urinals, and linen soiled by solid materials, and similar type procedures; and

 

iv)        equipment and facilities for sanitizing bed pans, emesis basins, urine bottles, and other utensils, which meet accepted methods and procedures for such sanitation.

 

B)        Based upon approval of the program narrative, the Department will consider a waiver of this subsection for Intermediate Care Facilities.

 

(Source:  Amended at 16 Ill. Reg. 17089, effective November 3, 1992)

 

Section 300.3070  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 and if combined shall have an area of not less than 20 square feet per resident bed.

 

2)         The dining room shall be sufficient in area to allow 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.  Such a variance may be granted based upon the population and condition of the residents.

 

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. 4684, effective March 24, 1989)

 

Section 300.3080  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. 4684, effective March 24, 1989)

 

Section 300.3090  Service Departments

 

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 40 or more beds.  Any deviation from this requirement must receive approval from the Department.  Such approval will only be granted if it can be shown that sufficient space can be provided to meet the needs of the residents.  (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 the 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.  A commercial type dishwasher is recommended. (B)

 

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. 4684, effective March 24, 1989)

 

Section 300.3100  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, based on the number, population, and condition of the residents.  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" (77 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 have not be less than seven feet, eight inches ceiling height.

 

3)         Suspended tracks, rails and pipes 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 attendants at all times.  (B)

 

4)         Resident toilet rooms shall open directly into a corridor or into a resident's bedroom.  (B)

 

5)         The doors for the toilet rooms used by residents shall have a minimum door width of 30 inches.  (B)

 

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 egress from the room.  (B)

 

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, 16-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)         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 the 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 and 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. 17089, effective November 3, 1992)

 

Section 300.3110  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. 4684, effective March 24, 1989)

 

Section 300.3120  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 180 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 300.670(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 300.670(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. 3378, effective February 14, 2011)

 

Section 300.3130  Plumbing Systems

 

a)         General Plumbing Requirements

 

1)         All plumbing systems shall be designed and installed in accordance with the requirements of the Illinois Plumbing Code except that the number of water closets, lavatories, bath tubs, showers and other fixtures shall be as required by this Part and the facility program.

 

2)         New and replacement equipment, fixtures and fittings for mechanical, plumbing and electrical systems shall conform to and be installed in accordance with Subpart N of this Part.

 

b)         Plumbing Fixtures

 

1)         Plumbing fixtures shall be fabricated from non-absorptive and 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 are installed, 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)         Existing stop valves currently in place, serving the water service main, branch main, riser, and branch to a group of fixtures or to a group of fixtures shall be maintained in use.

 

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.

 

5)         Protective measures, including 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.

 

d)         Hot Water Heaters and Tanks.  Water storage tanks shall be fabricated from corrosion resistant metal or lined with noncorrosive 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.

 

f)         Fire Extinguishment Systems.  All fire extinguishment systems shall be designed and installed in accordance with NFPA 101 and NFPA 13.  All fire extinguishment systems shall be maintained in accordance with NFPA 25.

 

(Source:  Amended at 45 Ill. Reg. 11096, effective August 27, 2021)

 

Section 300.3140  Electrical Requirements

 

a)         The electrical installation for existing facilities shall continue to meet all the requirements of NFPA 70.

 

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 reading light shall be provided for each resident.

 

d)         Receptacles Convenience Outlets.  Each resident room shall have adequate duplex type receptacles.

 

e)         Nurses' Calling System.

 

1)         In resident areas, each room shall be served by at least one calling station and each bed shall be provided with a call station.  One call station may serve two adjacent beds. A nurse call shall register at a central station serving the floor.  In intermediate facilities only, an intercommunication system that provides only voice communication between a resident room and the nurses' station shall not be used unless approved by the Department.

 

2)         A nurses' call emergency station shall be provided for residents' use at each resident's toilet, bath, and shower location.  The cord shall extend to within six inches of the floor.  See Section 300.3140 (e)(1) for exception of intermediate facilities only.

 

f)         Door Alarm System.  See Section 300.3100(d)(2).

 

g)         Fire Alarm System

 

1)         A manually operated, electrically supervised fire alarm system shall be installed. Pre-signal systems are not permitted.

 

2)         A fire detection and alarm system, approved by the Department, shall be installed throughout the facility.

 

3)         The fire alarm signals shall automatically transmit the alarm to any available municipal fire department by direct private line or through a central station that complies with the applicable provisions of NFPA 72.

 

h)         Emergency Electrical Requirements

 

1)         To provide electricity during an interruption of the normal electric supply, an emergency source of electricity shall be provided and connected to the circuits pursuant to NFPA 70 and NFPA 99.

 

2)         The source of this emergency electrical service shall be one of the following:

 

A)        An emergency generating set when the normal service is supplied by only the utility company.

 

B)        Automatic battery operated system or equipment that will be effective four or more hours and 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.

 

(Source:  Amended at 45 Ill. Reg. 11096, effective August 27, 2021)

SUBPART P: RESIDENT'S RIGHTS

 

Section 300.3210  General

 

a)         No resident shall be deprived of any rights, benefits, or privileges guaranteed by State or federal law, the Constitution of the State of Illinois, or the Constitution of the United States solely on account of the resident's status as a resident of a facility.

 

1)         Residents shall have the right to be treated with courtesy and respect by employees or persons providing medical services or care and shall have their human and civil rights maintained in all aspects of medical care as defined in the State Operations Manual for Long-Term Care Facilities.

 

2)         Residents shall have their basic human needs, including but not limited to water, food, medication, toileting, and personal hygiene, accommodated in a timely manner, as defined by the person and agreed upon by the interdisciplinary team.

 

A)        A facility shall treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of the resident's quality of life, recognizing each resident's individuality.

 

B)        A facility shall protect and promote the rights of the resident.

 

C)        Residents have the right to reside in and receive services in the facility with reasonable accommodation of their needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

 

3)         Residents have the right to maintain their autonomy as much as possible.  (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 their 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 complaints.  (Section 2-103 of the Act)

 

h)         The facility 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 such 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.  Residents shall not perform labor or services for the facility unless consistent with the requirements in subsections (k)(1) through (k)(3).

 

1)         The activities must be included for therapeutic purposes and be appropriately goal related to the individual's care plan.  If a resident chooses to perform labor or services, the resident must be compensated at or above the prevailing wage rate.  (Section 2-113 of the Act)

 

2)         The resident has a right to choose or refuse to perform services for the facility and the facility shall not require a resident to perform services for the facility. 

 

3)         The resident may perform services for the facility if the resident chooses when:

 

A)        The facility has documented the resident's need or desire for work in the plan of care;

 

B)        The plan specifies the nature of the services performed and whether the services are voluntary or paid;

 

C)        Compensation for paid services is at or above prevailing rates; and

 

D)        The resident agrees to the work arrangement described it the plan of care.

 

l)          A resident shall be permitted the free exercise of religion.  Upon a resident's request, and if necessary at his or her 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 as it pertains to absentee voting for residents of licensed long-term care facilities.

 

n)         The facility shall immediately notify the resident's next of kin, 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 also 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)         An identification wristlet may be employed for any resident upon a physician's order, which shall document the need for the identification wristlet in the resident's clinical record.  Nothing in this Section prohibits a facility from allowing any resident who requests an identification wristlet from having one. A facility may provide an identification wristlet to any resident if requested by the resident. 

 

r)          A facility may require a resident residing in an Alzheimer's disease unit, as defined in Subpart U, with a history of wandering to wear an identification wristlet, unless the resident's guardian or power of attorney directs that the wristlet be removed. 

 

s)         All identification wristlets shall include, at a minimum, the resident's name and the name, telephone number, and address of the facility issuing the identification wristlet.  (Section 2-106a of the Act)

 

t)          The facility shall ensure that residents are not subjected to physical, verbal, sexual or psychological abuse, neglect, exploitation, or misappropriation of property.

 

u)         Cook County facilities with Colbert Class Members shall provide residents access to the supports and services they need in the most integrated settings appropriate to their needs, including community-based settings, to promote and maximize their independence, choice, and opportunities to develop and use independent living skills.  For the purposes of this subsection (u), "community-based setting" means the most integrated setting appropriate to promote the resident's independence in daily living and ability to interact with persons without disabilities to the fullest extent possible.

 

v)         All Cook County facilities with Colbert Class Members shall provide educational materials and information to all newly admitted Colbert Class Members within one to three days of admission, informing them of their rights and services under the Colbert Consent Decree, as prescribed by the Colbert Lead Defendant Agency. All Cook County facilities shall provide verification that the educational materials and information were given to the Colbert Class Members, as requested by a Colbert Defendant Agency. 

 

(Source:  Amended at 49 Ill. Reg. 760, effective December 31, 2024)

 

Section 300.3220  Medical Care

 

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.  (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)         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 committee appointed by the administrator of the facility where such research and treatment is conducted.  (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 charge nurse designee 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, and 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,  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 set forth in 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 set forth in 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 his or her permission to be present.  (Section 2-105 of the Act)

 

(Source:  Amended at 35 Ill. Reg. 3378, effective February 14, 2011)

 

Section 300.3230  Restraints (Repealed)

 

(Source:  Repealed at 22 Ill. Reg. 16609, effective September 18, 1998)

 

Section 300.3240  Abuse and Neglect

 

a)         An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident.  (Section 2-107 of the Act)

 

b)         A facility employee or agent who becomes aware of abuse or neglect of a resident 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 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)         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)

 

e)         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)

 

f)         A facility that becomes aware of photographing or recording of a resident, without the resident's consent or knowledge, or any other abuse, shall comply with subsections (a) through (e) of this Section.

 

g)         A facility shall comply with all requirements for reporting abuse and neglect pursuant to the Abused and Neglected Long Term Care Facility Residents Reporting Act.

 

(Source:  Amended at 45 Ill. Reg. 11096, effective August 27, 2021)

 

Section 300.3250  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 facility 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 facility 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 l0:00 A.M. and 8:00 P.M.  These visiting hours shall be posted in plain view of visitors.

 

e)         The facility 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) of this Section, 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.  (Section 2-110(b) of the Act)

 

k)         The facility shall provide each resident with the right to personal privacy.

 

(Source:  Amended at 45 Ill. Reg. 11096, effective August 27, 2021)

 

Section 300.3260  Resident's Funds

 

a)         A resident shall be permitted to manage his own financial affairs unless he or his guardian or if the resident is a minor, his parent, authorizes the administrator of the facility in writing to manage such resident's financial affairs under subsections (b) through (o) of this Section.  (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 residents 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 acknowledgement from each resident 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 2-101(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 Insurance 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 must be issued by a company licensed to do business in Illinois, the amount of bond must be equal to or greater than all resident funds managed by the facility, and the obligee named in the bond must be the Illinois Department of Public Health or its assignees.

 

2)         If an alternative to a surety bond is secured, the alternative must provide a protection equivalent to that afforded by a surety bond.  To be acceptable, the alternative must have a person(s) or entity(ies) designated who can collect in case of loss (e.g., residents, the Department).  The alternative must also provide a guarantee that lost funds will be repaid.  The guarantee may be made either by an independent entity (e.g., a bank) or the facility.  If the facility provides the guarantee, it must be backed by facility money at least equal to resident funds.  This money must 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 must 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.  Alternatives that meet the requirements of this Section and were in place prior to October 1, 1994, must be submitted to the Department for review and approval within 120 days after October 1, 1994.

 

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 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 2-2-1(9) of the Act)

 

l)          Unless otherwise provided by State law, the facility shall upon the death of a resident 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.  (Section 2-201(9)(b) of the Act) "Personal needs allowance," for the purposes of this subsection, refers to the monthly allowance allotted by the Illinois Department of Public Aid to public aid recipients.

 

(Source:  Amended at 18 Ill. Reg. 15868, effective October 15, 1994)

 

Section 300.3270  Residents' Advisory Council

 

Each resident shall have the right to participate in a residents' advisory council as indicated in Section 300.640.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.3280  Contract With Facility

 

Each resident shall have the right to contract with the facility as indicated in Section 300.630.

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.3290  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) of this Section.

 

b)         The owner and licensee of a facility 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 three times the actual damages, or $500, whichever is greater, 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 and this Part 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 subsection (b) through (i) of this Section, including minimum damages as provided by this Part, may be recovered in any action which a court may authorize to be brought as a class action pursuant to Part 8 of the Civil Practice law (Ill. Rev. Stat. 1987, ch. 110, par. 2-801 et seq.).  The remedies provided in subsections (b) through (i) of this Section 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) of this Section shall be exempt for purposes of determining initial or continuing eligibility for medical assistance under "The Illinois Public Aid Code," (Ill. Rev. Stat. 1987, ch. 23, par. 1-1 et seq.) as now or hereafter amended, 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 legal representative of the right to commence an action under subsections (b) through (i) of this Section, 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) of this Section 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 of resident abuse or neglect, brings or testifies in a private right of action, or files a complaint, because of the such action or testimony. (B)  (Section 3-608 of the Act)

 

(Source:  Amended at 13 Ill. Reg. 4684, effective March 24, 1989)

 

Section 300.3300  Transfer or Discharge

 

a)         A resident may be discharged from a facility after the resident gives the administrator, a physician, or a nurse of the facility written notice of their 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 their guardian or if the resident is a minor, their 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 (y) of this Section.

 

c)         Reasons for Transfer or Discharge

 

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

 

A)        for medical reasons;

 

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) of this Section, 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 (c) 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 the resident is a recipient of or an applicant for the Medical Assistance Program.  (Section 3-401.1(a) of the Act) For the purposes of Section 3-401.1 of the Act, 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) of this Section 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 (j) 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 ordered by the resident's attending physician because of the resident's health care needs. The State Long Term Care Ombudsman shall be notified at the time of the emergency transfer or discharge; (Section 3-402(a) of the Act)

 

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 and the State Long Term Care Ombudsman shall be notified prior to any such involuntary transfer or discharge.  The Department will immediately offer transfer, or discharge and relocation assistance to residents transferred or discharged under this subsection (d)(2), and the Department may place relocation teams as provided in Section 3-419 of the Act; or (Section 3-402(b) of the Act)

 

3)         When an identified offender is within the provisional admission period defined in Section 1-120.3 of the Act and Section 300.330 of this Part.  If the Identified Offender Report and Recommendation prepared under Section 2-201.6 of the Act shows that the identified offender poses a serious threat or danger to the physical safety of other residents, the facility staff, or facility visitors in the admitting facility, and the facility determines that it is unable to provide a safe environment for the other residents, the facility staff, or facility visitors, the facility shall transfer or discharge the identified offender within 3 days after its receipt of the Identified Offender Report and Recommendation.  (Section 3-402(c) of the Act)

 

e)         For transfer or discharge made under subsection (d), the notice of transfer or discharge shall be made as soon as practicable before the transfer or discharge. 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 or the State Long Term Care Ombudsman at the telephone numbers listed below."; (Section 3-403(c) of the Act)

 

4)         A hearing request form, together with a postage paid, preaddressed envelope to the Department; and (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. (Section 3-403(e) of the Act)

 

f)         A request for a hearing made under subsection (e) of this Section and Section 3-403 of the Act 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) of this Section develops in the interim.  (Section 3-404 of the Act)

 

g)         A copy of the notice required by subsection (d)(1) of this Section and Section 3-402 of the Act shall be placed in the resident's clinical record and a copy shall be transmitted to the Department, the State Long-Term Care Ombudsman, the resident, and the resident's representative.  (Section 3-405 of the Act)

 

h)         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 Title XIX 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)

 

i)          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)

 

j)          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)

 

k)         The facility shall offer the resident counseling services before the transfer or discharge of the resident.  (Section 3-409 of the Act)

 

l)          A resident subject to involuntary transfer or discharge from a facility, the resident's guardian or if the resident is a minor, the resident's, 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)

 

m)        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)

 

n)         The hearing before the Department provided under subsection (m) of this Section 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)

 

o)         If the Department determines that a transfer or discharge is authorized under subsection (c) of this Section, the resident shall not be required to leave the facility before the 34^th day following receipt of the notice required under subsection (d) of this Section, 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) of this Section develops in the interim.  (Section 3-413 of the Act)

 

p)         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 Title XIX recipients affected by subsection (c) of this Section.  (Section 3-414 of the Act)

 

q)         The Department will 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)         The 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.  (Section 3-415(e) of the Act)

 

r)          In deciding to transfer or discharge a resident from a facility under subsection (q) of this Section, the Department will consider the likelihood of serious harm which may result if the resident remains in the facility.  (Section 3-416 of the Act)

 

s)         The Department will offer transfer or discharge and relocation assistance to residents transferred or discharged under subsections (c) through (q) of this Section, 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 will 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 shall be forced to remain in a temporary or permanent placement.  When 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 3 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.  When the Department provides information on available alternative placements in community-based settings for individuals being discharged or transferred from facilities licensed under the Act, the information must include a comprehensive list of a range of appropriate, client-oriented services and the name of and contact information for the ADA coordinator in the relocation locale.  The comprehensive list must include the name and contact information for each agency or organization providing those services and a summary of the services provided by each agency or organization.  A hotline or similar crisis telephone number must also be provided to individuals relocating into the community.  (Section 3-417 of the Act)

 

t)          The Department will 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 will design and implement such plans in advance of transfer or discharge.  (Section 3-418 of the Act)

 

u)         The Department will 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)

 

v)         In any transfer or discharge conducted under subsections (q) through (t) of this Section the Department will:

 

1)         Provide written notice to the facility prior to the transfer or discharge.  The notice will state the basis for the order of transfer or discharge and will 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 (x) of this Section.  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 will, 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 will affirm, modify or overrule its previous decision. Except in an emergency, transfer or discharge shall 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 will state the reason for which transfer or discharge is ordered and will inform the resident of the resident's right to challenge the transfer or discharge under subsection (x) of this Section. The Department will 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)

 

w)        In any transfer or discharge conducted under subsection (q)(5) of this Section, the Department will notify the facility and any resident to be removed that an emergency has been found to exist and removal has been ordered, and will involve the residents in removal planning if possible.  With the consent of the resident or the resident's representative, the facility must inform the resident's designated care coordination unit, as defined in 89 Ill. Adm. Code 240.260, of the resident's pending discharge and must provide the resident or the resident's representative with the care coordination unit's telephone number and other contact information.  Following emergency removal, the Department will 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 (x) of this Section.  (Section 3-421 of the Act)

 

x)         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 will hold the hearing within 30 days after receipt of the request.  The hearing will 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 will assist the resident in returning to the facility if assistance is requested.  (Section 3-422 of the Act)

 

y)         The administrator of a facility licensed under the Act shall give 60 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 the Office of State Long Term Care Ombudsman, 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.  If the Department suspends, revokes, or denies renewal of the facility's license, then notice shall be given no later than the date specified by the Department.  Notice shall state the proposed date of closing and the reason for closing.  The facility shall submit a closure plan to the Department for approval which shall address the process for the safe and orderly transfer of residents.  The approved plan shall be included in the notice.  The facility shall offer to assist the resident in securing an alternative placement and shall advise the resident on available alternatives.  When 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.  A facility closing in its entirety shall not admit any new residents on or after the date written notice is submitted to the Department under the Act and this Part.  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 will place a relocation team in the facility as provided under subsection (u) of this Section.  (Section 3-423 of the Act)

 

(Source:  Amended at 48 Ill. Reg. 9947, effective June 21, 2024)

 

Section 300.3310  Complaint Procedures

 

a)         A resident shall be permitted to present grievances on behalf of himself or herself and others to the administrator, the Long-Term Care Facility Advisory Board, the residents' advisory council, State governmental agencies, or other persons of the resident's choice, free from restraint, interference, coercion, or discrimination and without threat of discharge or reprisal in any form or manner whatsoever.  Every facility licensed under the Act shall have a written internal grievance procedure that, at a minimum:

 

1)         sets forth the process to be followed;

 

2)         specifies time limits, including time limits for facility response;

 

3)         informs residents of their right to have the assistance of an advocate;

 

4)         provides for a timely response within 25 days by an impartial and nonaffiliated third party, including, but not limited to, the Long-Term Care Ombudsman, if the grievance is not otherwise resolved by the facility;

 

5)         requires the facility to follow applicable State and federal requirements for responding to and reporting any grievance alleging potential abuse, neglect, misappropriation of resident property, or exploitation; and

 

6)         requires the facility to keep a copy of all grievances, responses, and outcomes for 3 years and provide the information to the Department upon request.  (Section 2-112 of the Act)

 

b)         The administrator shall provide all residents or their representatives upon admission and at request with the name, address, and telephone number of the appropriate State governmental office where complaints may be lodged in language the resident can understand that must include notice of the grievance procedure of the facility or program and addresses and phone numbers for the Department's Office of Health Care Regulation and the Long-Term Care Ombudsman Program.  (Section 2-112 of the Act)  Facilities shall:

 

1)         Provide all residents with a list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups including, but not limited to the State Long-Term Care Ombudsman Program, the protection and advocacy agency, adult protective services where State law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community, and the Medicaid Fraud Control Unit; and

 

2)         Post a statement that the resident may file a complaint with the Department of Public Health concerning any suspected violation of State or federal nursing facility laws or regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.

 

3)         Information provided to residents shall be in a format and a language (including Braille) that is clear and understandable to the resident or the resident's representative.

 

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, by electronic means, 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 will be provided in writing to the licensee, owner or administrator no earlier than at the commencement of the on-site inspection of the facility that takes place pursuant to the complaint. (Section 3-702(b) of the Act)

 

e)         The Department will 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.  The complainant will be given the opportunity to withdraw the complaint before disclosure.  Upon the request of the complainant, the Department will 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 will determine whether the Act or this Part has been or is being violated.  The Department will 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 with 24 hours after receipt of the complaint. All other complaints shall be investigated within 30 days after the receipt of the complaint, except that, during a statewide public health emergency, as defined in the Illinois Emergency Management Agency Act, all other complaints will be investigated within appropriate time frames to the extent feasible.  (Section 3-702(d) of the Act)

 

g)         The Department employees investigating a complaint will conduct a brief, informal exit conference with the facility to alert its administration of any suspected serious deficiency that poses a direct threat to the health, safety, or welfare of a resident to enable an immediate correction for the alleviation or elimination of the threat. Information and findings discussed in the brief exit conference will become a part of the investigating record but will not in any way constitute an official or final notice of violation as provided under Section 3-301 of the Act and Section 300.276 of this Part.  All complaints will be classified as "an invalid report," "a valid report," or "an undetermined report."  For any complaint classified as "a valid report," the Department will determine within 30 working days after any Department employee enters a facility to begin an on-site inspection if this Part or provision of the Act has been or is being violated.  (Section 3-702(d) of the Act)

 

h)         In all cases, the Department will inform the complainant of its findings within ten days after its determination unless otherwise indicated by the complainant, and the complainant may direct the Department to send a copy of the 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 will also notify the facility of these findings within ten days after the determination, but the name of the complainant or residents will not be disclosed in this notice to the facility. The notice of findings will include a copy of the written determination; the correction order, if any; the warning notice, if any; the inspection report; or 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, together with the facility's response, will be available for public inspection, but the name of the complainant or resident will not be disclosed without their 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) of this Section.  The facility will be given notice of the hearing and may participate in the hearing as a party.  If a facility requests a hearing under subsection (k) of this Section that concerns a matter covered by a complaint, the complainant will 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) of this Section.  Upon receipt of the request the Department will conduct a hearing as provided under subsection (k) of this Section.  (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 in accordance with 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 will issue an order requiring the facility to reimburse the resident for injuries incurred, or $100, whichever is greater.

 

(Source:  Amended at 49 Ill. Reg. 760, effective December 31, 2024)

 

Section 300.3320  Confidentiality

 

a)         The Department, the facility and all other public or private agencies 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 facility shall ensure the rights of all residents to confidentiality of their personal and medical records.

 

(Source:  Amended at 45 Ill. Reg. 11096, effective August 27, 2021)

 

Section 300.3330  Facility Implementation

 

a)         The 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 the Act.  The policies 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, representative payees 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.  For residents of facilities participating in Title 18 or 19 of the Social Security Act, the explanation shall include an explanation of residents' rights enumerated in the 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.  At the time of implementation of the Act each resident shall be given a written summary of all the rights enumerated in Part I of Article II of the Act.  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 such rights.

 

e)         The facility shall ensure that its staff is familiar with and observes the rights and responsibilities enumerated in the Act and this Part.   (Section 2-212 of the Act) (B)

 

(Source:  Amended at 17 Ill. Reg. 19279, effective October 26, 1993)

 

Section 300.3340  Social Isolation

 

a)         For the purposes of this Section:

 

1)         "Assistive and supportive technology and devices" means computers, video conferencing equipment, distance-based communication technology, or other technological equipment, accessories, or electronic licenses as may be necessary to ensure that residents are able to engage in face-to-face, verbal-based, or auditory-based contact, communication, religious activity, or recreational activity with other facility residents and with family members, friends, loved ones, caregivers, and other external support systems, through electronic means, in accordance with the provisions of the Act and subsections (d)(2) and (3).

 

2)         "Religious and recreational activities" includes any religious, social, or recreational activity that is consistent with a resident's preferences and choosing, regardless of whether the activity is coordinated, offered, provided, or sponsored by facility staff or by an outside activities provider.

 

3)         "Resident's representative" has the same meaning as provided in Section 1-123 of the Act and Section 300.330. 

 

4)         "Social isolation" means a state of isolation wherein a resident of a long-term care facility is unable to engage in social interactions and religious and recreational activities with other facility residents or with family members, friends, loved ones, caregivers and external support systems.

 

5)         "Virtual visitation" means the use of face-to-face, verbal-based, or auditory-based contact through electronic means.  (Section 3-102.3(a) of the Act)

 

b)         Each facility shall adopt and implement written policies that provide for the availability of assistive and supportive technology and devices to facility residents.  Facilities shall ensure that appropriate staff are in place to help prevent the social isolation of facility residents.  (Section 3-102.3(b)(1) of the Act)

 

c)         The virtual visitation policies shall not be interpreted as a substitute for in-person visitation, but shall be wholly in addition to existing in-person visitation policies.  (Section 3-102.3(b)(2) of the Act)

 

d)         The social isolation prevention policies adopted by each long-term care facility pursuant to this Section shall be consistent with rights and privileges guaranteed to residents and constraints provided under Sections 2-108, 2-109, and 2-110 of the Act and this Subpart P, and shall include the following:

 

1)         Authorization and inclusion of specific protocols and procedures to encourage and enable residents of the facility to engage in in-person contact, communication, religious activity, and recreational activity with other facility residents and with family members, friends, loved ones, caregivers, and other external support systems, except when prohibited, restricted, or limited by federal or State statute, rule, regulation, executive order, or guidance;

 

2)         Authorization and inclusion of specific protocols and procedures to encourage and enable residents to engage in face-to-face, verbal-based, or auditory-based contact, communication, religious activity, and recreational activity with other facility residents and with family members, friends, loved ones, caregivers, and other external support systems through the use of electronic or virtual means and methods, including, but not limited to, computer technology, the Internet, social media, videoconferencing, videophone, and other innovative technological means or methods, whenever the resident is subject to restrictions that limit his or her ability to engage in in-person contact, communication, religious activity, or recreational activity as authorized by subsection (d)(1) and when the technology requested is not being used by other residents in the event of a limited number of items of technology in a facility;

 

3)         A mechanism for residents of the facility or the residents' representatives to request access to assistive and supportive technology and devices as may be necessary to facilitate the residents' engagement in face-to-face, verbal-based, or auditory-based contact, communication, religious activity, and recreational activity with other residents, family members, friends, and other external support systems, through electronic means, as provided by subsection (d)(2);

 

4)         Specific administrative policies, procedures, and protocols governing: 

 

A)        The acquisition, maintenance, and replacement of assistive and supportive technology and devices;

 

B)        The use of environmental barriers and other controls when the assistive and supportive technology and devices acquired pursuant to subsection (4)(A) are in use, especially in cases where the assistive and supportive technology and devices are likely to become contaminated with bodily substances, are touched frequently, or are difficult to clean; and

 

C)        The regular cleaning of the assistive and supportive technology and devices acquired pursuant to subsection (4)(A) and any environmental barriers or other physical controls used in association therewith; 

 

5)         A requirement that upon admission and at the request of a resident or the resident's representative, appropriate staff shall develop and update an individualized virtual visitation schedule while taking into account the individual's requests and preferences with respect to the residents' participation in social interactions and religious and recreational activities;

 

6)         A requirement that appropriate staff, upon the request of a resident or the resident's family members, guardian, or representative, shall develop an individualized virtual visitation schedule for the resident, which shall:

 

A)        Address the need for a virtual visitation schedule and establish a virtual visitation schedule if deemed to be appropriate;

 

B)        Identify the assessed needs and preferences of the resident and any preferences specified by the resident's representative, unless a preference specified by the resident conflicts with a preference specified by the resident's representative, in which case the resident's preference shall take priority;

 

C)        Document the facility's defined virtual hours of visitation and inform the resident and the resident's representative that virtual visitation pursuant to subsection (d)(2) will adhere to the defined visitation hours;

 

D)        Describe the location within the facility and assistive and supportive technology and devices to be used in virtual visitation; and

 

E)        Describe the respective responsibilities of staff, visitors, and the resident when engaging in virtual visitation pursuant to the individualized visitation plan;

 

7)         A requirement that, upon admission and at the request of the resident or the resident's representative, the facility provides notification to the resident and the resident's representative that they have the right to request of facility staff the creation and review of a resident's individualized virtual visitation schedule;

 

8)         A requirement that, upon admission and at the request of the resident or resident's representative, the facility provide, in writing to the resident or resident's representative, virtual visitation hours, how to schedule a virtual visitation, and how to request assistive and supportive technology and devices;

 

9)         Specific policies, protocols, and procedures governing a resident's requisition, use, and return of assistive and supportive technology and devices maintained pursuant to subsection (4)(A) and require appropriate staff to communicate those policies, protocols, and procedures to residents; and

 

10)        The designation of at least one member of the therapeutic recreation or activities department, or, if the facility does not have this department, the designation of at least one senior staff member, as determined by facility management, to train other appropriate facility employees, including, but not limited to, activities professionals and volunteers, social workers, occupational therapists, and therapy assistants, to provide direct assistance to residents upon request and on an as-needed basis, as necessary to ensure that each resident is able to successfully access and use, for the purposes specified in subsections (d)(2) and (3), the assistive and supportive technology and devices acquired pursuant to subsection (4)(A).  (Section 3-102.3(c) of the Act)

 

e)         A facility may apply to the Department for competitive civil monetary penalty fund grants for assistive and supportive technology and devices and may request other available federal and State funds.  (Section 3-102.3(d) of the Act)

 

f)         In addition to any other applicable penalties provided by law, a facility that fails to comply with the provisions of this Section or properly implement the written policies, protocols, and procedures adopted pursuant to subsection (b) shall be liable to pay an administrative penalty as a Type "C" violation, the amount of which shall be determined in accordance with subsections (f) and (g) of Section 300.282.  (Section 3-102.3(e) of the Act)

 

g)         Implementation of an administrative penalty as a Type "C" violation under this subsection will not be imposed prior to January 1, 2023.  (Section 3-102.3(e) of the Act)

 

h)         This Section does not impact, limit, or constrict a resident's right to or usage of his or her personal property or electronic monitoring under Section 2-115 of the Act.  (Section 3-102.3(g) of the Act)

 

i)          Specific protocols and procedures shall be developed to ensure that the quantity of assistive and supportive technology and devices maintained on-site at the facility remains sufficient, at all times, to meet the assessed social and activity needs and preferences of each facility resident. Residents' family members or caregivers shall be considered, as appropriate, in the assessment and reassessment.  (Section 3-102.3(h) of the Act)

 

j)          No administrative penalty shall be imposed against a facility for internet bandwidth limitations or internet access barriers beyond the control of the facility, such as a natural disaster.

 

k)         Nothing in this Section shall be interpreted to mean that addressing the issues of social isolation shall take precedence over providing for the health and safety of the residents.  (Section 3-102.3(k) of the Act)

 

(Source:  Added at 46 Ill. Reg. 14237, effective July 27, 2022)