Section 330.110 General
Requirements
a) This Part applies to the operator/licensee of facilities, or
distinct parts of facilities, that are licensed and classified to provide
sheltered care pursuant to the terms and conditions of the 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 shall 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
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. (Section 3-318(a)(6) of the Act)
2) Open or operate a facility without a license. (Section
3-318(a)(7) of the Act)
f) A violation of subsection (e) is a business offense,
punishable by a fine not to exceed $10,000, except as otherwise provided in
subsection (2) of Section 3-103 of the Act and subsection 330.120(d) as
to submission of false or misleading information in a license application.
(Section 3-318(b) of the Act)
g) A facility shall not use in its title or description
"Hospital", "Sanitarium", "Sanatorium",
"Rehabilitation Center", "Skilled Nursing Facility", "Assisted
Living or Shared Housing Establishment", 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.
h) Any person establishing, constructing, or modifying a
health care facility or portion thereof 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 closing any part of a facility, or prior to closing any part of a
facility if closing the part will require the transfer or discharge of
more than 10% of the residents. Notice shall be given to the Department, to
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. Where the resident is unable to choose an alternate placement
and is not under guardianship, the Department shall be notified of the need for
relocation assistance. A facility closing in its entirety shall not admit any
new residents on or after the date written notice is submitted to the
Department as specified 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 may place a relocation team in the facility as provided under Section
3-419 of the Act and Section 330.4300 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.
The licensee shall designate the level of care that will be provided in each bedroom.
Bedrooms of like licensed levels of care shall be contiguous to each other
within each "nursing unit" as defined in Section 330.330. Each
nursing unit may have up to two levels of care and shall 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 licensed beds
as either ID/DD or MC/DD licensed under the ID/DD Community Care Act or the
MC/DD Act, respectively, the beds shall be located in a distinct part (as
defined in Section 330.330) of the facility.
k) Each facility shall notify the Department electronically at DPH.StrikePlan@illinois.gov
within 24 hours after receiving a notice of impending strike of staff providing
direct care. The facility shall submit a strike contingency plan to the
Department no later than three calendar days prior to the impending strike.
l) Each facility shall have a facility-specific email address
and shall provide that email address to the Department. The facility shall not
change the email address without prior notice to the Department.
m) 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 48 Ill. Reg. 7397, effective May 3, 2024)
Section 330.120 Application
for License
a) Any person acting individually or jointly with other persons
who proposes to build, own, establish, or operate a sheltered care 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. The application form
and other required information shall be submitted and approved prior to surveys
of the physical plant or review of building plans and specifications.
b) Application for a license to establish or operate
a sheltered care 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)
c) 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)
d) 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)
e) 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.
f) 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)
g) 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. 11513, effective June 29, 2011)
Section 330.130 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. 6562, effective April 17, 1989)
Section 330.140 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
they find:
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) That the facility is under the supervision of an administrator
who is licensed, if required, under the Nursing Home Administrators Licensing
and Disciplinary Act, as now or hereafter amended; 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, 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 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 will 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 49 Ill. Reg. 802, effective December 31, 2024)
Section 330.150 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 they
find:
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) That the facility is under the supervision of an
administrator who is licensed, if required, under the Nursing Home
Administrators Licensing and Disciplinary Act, as now or hereafter amended; 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 new 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 will issue a conditional
license and plan of correction as provided in Section 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 will be valid
for 120 days unless sooner suspended or revoked under Section 3-119 of the
Act. (Section 3-116 of the Act).
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 will 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 49 Ill. Reg. 802, effective December 31, 2024)
Section 330.160 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
330.163 of this Part, if applicable. (Section 3-115 of the Act)
(Source: Amended at 24 Ill. Reg. 17304, effective November 1, 2000)
Section 330.163 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
treatmemt 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. 1085, effective January 15, 1999)
Section 330.165 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 be limited to, any of the following:
A) termination
of Medicare or Medicaid certification by the Centers for Medicare and Medicaid
Services; or
B) a failure by the facility to pay any fine assessed under the
Act after the Department has sent to the facility 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 330.910, 330.920, and 330.930, will be considered in making
this determination. (Section 3-119(a)(3) of the Act)
5) Financial or other resources are insufficient
financial or other resources 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 330.120(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 330.510. (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. 11513, effective June 29, 2011)
Section 330.170 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 330.165 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 330.165(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 these rules 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. 11513, effective June 29, 2011)
Section 330.175 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
330.165(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. 11513, effective June 29, 2011)
Section 330.180 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 330.165(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 330.282(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. 11513, effective June 29, 2011)
Section 330.190 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. (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 330.4510.
(Source: Amended at 13 Ill. Reg. 6562, effective April 17, 1989)
Section 330.200 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 such
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 this Act and the rules promulgated under the
Act. In addition, representatives of the Department shall have access to
and may reproduce or photocopy at the Department's 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 (Section 3-318(a)(2) of the Act);
2) Intentionally prevent or attempt to prevent any examination
of any relevant books or records pertinent to investigations and enforcement of
the Act or this Part (Section 3-318(a)(3) of the Act);
3) Intentionally prevent or interfere with the preservation of
evidence pertaining to any violation of the Act or this Part (Section
3-318(a)(4) of the Act);
4) Intentionally retaliate or discriminate against any
resident or employee for contacting or providing information to any state
official, or for initiating, participating in, or testifying in an action for
any remedy authorized under the Act or this Part. (Section 3-318(a)(5)
of the Act)
c) A violation of subsection (b) is a business offense,
punishable by a fine not to exceed $10,000, except as otherwise provided in
subsection (2) of Section 3-103 of the Act and subsection 330.120(d) 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 and correction of violations:
3) penalties or other enforcement actions;
4) the number and severity of complaints received about
the facility;
5) any allegations of resident abuse or neglect;
6) weather conditions
7) health emergencies; or
8) other reasonable belief that deficiencies exist.
(Section 3-212(b) of the Act)
e) Upon completion of each inspection, survey and evaluation,
the appropriate Department personnel who conducted the inspection, survey or
evaluation shall submit a physical or electronic copy of their report to the
licensee upon exiting the facility, and shall submit the actual report to the
appropriate regional office of the Department. 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)
f) Consultation consists of providing advice or suggestions to
the staff of a facility at their request relative to specific methods of the
scope of regulation, method of compliance with the Act or rules, or general
matters of resident care.
(Source: Amended at 48 Ill. Reg. 7397,
effective May 3, 2024)
Section 330.210 Filing an
Annual Attested Financial Statement
a) Filing Requirement
1) 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.
(Section 3-208 of the Act)
2) 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.
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) Additional Filing Requirements
1) 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.
2) 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) Filing Deadline and Completeness
1) The financial statement shall be filed with the Department
within 90 days following the end of the designated reporting period.
2) 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, but is not limited to, the following:
1) Facility information, including: facility name and address,
licensure information, type of ownership, licensed bed capacity, date and cost
of building construction and additions, date and cost of acquisition of
buildings, building sizes, equipment costs and dates of acquisition.
2) Resident information, including: number and level of care of
residents by source of payment, income from residents by level of care.
3) Cost information by level of care, including:
A) General service costs; such as dietary, food, housekeeping,
laundry, utilities, and plant operation and maintenance.
B) Health care costs; such as medical director, nursing,
medications, oxygen, activities, medical records, other medical services,
social services, and utilization reviews.
C) General Administration; such as administrative salaries,
professional services, fees, subscriptions, promotional, 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. 6562, effective April 17, 1989)
Section 330.220 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 (42 USCA 301
et seq.);
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) of this Section 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. 11513, effective June 29, 2011)
Section 330.230 Information
to be Made Available to the Public by the Licensee
a) Every facility shall conspicuously post or display in an
area of it 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 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)
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 5 years;
2) A copy of every order pertaining to the facility issued by
the Department or a court during the past 5 years;
3) A description of the services provided by the facility and
the rates charged for those services and items for which a resident may be
separately charged;
4) A copy of the Statement of Ownership required by Section
3-207 of the Act;
5) A record of personnel employed or retained by the facility
who are licensed, certified or registered by the Department of Professional
Regulation.
6) a complete copy of the most recent inspection report of the
facility received from the Department; and
7) a copy of the current Consumer Choice Information Report
required by Section 2-214 of the Act. (Section 3-210 of the Act)
(Source: Amended at 48 Ill. Reg. 7397,
effective May 3, 2024)
Section 330.240 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 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. 6562, effective April 17, 1989)
Section 330.250 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 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. 14826, effective November 15, 2017)
Section 330.260 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. 15089, effective September 3, 1993)
Section 330.270 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; or
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. (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 monitor's 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 and mental 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 by 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 cost 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. 11567, effective July 29, 1995)
Section 330.271 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.
Video-taped recordings shall not be allowed.
i) Surveyors shall not conduct an exit conference for the
following reasons:
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. 15089, effective September 3, 1993)
Section 330.272
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 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 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 330.200(e). (Section 3-212(c)
of the Act)
c) In determining whether the findings warrant the issuance of a
notice of violation, the Director will consider the following factors:
1) The severity of the finding. The Director 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 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
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 will
consider whether the same finding or a similar finding relating to the same
condition or occurrence has been included in previous reports and whether the
facility has allowed the condition or occurrence to continue or to recur.
(Section 3-212(c) of the Act)
d) If the Department finds a situation, condition or practice that
violates the Act or this Part, that does not constitute a type "AA",
Type "A", Type "B", or Type "C" violation, the
Department will issue an administrative warning. Any administrative
warning shall be served upon the facility in the same manner as the notice of
violation under Section 3-301 of the Act. A written plan of correction
is required to be filed for an administrative warning issued for violations of
Sections 3-401 through 3-413 of the Act or Section 330.4300. (Section
3-303.2(a) of the Act)
e) If, however, the situation, condition or practice that resulted
in the issuance of an administrative warning, with the exception of
administrative warnings issued pursuant to Sections 3-401 through 3-413 of
the Act and Section 330.4300, is not corrected by the next on-site
inspection by the Department that occurs no earlier than 90 days from
the issuance of the administrative warning, a written plan of correction must
be submitted in the same manner as provided in subsection (b) of Section 3-303 of
the Act and Section 330.278(b). (Section 3-303.2(b) of the Act)
f) 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 48 Ill. Reg. 7397,
effective May 3, 2024)
Section 330.274
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 will review the
findings that are the basis of the violation, and any comments and
documentation provided by the facility, to determine the type of the
violation. Each violation shall be determined to be either a Type "AA",
Type "A", Type "B", or Type "C" violation based
on the criteria in this Section.
b) The following definitions of types of violations shall be used
in determining the type of each violation:
1) A Type
"AA" violation is a violation of the Act or this Part
that creates a condition or occurrence relating to the operation and
maintenance of a facility that proximately caused a resident's death. (Section
1-128.5 of the Act)
2) A Type "A" violation is a violation of the Act
or this Part that creates a condition or occurrence relating to
the operation and maintenance of a facility that creates a substantial
probability that the risk of death or serious mental or physical harm will
result therefrom or has resulted in actual physical or mental harm to a
resident. (Section 1-129 of the Act)
3) A Type "B" violation is a violation of the Act
or this Part that creates a condition or occurrence relating to
the operation and maintenance of a facility that is more likely than not to
cause more than minimal physical or mental harm to a resident. (Section
1-130 of the Act)
4) A Type
"C" violation is a violation of the Act or this Part
that creates a condition or occurrence relating to the operation and
maintenance of a facility that creates a substantial probability that less than
minimal physical or mental harm to a resident will result therefrom. (Section
1-132 of the Act)
c) In determining the type of a violation, the Director will
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 48 Ill. Reg. 7397,
effective May 3, 2024)
Section 330.276 Notice of
Violation
a) Each notice of violation shall be prepared 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 alleged
by the Department to have been violated. (Section 3-301 of the Act)
3) A statement of the type of violation as determined pursuant to
Section 330.274.
4) Information regarding any action the Department may take
under the Act, including the requirement of a facility plan of correction under
Section 3-303 of the Act; placement of a facility on a list prepared
under Section 3-304 of the Act; assessment of a penalty under Section
3-305 of the Act; issuance of a conditional license under Sections 3-311
through 3-317 of the Act; or license suspension or revocation under
Section 3-119 of the Act.
5) Information regarding the rights to a hearing under Section
3-703 of the Act. (Section 3-301(a) of the Act)
6) One of the following requirements for corrective action:
A) For Type "AA" violations and Type "A violations,
a statement that necessary corrective action to abate or eliminate the
situation, condition or practice constituting a Type "AA" violation
or a Type "A" violation shall be taken 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) In setting this period, the Department will consider
whether harm to residents of the facility is imminent, whether necessary
precautions can be taken to project residents before the corrective action is
completed, and whether delay would pose additional risks to the residents.
B) For Type "B" violations, a request that the
facility submit a plan of correction within ten days after receipt of the
notice of violation pursuant to Section 3-303(b) of the Act and Section
330.278. (Section 3-303(b) of the Act)
b) Each notice of violation shall be sent to the facility and the
licensee or served personally at the facility within ten days after the
Director determines that issuance of a notice of violation is warranted under
Section 300.272. (Section 3-301(a) of the Act).
(Source: Amended at 48 Ill. Reg. 7397,
effective May 3, 2024)
Section 330.277
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 330.272.
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
330.278. The Department will consider the plan of correction and take any
necessary action in accordance with Section 330.278. (Section 3-303.2(b) of
the Act)
(Source: Amended at 35 Ill.
Reg. 11513, effective June 29, 2011)
Section 330.278 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 330.277(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 330.120(d) 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 or
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 48 Ill. Reg. 7397,
effective May 3, 2024)
Section 330.280 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 shall be submitted within the time periods required in
Section 330.278 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 that
have caused or contributed to the conditions or occurrences. Evidence of the
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 the facility has taken to avoid
future occurrences of the same and similar violations;
3) The specific date on which the corrective action was completed;
and
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 will not be considered an
admission by the facility that the violation has occurred.
d) The Department will review and approve or disapprove the
report of correction based on the criteria outlined in Section 330.278(e) 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 330.278.
e) The Department will 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 48 Ill. Reg. 7397,
effective May 3, 2024)
Section 330.282 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). (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) 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 Department will assess only
one fine, which shall not exceed 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 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
330.715(a)
2) Section
330.715(b)
3) Section
330.715(c)
4) Section
330.725(a)
5) Section
330.725(b)
6) Section
330.725(c)
7) Section
330.725(f)
8) Section
330.725(j)
9) Section
330.725(k)
10) Section
330.725(l)
11) Section
330.725(n)
12) Section
330.725(o)
13) Section
330.727(c)
14) Section
330.727(d)
15) Section
330.727(e)
16) Section
330.780
17) Section
330.785(b)
18) Section
330.790
19) Section
330.911
20) Section
330.4240(a)
21) Section
330.4240(d)
22) Section
330.4240(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 330.282, 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 rights 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, which 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)
m) For
the purpose of computing a penalty under subsections (c) through (f),
the number of residents per day shall be based on the average number of
residents in the facility during the 30 days preceding the discovery of the
violation. (Section 3-305(5) of the Act)
n) For
purposes of assessing fines under this Section, a repeat violation shall
be a violation which has been cited during one inspection of the facility for
which an accepted plan of correction was not complied with or a new citation of
the same rule if the licensee is not substantially addressing the issue
routinely throughout the facility. (Section 3-305(7) of the Act)
(Source: Amended at 48 Ill. Reg. 7397,
effective May 3, 2024)
Section 330.284 Calculation
of Penalties (Repealed)
(Source: Repealed at 35 Ill.
Reg. 11513, effective June 29, 2011)
Section 330.286 Notice of Penalty Assessment; Response by Facility
a) If the Director determines that a penalty is to be assessed, a
written notice of penalty assessment shall be sent to the facility. Each
notice of penalty assessment shall include:
1) The amount of the penalty assessed as provided in
Section 330.282.
2) The amount of any reduction or whether the penalty has been
waived pursuant to Section 330.288.
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 48 Ill. Reg. 7397,
effective May 3, 2024)
Section 330.287 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. Then 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.
Those 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. 11513, effective June 29, 2011)
Section 330.288 Reduction or
Waiver of Penalties
a) Reductions for all types of violations subject to penalties.
1) The Director consider the factors contained in Section 330.287
in determining whether to reduce the amount of the penalty to be assessed from
the amount calculated pursuant to Section 330.282 and in determining the amount
of such reduction.
2) When the Director finds that correction of a violation
required capital improvements or repairs in the physical plant of the facility
and the facility has a history of compliance with physical plant requirements,
the penalty will be reduced by the amount of the cost of the improvements or
repairs. This reduction, however, shall not reduce the penalty for a Type "AA"
or Type "A" violation to an amount less than $1000.
b) Reductions and waivers for Type "B" violations.
1) Penalties resulting from Type "B" violations may be
reduced or waived only under one of the following conditions:
A) The facility submits a true report of correction within 10
days after the notice of violation is received, and the report is
subsequently verified by the Department.
B) The facility submits a plan of correction within ten days
after the notice of violation is received, and once the plan is approved by the
Department, the facility submits a true report of correction within 15 days
after submission of the plan of correction, and the report is subsequently
verified by the Department.
C) The facility submits a plan of correction within ten days
after the notice of violation is received, which provides for a correction
time that is less than or equal to 30 days and the Department approves the
plan.
D) Correction of the violation requires substantial capital
improvements or repairs in the physical plan of the facility, the facility
submits a plan of correction for violations involving substantial capital improvements,
which provides for correction within the initial 90-day limit provided under Section
3-303 of the Act, and the plan is approved by the Department. (Section
3-308 of the Act)
2) Under these conditions, the Director will consider the factors
outlined in Section 330.287 in determining whether to reduce or waive the
penalty and in setting the amount of any reduction.
(Source: Amended at 48 Ill. Reg. 7397,
effective May 3, 2024)
Section 330.290 Quarterly
List of Violators (Repealed)
(Source: Repealed at 24 Ill. Reg. 17304, effective November 1, 2000)
Section 330.300 Alcoholism
Treatment Programs in Long-Term Care Facilities
a) A facility that desires to provide an alcoholism treatment
program shall first receive written approval from the Department. Approval
will be granted only if the facility can demonstrate the program will not
interfere in any way with the residents in the other parts of the facility.
b) Any alcoholism treatment program in a facility shall meet the requirements
of the Alcoholism and Substance Abuse Treatment and Intervention Licenses and
the Substance Use Disorder Act.
c) The alcoholism treatment program shall be in a separate
distinct part of the facility, and shall include all beds in that distinct
part. It shall be separated from the rest of the facility, and have separate
entrances.
d) Beds designated for alcoholism treatment 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 shall not be utilized
in performing services in the long-term care distinct part of the facility, nor
shall long-term care program staff provide any services in the alcoholism
treatment designated area.
f) Joint use of laundry, food service, housekeeping and
administrative services is permitted, provided written approval is obtained
from the Department. Approval will be granted only if the facility can
demonstrate that joint usage will not interfere in any way with the residents
in other distinct parts of the facility.
(Source: Amended at 48 Ill. Reg. 7397,
effective May 3, 2024)
Section 330.310 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
again operating without a license. (Section 3-107 of the Act)
(Source: Amended at 13 Ill. Reg. 6562, effective April 17, 1989)
Section 330.315 Supported
Congregate Living Arrangement Demonstration (Repealed)
(Source: Repealed at 49 Ill. Reg. 802, effective December 31, 2024)
Section 330.320 Waivers
a) Upon application by a facility, the Director may grant or
renew the waiver of the facility's compliance with the Act or this Part
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(a) 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(a) 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 this Part;
2) the validity and effect upon patient health and safety 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 this Part.
(Section 3-303.1(a) of the Act)
d) The Department will renew waivers relating to
physical plant standards issued pursuant to the Act at the time of the
indicated reviews, unless it can show why these 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 this Part without substantial
increase in cost. (Section 3-303.1(b) of the Act)
(Source: Amended at 48 Ill. Reg. 7397,
effective May 3, 2024)
Section 330.330 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 330.1145 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
330.277 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.
Approved – acceptable to the authority having jurisdiction.
Assessment −
the use of an objective system with which to evaluate the physical, social,
developmental, behavioral, and psychosocial aspects of an individual.
Autism or
autism spectrum disorder − a disorder that is characterized by persistent
deficits in social communication and social interaction across multiple
contexts, including deficits in social reciprocity, nonverbal communicative
behaviors used for social interaction, and skills in developing maintaining,
and understanding relationships. In addition to the social communication
deficits, the diagnosis of autism spectrum disorder requires the presence of
restricted, repetitive patterns of behavior, interests, or activities.
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. When due to grade difference, two levels each 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, mental retardation, 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. Nursing assistants shall function under the supervision of a licensed
nurse.
Charge Nurse −
a registered professional nurse or a licensed practical nurse in charge of the
nursing activities for a specific unit or floor during a shift.
Chemical
Restraint − any drug that is used for discipline or convenience
and is not required to treat medical symptoms or behavior
manifestations of mental illness. (Section 2-106(a) of the Act) For the
purposes of this term and its use in Section 330.1145, "convenience"
means the use of any restraint by the facility to control resident behavior or
maintain a resident that is not in the resident's best interest, and with less
use of the facility's effort and resources than would otherwise be required by
the facility.
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.
Convenience −
the use of any restraint by the facility to control resident behavior or
maintain a resident, which is not in the resident's best interest, and with
less use of the facility's effort and resources than would otherwise be
required by the facility. This definition is limited to the definition of
chemical restraint and Section 330.1145 of this Part.
Cruelty and
Indifference to Welfare of the Resident − failure to provide a resident
with the care and supervision he or she requires, or the infliction of mental
or physical abuse.
Dentist −
any person licensed by the State of Illinois to practice dentistry, includes
persons holding a Temporary Certificate of Registration, as provided in the
Illinois Dental Practice Act [225 ILCS 25].
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; or
is a graduate
of a dietetic and nutrition school or program authorized by the Accreditation
Council for Education in Nutrition and Dietetics, the Academy of Nutrition and
Dietetics, or the American Clinical Board of Nutrition; or
is a graduate,
prior to July 1, 1990, of a Department-approved course that provided 90 or more
hours of classroom instruction in food service supervision and has had
experience as a supervisor in a health care institution, which included
consultation from a dietitian; or
has successfully
completed an Association of Nutrition & Foodservice Professionals approved Certified
Dietary Manager or Certified Food Protection Professional course; or
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 licensed as a dietitian or a licensed dietitian nutritionist
under 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 designee. (Section 1-110 of the
Act)
Director of
Nursing Service − the full-time Professional Registered 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
that present imminent danger of death or serious physical or mental harm
to residents of a facility and are clinically documented in the resident's
medical record. (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.
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 1396 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 United States Department of
Veterans Affairs. (Section 1-113 of the Act)
Facility,
Sheltered Care − when used in this Part is synonymous with a sheltered
care facility, which facility provides maintenance and personal care.
Financial
Responsibility − having sufficient assets to provide adequate services
such as: staff, heat, laundry, foods, supplies, and utilities for at least a
two-month period of time.
Full-time −
on duty a minimum of 36 hours, four days per week.
Goal −
an expected result or 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.
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.
"High
Risk Designation – a violation, as described in Section 330.282(i),
of a provision that has been identified by the Department in Section
330.282(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, 405.1, 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 I of
Section 10 of the Sex Offender Management Board Act; or
Is any other resident as
determined by the Department of State Police. (Section 1-114.01 of the Act)
Immediate
family – the spouse, an adult child, a parent, an adult brother or sister, or
an adult grandchild of a person. (Section 1-114.1 of the Act)
Intellectual
Disability or Intellectually Disabled – a disorder with onset during the
developmental period that includes both intellectual and adaptive functioning
deficits in conceptual, social, and practical domains. The essential features
of intellectual disability are deficits in general intellectual abilities and
impairment in everyday adaptive functioning.
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 nurse with responsibility for the resident, 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 their
guardian may also invite other individuals to meet with the Interdisciplinary
Team and participate in the process of identifying the resident's strengths and
needs.
Licensed
Practical Nurse − a person with a valid Illinois license 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 or the consent of a resident's guardian or
representative. 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. (Section 1-116.5 of the Act)
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 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 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 and this Part.
(Section 1-119 of the Act)
Person −
with regard to the term "owner" above, "person" means any
individual, partnership, corporation, association, municipality, political subdivision,
trust, estate or other legal entity.
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 their person, whether or not a guardian
has been appointed for that 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 that restricts freedom of movement or normal access to
one's body. (Section 2-106(a) of the Act)
Physical
Therapist – a person who is licensed as a physical therapist under the Illinois
Physical Therapy Act.
Physical
Therapist Assistant − a person who has graduated from a two-year college
level program approved by the American Physical Therapy Association.
Physician −
any person licensed by the State of Illinois 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 successfully completed a residency program in psychiatry
accredited by either the Accreditation Council for Graduate Medical Education
or the American Osteopathic Association.
Psychologist −
a person who is licensed to practice clinical psychology under the Clinical
Psychologist Licensing Act.
Reasonable Visiting
Hour − any time between the hours of 10 a.m. and 8 p.m. daily.
(Section 1-121 of the Act)
Registered
Nurse − a person with a valid Illinois 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 and this Part, a violation that has been cited during one
inspection of the facility for which a subsequent inspection indicates that
an accepted plan of correction was not complied with, within a period of
not more than 12 months from the issuance of the initial violation, or a new
citation of the same rule if the licensee is not substantially addressing the
issue routinely throughout the facility. (Section 3-305(7) of the Act)
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
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
no other
satisfactory evidence indicates that the moral character of the applicant, or
manager, or supervisor of the facility is not reputable.
Resident −
a 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's
Representative − a person other than the owner not related to the
resident, or an agent or employee of a facility not related to the resident,
designated in writing by a resident to be their representative, or the
resident's guardian. (Section 1-123 of the Act)
Restorative −
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 or
confinement − 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.
Sheltered
Care − maintenance and personal care. (Section 1-124 of the Act)
Social Worker −
a person who is a licensed social worker or a licensed clinical social worker
under the Clinical Social Work and Social Work Practice Act.
State Fire
Marshal − the Illinois State Fire Marshal, who serves as the executive
director of the Office of the State Fire Marshal. (Section 1 of the State
Fire Marshal Act)
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.
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 330.140(a)(3) and 330.150(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 330.165(b)(1).
Supervision −
authoritative guidance by a qualified person for the accomplishment of a
function or activity within their 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.
Title XVIII
− Title XVIII of the Federal Social Security Act. (Section 1-126 of
the Act)
Title XIX −
Title XIX of the Federal Social Security Act. (Section 1-127 of the Act)
Transfer −
a change in status of a resident's living arrangements from one facility to
another facility. (Section 1-128 of the Act)
Type "AA" violation –
a violation of the Act or this Part 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 48 Ill. Reg. 7397,
effective May 3, 2024)
Section 330.340 Incorporated
and Referenced Materials
a) The following standards and guidelines are incorporated in
this Part:
1) For existing facilities (see Subpart O), National Fire
Protection Association (NFPA) 101 (2012): Life Safety Code Chapter 19, applies
to and is part of this Part, which may be obtained from the National Fire
Protection Association, 1 Batterymarch Park, Quincy, MA 01269.
A) All appropriate references under NFPA 101 (2012), Chapter 2,
Referenced Publications; and
B) NFPA 101 A (2013), Guide on Alternative Approaches to Life
Safety
2) For
new facilities (see Subpart M), NFPA 101 (2012): Life Safety Code, Chapter 18
and all appropriate references under Chapter 2, Referenced Publications,
applies to and is part of this Part, which may be obtained from the National
Fire Protection Association, 1 Batterymarch Park, Quincy, MA 01269:
A) NFPA
20 (2010), Standard for the Installation of Stationary Pumps for Fire
Protection
B) NFPA
22 (2008), Standard for Water Tanks for Private Fire Protection
3) The
following guidelines and toolkits of the Center for Infectious Diseases,
Centers for Disease Control and Prevention, United States Public Health
Service, Department of Health and Human Services may be obtained from the National
Technical Information Services (NTIS), 5301 Shawnee Road, Alexandria, VA 22312,
info@ntis.gov, or the following Internet addresses:
A) Guideline
for Hand Hygiene in Health-Care Settings (October 25, 2002), available at: https://www.cdc.gov/infection-control/media/pdfs/Guideline-Hand-Hygiene-P.pdf
B) Guidelines
for Preventing Healthcare-Associated Pneumonia, 2003 (March 26, 2004),
available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm
C) 2007 Guideline
for Isolation Precautions: Preventing Transmission of Infectious Agents in
Healthcare Settings (September 20, 2024), available at: https://www.cdc.gov/infection-control/media/pdfs/guideline-isolation-h.pdf?CDC_AAref_Val=https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf
D) 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)
E) The
Core Elements of Antibiotic Stewardship for Nursing Homes (March 18, 2024), available
at: https://www.cdc.gov/antibiotic-use/media/pdfs/core-elements-antibiotic-stewardship-508.pdf?CDC_AAref_Val=https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-H.pdf
F) The
Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A: Policy
and Practice Actions to Improve Antibiotic Use (March 18, 2024), available at: https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdf
G) Nursing
Home Antimicrobial Stewardship Guide, available at: https://www.ahrq.gov/nhguide/index.html
(March 2023)
H) 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)
I) Toolkit
for Controlling Legionella in Common Sources of Exposure (January 13, 2021),
available at: https://www.cdc.gov/control-legionella/media/pdfs/Control-Toolkit-All-Modules.pdf
4) 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 330.4220.)
5) American
Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE):
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.
b) All incorporations by reference of federal guidelines and the
standards of nationally recognized organizations refer to the standards on the
date specified and do not include any amendments or editions subsequent to the
date specified.
c) The following statutes, federal regulation, 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) Federal regulation: 38 CFR 17.73, Medical Foster Homes –
General (July 1, 2023)
3) 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 Health Facilities Planning Act [20 ILCS 3960]
J) Illinois Municipal Code [65 ILCS 5]
K) Life Care Facilities Act [210 ILCS 40]
L) Local Governmental and Governmental Employees Tort Immunity Act
[745 ILCS 10]
M) Medical Practice Act of 1987 [225 ILCS 60]
N) Mental Health and Developmental Disabilities Code [405 ILCS 5]
O) Nurse Practice Act [225 ILCS 65]
P) Nursing Home Administrators Licensing and Disciplinary Act
[225 ILCS 70]
Q) Nursing Home Care Act [210 ILCS 45]
R) Illinois Occupational Therapy Practice Act [225 ILCS 75]
S) Pharmacy Practice Act [225 ILCS 85]
T) Illinois Physical Therapy Act [225 ILCS 90]
U) Private Sewage Disposal Licensing Act [225 ILCS 225]
V) Probate Act of 1975 [755 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 40]
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) MC/DD Act [210 ILCS 46]
JJ) Community Living Facilities Licensing Act [210 ILCS 35]
KK) Community-Integrated Living Arrangements Licensure and
Certification Act [210 ILCS 135]
LL) Counties Code [55 ILCS 5]
MM) Alzheimer's
Disease and Related Dementias Special Care Disclosure Act [210 ILCS 4]
NN) State
Fire Marshal Act [20 ILCS 2905]
OO) Illinois Act on the Aging
[20 ILCS 105]
PP) Illinois
Speech-Language Pathology and Audiology Practice Act [225 ILCS 110]
QQ) Assisted Living and Shared
Housing Act [210 ILCS 9]
RR) Alternative Health Care
Delivery Act [210 ILCS 3]
SS) Podiatric Medical Practice
Act of 1987 [225 ILCS 100]
TT) Illinois Optometric
Practice Act of 1987 [225 ILCS 80]
UU) Physician Assistant
Practice Act of 1987 [225 ILCS 95]
VV) Language Assistance
Services Act [210 ILCS 87]
WW) ID/DD Community Care Act
[210 ILCS 47]
XX) Authorized
Electronic Monitoring in Long-Term Care Facilities Act [210 ILCS 32]
YY) Illinois
Emergency Management Agency Act [20 ILCS 3305]
ZZ) Latex
Glove Ban Act [410 ILCS 180]
4) State of Illinois rules:
A) Capital Development Board, Illinois Accessibility Code (71 Ill.
Adm. Code 400)
B) 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 Records of the Department of Public Health (2 Ill.
Adm. Code 1127)
x) Practice and Procedure in Administrative Hearings (77 Ill.
Adm. Code 100)
xi) Skilled Nursing and Intermediate Care Facilities Code (77 Ill.
Adm. Code 300)
xii) Intermediate Care for the Developmentally Disabled Facilities
Code (77 Ill. Adm. Code 350)
xiii) Medically Complex for the Developmentally Disabled Facilities
Code (77 Ill. Adm. Code 390)
xiv) Long-Term Care Assistants and Aides Training Programs Code (77
Ill. Adm. Code 395)
xv) Control of Tuberculosis Code (77 Ill. Adm. Code 696)
xvi) Health Care Worker Background Check Code (77 Ill. Adm. Code
955)
xvii) Language Assistance Services Code (77 Ill. Adm. Code 940)
xviii) Authorized Electronic Monitoring in Long-Term Care Facilities
Code (77 Ill. Adm. Code 389)
C) Department of Human Services, Alcoholism and Substance Abuse
Treatment and Intervention Licenses (77 Ill. Adm. Code 2060)
D) Office of the State Fire Marshal, Fire Prevention and Safety
(41 Ill. Adm. Code 100)
E) Department on Aging, Community Care Program (89 Ill. Adm. Code
240)
(Source: Amended at 49 Ill.
Reg. 802, effective December 31, 2024)
