Section 340.1000  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 [210 ILCS 45].

 

            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 his 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 340.1580 as a physical restraint.

 

            Adequate − 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 340.1220 of this Part and Section 3-303.2 of the Act, which indicates that a situation, condition, or practice in the facility violates the Act or the Department's rules, but is not a Type AA, Type A, Type B, or Type C violation.

 

            Administrator − the person who is directly responsible for the operation and administration of the facility, irrespective of the assigned title.  (See Licensed Nursing Home Administrator.)

 

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

 

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

 

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

 

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

 

            Audiologist − a person who is licensed as an audiologist under the Speech-Language Pathology and Audiology Practice Act [225 ILCS 110].

 

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

 

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

 

            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 tour of duty.

 

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

 

            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, 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.  This definition is limited to the definition of chemical restraint and Section 340.1580 of this Part.

 

            Corporal Punishment − painful stimuli inflicted directly upon the body.

 

            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 to practice dentistry, including persons holding a Temporary Certificate of Registration, as provided in the Illinois Dental Practice Act [225 ILCS 25].

 

            Department − as used in this Part means the Illinois Department of Public Health.

 

            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 mental retardation, 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 technician or dietetic assistant training program, corresponding or classroom, approved by the American Dietetic Association; 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 a Dietary Manager's Association approved dietary managers course; or

 

            is certified as a dietary manager by the Dietary Manager's Association; or

 

            has training and experience in food service supervision and management in a military service equivalent in content to the programs in the second, third or fourth paragraph of this definition.

 

            Dietitian − a person who  is a licensed dietitian as provided in the Dietetic and Nutrition Services Practice Act [225 ILCS 30].

 

            Direct Supervision − work performed 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 the Department 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 which present imminent danger of death or serious physical or mental harm to residents of a facility.  (Section 1-112 of the Act)

 

            Existing Long-Term Care 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 long-term care 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 [55 ILCS 5], 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 USCA 1395 et seq. and 1936 et seq.). It also includes homes, institutions, or other places operated by or under the authority of the Illinois Department of Veterans' Affairs.  A "facility" may consist of more than one building as long as the buildings are on the same tract or adjacent tracts of land. However, there shall be no more than one "facility" in any one building.  "Facility" does not include the following:

 

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

 

            A hospital, sanitarium, or other institution whose principal activity or business is the diagnosis,  care and treatment of human illness through the maintenance and operation as organized facilities therefor, which is required to be licensed under the Hospital Licensing Act [210 ILCS 85];

 

            Any "facility for child care" as defined in the Child Care Act of 1969 [225 ILCS 10];

 

            Any "community living facility" as defined in the Community Living Facilities Licensing Act [210 ILCS 35];

 

            Any "community residential alternative" as defined in the Community Residential Alternatives Licensing Act [210 ILCS 140];

 

            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 [210 ILCS 135]; 

 

            Any supportive residence licensed under the Supportive Residences Licensing Act [210 ILCS 65];

 

            Any supportive living facility in good standing with the demonstration project established under Section 5-5.01a of the Illinois Public Aid Code [305 ILCS 5/5-5.01a];

 

            Any assisted living or shared housing establishment licensed under the Assisted Living and Shared Housing Act [210 ILCS 9];

 

            An Alzheimer's disease management center alternative health care model licensed under the Alternative Health Care Delivery Act [210 ILCS 3]; or

 

A facility licensed under the MR/DD Community Care Act [210 ILCS 47]. (Section 1-113 of the Act)

 

            Financial Resources − 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.

 

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

 

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

 

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

 

            High Risk Designation – a violation, as described in Section 340.1245(i), of a provision that has been identified by the Department in Section 340.1245(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 in-patient.

 

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 (c) of Section 10 of the Sex Offender Management Board Act; or

 

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

 

            Illinois Veterans' Home − a facility operated by or under the authority of the Illinois Department of Veterans' Affairs. (Section 1-113(1) of the Act)

 

            Interdisciplinary Team − a group of persons that represents those professions, disciplines, or service areas that are relevant to identifying an individual's strengths and needs, and designs a program to meet those needs.  This team shall include at least a physician, a social worker and other professionals.  The Interdisciplinary Team includes at least the resident, the resident's guardian, the resident's primary service providers, including staff most familiar with the resident; and other appropriate professionals and caregivers as determined by the resident's needs.  The resident or his or her guardian may also invite other individuals to meet with the Interdisciplinary Team and participate in the process of identifying the resident's strengths and needs.

 

            Licensed Nursing Home Administrator − a person who is charged with the general administration and supervision of a facility and licensed under the Nursing Home Administrators Licensing and Disciplinary Act.

 

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

 

            Licensee − the person or entity licensed to operate the facility as provided under the Act.  (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)

 

            Misappropriation of Property − using a resident's cash, clothing, or other possessions without authorization by the resident or the resident's authorized representative; failure to return valuables after a resident's discharge; or failure to refund money after death or discharge when there is an unused balance in the resident's personal account.

 

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

 

            Neglect − a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident. (Section 1-117 of the Act)  This shall include any allegation in which:

 

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

 

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

 

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

 

            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.

 

            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 (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.

 

            Other Resident Injury − occurs where a resident is alleged to have suffered physical or mental harm and the allegation does not fall within the definition of abuse or neglect.

 

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

 

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

 

            Person − any individual, partnership, corporation, association, municipality, political subdivision, trust, estate or other legal entity whatsoever.

 

Personal Care − assistance with meals, dressing, movement, bathing or other personal needs or maintenance, or general supervision and oversight of the physical and mental well-being of an individual who is incapable of maintaining a private, independent residence or who is incapable of managing his person, whether or not a guardian has been appointed for such individual.  (Section 1-120 of the Act)

 

            Pharmacist, Registered − a person who holds a certificate of registration as a registered pharmacist, a local registered pharmacist or a registered assistant pharmacist under the Pharmacy Practice Act of 1987.

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

            Restorative Care − a health care process designed to assist residents to attain and maintain the highest degree of function of which they are capable (physical, mental, and social).

 

            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.

 

            Satisfactory − same as adequate.

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

            Substantial Failure − the failure to meet requirements other than a variance from the strict and literal performance, which results in unimportant omissions or defects given the particular circumstances involved.  This definition is limited to the phrase as used in Section 340.1130(b)(1).

 

            Sufficient − same as adequate.

 

            Supervision − authoritative procedural guidance by a qualified person for the accomplishment of a function or activity within his sphere of competence, with initial direction and periodic inspection of the actual act of accomplishing the function or activity. Unless otherwise stated in this Part, the supervisor must be on the premises if the person does not meet assistant level (two-year training program) qualifications specified in these definitions.

 

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

 

            Time Out − removing an individual from a situation that results in undesirable behavior. It is a behavior modification procedure which is developed and implemented under the supervision of a qualified professional.

 

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

 

            Title XIX − Title XIX of the Federal Social Security Act as now or hereafter amended.  (Section 1-127 of the Act)

 

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

 

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

 

            Type A Violation − a violation of the Act or this Part that creates a condition or occurrence relating to the operation and maintenance of a facility that creates a substantial probability that the risk of death or serious mental or physical harm to a resident will result therefrom or has resulted in actual physical or mental harm to a resident.  (Section 1-129 of the Act)

 

            Type B Violation − a violation of the Act or this Part that creates a condition or occurrence relating to the operation and maintenance of a facility that is more likely than not to cause more than minimal physical or mental harm to a resident. (Section 1-130 of the Act)

 

Type C Violation – a violation of the Act or this Part that creates a condition or occurrence relating to the operation and maintenance of a facility that creates a substantial probability that less than minimal physical or mental harm to a resident will result therefrom.  (Section 1-130 of the Act)

 

            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 35 Ill. Reg. 11896, effective June 29, 2011)

 

Section 340.1010  Incorporated and Referenced Materials

 

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

 

1)         Private and professional association standards:

 

A)        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 117223, Atlanta, GA  30368-7223 (800-762-2264). (See Section 340.1550.)

 

B)        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.

 

2)         Federal guidelines:

 

A)        The following guidelines of the Center for Infectious Diseases, Centers for Disease Control and Prevention, United States Public Health Service, Department of Health and Human Services, may be obtained from the National Technical Information Service (NTIS), U.S. Department of Commerce, 5285 Port Royal Road, Springfield, VA  22161:

 

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

 

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

 

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

 

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

 

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

 

vi)        2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, available at: https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (May 2022);

 

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

 

B)        The following publication may be obtained at the Centers for Disease Control and Prevention website:  Toolkit for Controlling Legionella in Common Sources of Exposure (January 13, 2021), available at https://www.cdc.gov/legionella/downloads/Control-Toolkit-All-Modules.pdf

 

3)         Federal regulations:

 

A)        Definitions (38 CFR 51.2, effective July 1, 2021);

 

B)        Resident rights (38 CFR 51.70, effective July 1, 2021);

 

C)        Admission, transfer and discharge rights (38 CFR 51.80, effective July 1, 2021);

 

D)        Resident behavior and facility practices (38 CFR 51.90, effective July 1, 2021);

 

E)        Quality of life (38 CFR 51.100, effective July 1, 2021);

 

F)         Resident assessment (38 CFR 51.110, effective July 1, 2021);

 

G)        Quality of care (38 CFR 51.120, effective July 1, 2021);

 

H)        Nursing services (38 CFR 51.130, effective July 1, 2021);

 

I)         Dietary services (38 CFR 51.140, effective July 1, 2021);

 

J)         Physician services (38 CFR 51.150, effective July 1, 2021);

 

K)        Specialized rehabilitative services (38 CFR 51.160, effective July 1, 2021);

 

L)        Dental services (38 CFR 51.170, effective July 1, 2021);

 

M)       Pharmacy services (38 CFR 51.180, effective July 1, 2021);

 

N)        Infection control (38 CFR 51.190, effective July 1, 2021);

 

O)        Physical environment (38 CFR 51.200, effective July 1, 2021);

 

P)         Administration (38 CFR 51.210, effective July 1, 2021);

 

Q)        Prescriptions (21 CFR 1306, effective April 1, 2021).

 

R)        Medical Foster Homes - General (38 CFR 17.73, effective July 1, 2021)

 

b)         The following federal and State statutes are referenced in this Part:

 

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

 

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

 

3)         Veterans' Benefits (38 USC 101; 38 U.S.C. 641 et seq.);

 

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

 

5)         Illinois Dental Practice Act [225 ILCS 25];

 

6)         Election Code [10 ILCS 5];

 

7)         Freedom of Information Act [5 ILCS 140];

 

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

 

9)         Illinois Health Facilities Planning Act [20 ILCS 3960];

 

10)        Nurse Practice Act [225 ILCS 65];

 

11)        Illinois Occupational Therapy Practice Act [225 ILCS 75];

 

12)        Illinois Physical Therapy Act [225 ILCS 90];

 

13)        Life Care Facilities Act [210 ILCS 40];

 

14)        Medical Practice Act of 1987 [225 ILCS 60];

 

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

 

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

 

17)        Nursing Home Care Act [210 ILCS 45];

 

18)        Pharmacy Practice Act [225 ILCS 85];

 

19)        Probate Act of 1975 [755 ILCS 5];

 

20)        Illinois Public Aid Code [305 ILCS 5].

 

21)        Counties Code [55 ILCS 5];

 

22)        Hospital Licensing Act [210 ILCS 85];

 

23)        Child Care Act of 1969 [225 ILCS 10];

 

24)        Community Living Facilities Licensing Act [210 ILCS 35];

 

25)        Supportive Residences Licensing Act [210 ILCS 65];

 

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

 

27)        Alternative Health Care Delivery Act [210 ILCS 3];

 

28)        Clinical Psychologist Licensing Act [225 ILCS 15];

 

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

 

30)        Alzheimer’s and Related Dementias Special Care Disclosure Act [210 ILCS 4];

 

31)        Illinois Administrative Procedure Act [5 ILCS 100];

 

32)        Illinois Act on the Aging [20 ILCS 105];

 

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

 

34)        Illinois Controlled Substances Act [720 ILCS 570];

 

35)        Wrongs to Children Act [720 ILCS 150];

 

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

 

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

 

38)        Illinois Living Will Act [755 ILCS 35];

 

39)        Health Care Surrogate Act [755 ILCS 40];

 

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

 

41          Illinois Optometric Practice Act of 1987 [225 ILCS 80];

 

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

 

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

 

c)         The following State of Illinois rules are referenced:

 

1)         Department of Public Health, Control of Communicable Diseases Code (77 Ill. Adm. Code 690);

 

2)         Department of Public Health, Control of Sexually Transmissible Infections Code (77 Ill. Adm. Code 693);

 

3)         Department of Public Health, Food Code (77 Ill. Adm. Code 750);

 

4)         Department of Public Health, Illinois Plumbing Code (77 Ill. Adm. Code 890);

 

5)         Department of Public Health, Private Sewage Disposal Code (77 Ill. Adm. Code 905);

 

6)         Department of Public Health, Drinking Water Systems Code (77 Ill. Adm. Code 900);

 

7)         Department of Public Health, Water Well Construction Code (77 Ill. Adm. Code 920);

 

8)         Department of Public Health, Illinois Water Well Pump Installation Code (77 Ill. Adm. Code 925);

 

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

 

10)        Department of Public Health, Long-Term Care Assistants and Aides Training Programs Code (77 Ill. Adm. Code 395);

 

11)        Department of Public Health, Control of Tuberculosis Code (77 Ill. Adm. Code 696);

 

12)        Department of Public Health, Health Care Worker Background Check Code (77 Ill. Adm. Code 955);

 

13)        Department of Public Health, Language Assistance Services Code (77 Ill. Adm. Code 940);

 

14)        Department of Financial and Professional Regulation, Illinois Controlled Substances Act (77 Ill. Adm. Code 3100);

 

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

 

16)        Department of Healthcare and Family Services, Medical Payment (89 Ill. Adm. Code 140).

 

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

 

(Source:  Amended at 47 Ill. Reg. 7762, effective May 17, 2023)

 

Section 340.1110  General Requirements

 

a)         This Part applies to the licensure of Illinois Veterans' Homes, subject to the terms and conditions of the Nursing Home Care Act (Ill. Rev. Stat. 1991, ch. 111 ½, pars. 4151- 101 et seq.) [210 ILCS 45].

 

b)         The license issued to each licensee shall state the maximum bed capacity for which it is granted, the date the license was issued and the expiration date, licensee's name, facility name, address, the classification by level of service authorized for that facility.  (Section 3-110 of the Act)

 

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

 

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

 

e)         Any person constructing or modifying a long-term care facility or portion thereof shall obtain the required permit from the Health Facilities Planning Board to be eligible for licensure for that facility or portion thereof (Ill. Rev. Stat. 1991, ch. 111 ½, pars. 1163.1 et seq.) [20 ILCS 3960].

 

Section 340.1115  Federal Veterans' Regulations

 

The facility shall comply with the following:

 

a)         Definitions (38 CFR 51.2);

 

b)         Resident rights (38 CFR 51.70);

 

c)         Admission, transfer and discharge rights (38 CFR 51.80);

 

d)         Resident behavior and facility practices (38 CFR 51.90);

 

e)         Quality of life (38 CFR 51.100);

 

f)         Resident assessment (38 CFR 51.110);

 

g)         Quality of care (38 CFR 51.120);

 

h)         Nursing services (38 CFR 51.130);

 

i)          Dietary services (38 CFR 51.140);

 

j)          Physician services (38 CFR 51.150);

 

k)         Specialized rehabilitative services (38 CFR 51.160);

 

l)          Dental services (38 CFR 51.170);

 

m)        Pharmacy services (38 CFR 51.180);

 

n)         Infection control (38 CFR 51.190);

 

o)         Physical environment (38 CFR 51.200); and

 

p)         Administration (38 CFR 51.210).

 

(Source:  Amended at 25 Ill. Reg. 4869, effective April 1, 2001)

 

Section 340.1120  Application for License

 

a)         Application for a license to establish or operate a 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 3-1031of the Act)

 

b)         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 a new license is issued to operate the facility; or when operation is discontinued; or when operation is moved to a new location; or when the licensee (if an individual) dies; or when the licensee (if a corporation or partnership) dissolves or terminates; or when the licensee (whatever the entity) ceases to be.

 

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 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.  Fees for such licenses shall be prorated on the basis of the portion of a year for which they are issued. (Section 3-110 of the Act) 

 

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

 

f)         A 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 340.1125 of this Part, if applicable.  (Section 3-115 of the Act)

 

(Source:  Amended at 35 Ill. Reg. 11896, effective June 29, 2011)

 

Section 340.1125  Alzheimer's Special Care Disclosure

 

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

 

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

 

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

 

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

 

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

 

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

 

f)         The facility's physical environment;

 

g)         Activities available to clients at the facility;

 

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

 

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

 

(Source:  Added at 23 Ill. Reg. 1038, effective January 15, 1999)

 

Section 340.1130  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)         The Director or his or her designee may take adverse licensure action against a facility 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.  (Section 3-119(a)(1) of the Act)  For purposes of this provision, substantial failure is a failure to meet the requirements of the Act and 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 a felony, or of two or more misdemeanors involving moral turpitude, during the previous five years as shown by a certified copy of the record of the court of conviction.  (Section 3-119 (a)(2) of the Act)

 

3)         Personnel (or, for an initial applicant, the proposed personnel) are insufficient in number or unqualified by training or experience to properly care for the number and type of residents served by the facility.  (Section 3-119(a)(3) of the Act)

 

4)         Financial or other resources are insufficient to conduct or operate the facility in accordance with the Act and this Part.  (Section 3-119(a)(4) of the Act)

 

5)         The facility is not under the direct supervision of a full- time administrator as required by Section 340.1370.  (Section 3-119(a)(5) of the Act)

 

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

 

7)         The rights of residents of the facility have been violated 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 the resident's legal guardian.

 

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

 

8)         False information has been knowingly submitted by the facility either on the licensure or renewal application forms or during the course of an inspection or survey of the facility.

 

9)         Refusal to permit entry or inspection of the facility by agents of the Department.  (Section 3-214 of the Act).

 

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. 11896, effective June 29, 2011)

 

Section 340.1140  Denial of Initial License

 

a)         In addition to the criteria outlined in Section 340.1130, the Director may deny the issuance of an initial license based on revocation of a facility license. During the previous five years, if such prior license was issued to the individual applicant, a controlling owner or controlling combination of owners of the applicant; or any affiliate of the individual applicant or controlling owner of the applicant and such individual applicant, controlling owner of the applicant or affiliate of the applicant was a controlling owner of the prior license; provided, however, that the denial of an application for a license pursuant to this Part 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.  (Section 3-117 (5) of the Act)

 

b)         Immediately upon denial of any application or reapplication for a license, the Department shall notify the applicant in writing.  The notice of denial shall include a clear and concise statement of violations of Section 3-117 of the Act on which denial is based and notice of the opportunity for hearing.  (Section 3-118 of the Act)

 

Section 340.1150  Revocation or Denial of Renewal of License

 

a)         The license of a facility shall be revoked or 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 340.1130(b) and in Section 3-119(a) of the Act).

 

b)         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.

 

c)         The license of a facility will be revoked when the facility fails to abate or eliminate a Type A violation or when the facility has committed 2 Type "AA" violations within a 2-year period.  Section 3-119(a) of the Act)

 

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

 

1)         A clear and concise statement of the violations on which the nonrenewal or revocation is based.  (Section 3-119(b) of the Act) The statement shall include a citation to the provisions of the Act or this Part on which the application for renewal is being revoked or denied.

 

2)         A statement of the date on which revocation will take effect or the current license of the facility will expire as provided in Section 3-119(d) of the Act.

 

3)         A notice of the opportunity of the applicant for a hearing to contest the nonrenewal or revocation of the license. (Section 3-119(b) and (c) of the Act)

 

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

 

(Source:  Amended at 35 Ill. Reg. 11896, effective June 29, 2011)

 

Section 340.1160  Inspections, Surveys, Evaluations, and Consultations

 

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, State Fire Marshal's Office, State or federal department of Veterans' Affairs 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 the Act and this Part.  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.  A facility may charge the Department for such photocopying at a rate determined by the facility not to exceed the rate in the Department's Freedom of Information rules (2 Ill. Adm. Code 1126).  (Section 3-213 of the Act)

 

b)         Consultation consists of providing advice or suggestions to the staff of a facility at their request relative to specific matters of the scope of regulation, methods of compliance with the Act or this Part, or general matters of patient care.

 

Section 340.1170  Presentation of Findings by the Department

 

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 (e) of this Section, that the facility may have committed violations of the Act or this Part different than or in additional to those presented at the exit conference and the violations may be cited as either a Type A or repeat Type B violation, 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 surveyor will be advised of any code changes made after their recommendations are submitted.

 

g)         The facility shall have 5 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 be provided, at facility expense, to the surveyors at the conclusion of the exit conference.  No video-taped recording shall be allowed.

 

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

 

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

 

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

 

Section 340.1190  Ownership Disclosure

 

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) The statement of ownership shall include the following:

 

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

 

b)         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 or licensee is operating the facility that is the subject of the application or license; and

 

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

 

(Source:  Amended at 42 Ill. Reg. 1132, effective January 5, 2018)

 

Section 340.1200  Monitor and Receivership

 

a)         The Department may place an employee or agent to serve as a monitor in accordance with Section 3-501 of the Act. (Section 3-501 of the Act) The monitor shall meet the following minimum requirements:

 

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

 

2)         have an understanding of the Act and this Part which are the subject of the monitors' duties as evidenced in a personal interview of the candidate;

 

3)         be unrelated to the owners or licensee 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;

 

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 work experience in the long-term care industry of the State of Illinois.

 

b)         The monitor shall be under the supervision of the Department and shall perform the duties of a monitor delineated in Section 3-502 of the Act in accordance with the Department's instructions.

 

c)         All communications, including but not limited to data, memoranda, correspondence, records and reports shall be transmitted to and become the property of the Department, plus, 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.

 

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

 

e)         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)         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 the elderly in programs such as patient care, social work, advocacy, or facility inspection.

 

2)         have an understanding and working knowledge of the Act and this Part as evidenced in a personal interview of the candidate.

 

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

 

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

 

Section 340.1210  Determination of a Violation  

 

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

 

b)         In making this determination, the Director shall consider any comments and documentation provided by the facility within ten days of the facility's receipt of the report.

 

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

 

1)         The severity of the finding.  The Director or his designee will consider whether the finding constitutes merely a  technical, non-substantial error or whether the finding is serious enough to constitute an actual violation of the intent and purpose of the standard.  (Section 3-212 (c) of the Act)

 

2)         The danger posed to resident health and safety.  The Director or his designee will consider whether the finding could pose any direct harm to the residents.  (Section 3-212(c) of the Act)

 

3)         The diligence and efforts to correct deficiencies and correction of reported deficiencies by the facility. Consideration will be given to any evidence provided by the facility in its comments and documentation that steps have been taken to reduce noted findings and to ensure a reduction of deficiencies.  (Section 3-212(c) of the Act)

 

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

 

Section 340.1220  Determination of the Level of a Violation

 

a)         After determining that issuance of a notice of violation is warranted and prior to issuance of the notice, the Director or his or her designee will review the findings that are the basis of the violation, and any comments and documentation provided by the facility.  The level of violation shall be determined to be either a level AA, a level A, a level B, or a level C violation based on the definition of level of violation contained in the Act, Section 340.1000 of this Part and on the criteria in this Section.

 

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

 

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

 

2)         A "level A violation" or "Type A violation" is a violation of the Act or this Part which creates a condition or occurrence relating to the operation and maintenance of a facility that creates a substantial probability that the risk of death or serious mental or physical harm will result therefrom or has resulted in actual physical or mental harm to a resident.  (Section 1-129 of the Act)

 

3)         A "level B violation' or "Type B violation" is a violation of the Act or this Part which creates a condition or occurrence relating to the operation and maintenance of a facility that is more likely than not to cause more than minimal physical or mental harm to a resident.  (Section 1-130 of the Act)

 

4)         A "level C violation" or "Type C violation" is a violation of the Act or this Part which creates a condition or occurrence relating to the operation and maintenance of a facility that creates a substantial probability that less than minimal physical or mental harm to a resident will result therefrom.  (Section 1-132 of the Act)

 

c)         In determining the level of a violation, the Director or his or her designee shall consider the following criteria:

 

1)         The degree of danger to the resident or residents that is posed by the condition or occurrence in the facility.  The following factors will be considered in assessing the degree of danger:

 

A)        Whether the resident or residents of the facility are able to recognize conditions or occurrences that may be harmful and are able to take measures for self-preservation and self-protection.  The extent of nursing care required by the residents as indicated by review of patient needs will be considered in relation to this determination.

 

B)        Whether the resident or residents have access to the area of the facility in which the condition or occurrence exists and the extent of such access. A facility's use of barriers, warning notices, instructions to staff and other means of restricting resident access to hazardous areas will be considered.

 

C)        Whether the condition or occurrence was the result of inherently hazardous activities or negligence by the facility.

 

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

 

2)         The directness and imminence of the danger to the resident or residents by the condition or occurrence in the facility.  In assessing the directness and imminence of the danger, the following factors will be considered:

 

A)        Whether actual harm, including death, physical injury or illness, mental injury or illness, distress, or pain, to a resident or residents resulted from the condition or occurrence and the extent of such harm.

 

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

 

C)        Whether professional opinions and findings indicate that direct and imminent danger to the resident or residents will result from the condition or occurrence.

 

D)        Whether the condition or occurrence was limited to a specific area of the facility or was widespread throughout the facility.  Efforts taken by the facility to limit or reduce the scope of the area affected by the condition or occurrence will be considered.

 

E)        Whether the physical, mental, or emotional state of the resident or residents, who are subject to the danger, would facilitate or hinder harm actually resulting from the condition or occurrence.

 

(Source:  Amended at 35 Ill. Reg. 11896, effective June 29, 2011)

 

Section 340.1225  Administrative Warning

 

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

 

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

 

1)         A description of the nature of the violation.

 

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

 

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

 

c)         Each administrative warning shall be sent to the facility and the licensee or served personally at the facility within 10 days after the Director or his or her designee determines that issuance of an administrative warning is warranted under Section 300.272.

 

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

 

e)         If the Department finds, during the next on-site inspection which occurs no earlier than 90 days from the issuance of the administrative warning, that the facility has not corrected the situation, condition, or practice which resulted in the issuance of the administrative warning, the Department shall notify the facility of the finding.  The facility shall then submit a written plan of correction as provided in Section 340.1230.  The Department will consider the plan of correction and take any necessary action in accordance with Section 340.1230.  (Section 3-303.2(b) of the Act)

 

(Source:  Added at 35 Ill. Reg. 11896, effective June 29, 2011)

 

Section 340.1230  Plans of Correction and Reports 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 ten days after receipt of notice of violation for a Type B violation, or after receipt of a notice 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 may 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)         In lieu of submission of a plan of correction, a facility may submit a report of correction if corrective action has been completed.  The report of correction shall be submitted within the time period required in subsections (a) and (b) of this Section.

 

e)         Each plan of correction or report 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 such assessment and evaluation shall be maintained by the facility.  Each plan of correction or report of correction shall include:

 

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

 

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

 

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

 

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

 

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

 

1)         The plan or report does not 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 or report is not specific enough to indicate the actual actions the facility will be taking to abate, eliminate, or correct the violation.

 

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

 

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

 

5)         The plan or report 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 or report 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 to submit a modified plan.  (Section 3-303(b) of the Act)

 

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

 

(Source:  Amended at 35 Ill. Reg. 11896, effective June 29, 2011)

 

Section 340.1240  Calculation of Penalties (Repealed)

 

(Source:  Repealed at 35 Ill. Reg. 11896, effective June 29, 2011)

 

Section 340.1245  Conditions for Assessment of Penalties

 

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

 

a)         A licensee who commits a Type "AA" violation as defined in Section 1-128.5 of the Act is automatically issued a conditional license for a period of 6 months to coincide with an acceptable plan of correction and assessed a fine up to $25,000 per violation.  (Section 3-305(1) of the Act)

 

b)         A licensee who commits a Type "A" violation as defined in Section 1-129 of the Act is automatically issued a conditional license for a period of 6 months to coincide with an acceptable plan of correction and assessed a fine of up to $12,500 per violation. (Section 3-305(1.5) of the Act)

 

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

 

d)         A licensee who commits a Type "B" violation as defined in Section 1-130 of the Act shall be assessed a fine of up to $1,100 per violation.  (Section 3-305(2) of the Act)

 

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

 

f)         A licensee who commits 10 or more Type "C" violations, as defined in Section 1-132 of the Act, in a single survey shall be assessed a fine of up to $250 per violation.  A licensee who commits one or more Type "C" violations with a high risk designation shall be assessed a fine of up to $500 per violation.  (Section 3-305(2.5) of the Act)

 

g)         If an occurrence results in more than one type of violation as defined in the Act (that is, a Type "AA", Type "A", Type "B", or Type "C" violation), the maximum fine that may be assessed for that occurrence is the maximum fine that may be assessed for the most serious type of violation charged.  For purposes of the preceding sentence, a Type "AA" violation is the most serious type of violation that may be charged, followed by a Type "A", Type "B", or Type "C" violation, in that order. (Section 3-305(7.5) of the Act)

 

h)         The minimum and maximum fines that may be assessed pursuant to Section 3-305 of the Act and this Section 340.1245 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 340.1305(a)

 

2)         Section 340.1305(b)

 

3)         Section 340.1305(c)

 

4)         Section 340.1315(a)

 

5)         Section 340.1315(b)

 

6)         Section 340.1315(c)

 

7)         Section 340.1315(f)

 

8)         Section 340.1315(j)

 

9)         Section 340.1315(k)

 

10)         Section 340.1315(l)

 

11)         Section 340.1315(n)

 

12)         Section 340.1315(o)

 

13)         Section 340.1317(c)

 

14)         Section 340.1317(d)

 

15)         Section 340.1317(e)

 

16)         Section 340.1330

 

17)         Section 340.1335

 

18)         Section 340.1377

 

19)         Section 340.1380(b)

 

20)         Section 340.1440(a)

 

21)         Section 340.1440(d)

 

22)         Section 340.1440(e)

 

23)         Section 340.1505(b)

 

24)         Section 340.1505(e)

 

25)         Section 340.1505(g)

 

26)         Section 340.1580

 

27)         Section 340.1610

 

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 340.1245, 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)

 

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

 

(Source:  Amended at 35 Ill. Reg. 11896, effective June 29, 2011)

 

Section 340.1250  Reduction or Waiver of Penalties

 

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

 

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

 

1)         The facility submits a true report of correction within ten days after the notice of violation is received, and the report is subsequently verified by the Department.  (Section 3-308(a) of the Act)

 

2)         The facility submits a plan of correction within ten days after the notice of violation is received; the plan is approved by the Department; the facility submits a report of correction within 15 days after submission of the plan of correction; and the report is subsequently verified by the Department.  (Section 3-308(b) of the Act)

 

3)         The facility submits a plan of correction within ten days after the notice of a violation is received; the plan provides for correction time that is less than or equal to 30 days after submission of the plan of correction; and the Department approves such plan.  (Section 3-308(c) of the Act)

 

4)         Correction of the violation requires substantial capital improvements or repairs in the physical plant of the facility; the facility submits a plan of correction for violations involving substantial capital improvements which provides for correction within 90 days after submission of the plan, and the plan is approved by the Department. (Section 3-308(d) of the Act)

 

Section 340.1255  Supported Congregate Living Arrangement Demonstration

 

a)         A facility or location approved to participate in the Supported Congregate Living Arrangement Demonstration authorized by Section 4.02b of the Illinois Act on the Aging [20 ILCS 105/4.02b] and requesting a waiver of the Act and this Part shall submit to the Department a joint waiver request with the Department on Aging or documentation that the Department on Aging failed to act upon a waiver application within 60 days after the applicant submitted a request to the Department on Aging. (Section 4.02b of the Illinois Act on the Aging)

 

b)         The waiver application shall include the following:

 

1)         a specific listing of those portions of the Act and this Part for which a waiver is being requested; and

 

2)         the applicant's proposed Program Plan.

 

c)         The proposed Program Plan shall describe the types of residents to be served and the services that will be provided in the Supported Congregate Living Arrangement Demonstration.  (Section 3-102.2 of the Act)

 

d)         The Department will evaluate the waiver application based on the criteria in Section 340.1260 of this Part.  The applicant shall be notified within 10 days after the Department's waiver determination.

 

e)         The Department may revoke the waiver if the Department determines that the Supported Congregate Living Arrangement Demonstration:

 

1)         is not in compliance with the Program Plan submitted in accordance with subsection (b) of this Section (Section 3-102.2 of the Act);

 

2)         is not in compliance with the Department's waiver approval conditions; or

 

3)         has been terminated from the demonstration by the Department on Aging.

 

(Source:  Added at 22 Ill. Reg. 7162, effective April 15, 1998)

 

Section 340.1260  Waivers

 

a)         Upon application by a facility, the Director may grant or renew the waiver of the facility's compliance with 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 of the Act)

 

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

 

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

 

1)         the duration and basis for any current waiver with respect to the same rule or standard;

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

SUBPART B: POLICIES AND FACILITY RECORDS

 

Section 340.1300  Facility Policies

 

a)         The facility shall have written policies and procedures governing all services provided by the facility.  The written policies and procedures shall be formulated with the involvement of the administrator.  The policies shall comply with the Act and this Part.  The written policies shall be followed in operating the facility and shall be reviewed at least annually by the facility's advising physician or the medical advisory committee, as evidenced by a dated signature.

 

b)         An advisory physician, or a medical advisory committee composed of physicians, shall be responsible for advising the administrator on the overall medical management of the residents and the staff of the facility.

 

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

 

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

 

1)         Admission, transfer, and discharge of residents, including the types of services offered by the facility that would cause residents to be admitted, transferred or discharged, and transfers within the facility from one room to another;

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

g)         The advisory physician or medical advisory committee shall develop policies and procedures to be followed during the various medical emergencies that may occur from time to time in a facility. These medical emergencies include, but are not limited to:

 

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

 

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

 

3)         Traumatic injuries (for example, fractures, burns or lacerations);

 

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

 

5)         Other medical emergencies (for example, convulsions or shock).

 

h)         The facility shall maintain in a suitable location the equipment to be used during the emergencies detailed in subsection (g) of this Section. This equipment shall include, at a minimum, a portable oxygen kit, including a face mask or cannula, an airway, and a bag-valve-mask manual ventilating device.

 

(Source:  Amended at 37 Ill. Reg. 4983, effective March 29, 2013)

 

Section 340.1305  Request for Resident Criminal History Record Information

 

a)         A facility shall, within 24 hours after admission of a resident, request a criminal history background check pursuant to the Uniform Conviction Information Act [210 ILCS 2635] for all persons 18 or older seeking admission to the facility, unless a background check was initiated by a hospital pursuant to the Hospital Licensing Act.  Background checks shall be based on the resident's name, date of birth, and other identifiers as required by the Department of State Police.  (Section 2-201.5(b) of the Act) 

 

b)         The facility shall check for the individual's name on the Illinois Sex Offender Registration website at www.isp.state.il.us and the Illinois Department of Corrections sex registrant search page at www.idoc.state.il.us to determine if the individual is listed as a registered sex offender. 

 

c)         If the results of the background check are inconclusive, the facility shall initiate a fingerprint-based check, unless the fingerprint check is waived by the Director of Public Health based on verification by the facility that the resident is completely immobile or that the resident meets other criteria related to the resident's health or lack of potential risk, such as the existence of a severe, debilitating physical, medical, or mental condition that nullifies any potential risk presented by the resident.  (Section 2-201.5(b) of the Act) The facility shall arrange for a fingerprint-based background check or request a waiver from the Department within 5 days after receiving inconclusive results of a name-based background check.  The fingerprint-based background check shall be conducted within 25 days after receiving the inconclusive results of the name-based check.

 

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

 

e)         The facility shall provide for or arrange for any required fingerprint-based checks to be taken on the premises of the facility.  If a fingerprint-based check is required, the facility shall arrange for it to be conducted in a manner that is respectful of the resident's dignity and that minimizes any emotional or physical hardship to the resident.  (Section 2-201.5(b) of the Act) If a facility is unable to conduct a fingerprint-based background check in compliance with this Section, then it shall provide conclusive evidence of the resident's immobility or risk nullification of the waiver issued pursuant to Section 2-201.5 of the Act.

 

f)         The facility shall be responsible for taking all steps necessary to ensure the safety of residents while the results of a name-based background check or a fingerprint-based background check are pending; while the results of a request for waiver of a fingerprint-based check are pending; and/or while the Identified Offender Report and Recommendation is pending.

 

(Source:  Amended at 35 Ill. Reg. 11896, effective June 29, 2011)

 

Section 340.1310  Admission, Retention and Discharge Policies

 

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

 

b)         No resident determined by professional evaluation to be in need of services not readily available in a particular facility, or distinct part of a facility, or through arrangement with a qualified outside resource, shall be admitted to or kept in that facility.  The Department defines a "qualified outside source" as one recognized as meeting professional standards for services provided.

 

c)         Each facility shall have a policy concerning the admission of persons needing prenatal or maternity care, and a policy concerning keeping of persons who become pregnant while they are residents of the facility.  If these policies permit these persons to be admitted to or kept in the facility, then the facility shall have a policy concerning the provision of adequate and appropriate prenatal and maternity care to these persons from in-house or outside resources.  (See Section 340.1550.)

 

d)         Residents with a history of aggressive or self-abusive behavior may be admitted only if the facility has in place appropriate, effective and individualized programs to manage the resident's behaviors and adequate, properly trained and supervised staff to administer the programs.

 

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

 

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

 

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

 

h)         A facility shall document all leaves and temporary transfers.  Such documentation shall include date, time, condition of resident, person to whom the resident was released, planned destination, anticipated date of return, and any special instructions on medication dispensed.

 

i)          No person shall be admitted to or kept in the facility who is an identified offender, unless the requirements of Section 340.1305 for new admissions and the requirements of Section 340.1315 are met.

 

(Source:  Amended at 31 Ill. Reg. 6098, effective April 3, 2007)

 

Section 340.1314  Criminal History Background Checks for Persons Who Were Residents on May 10, 2006 (Repealed)

 

(Source:  Repealed at 35 Ill. Reg. 11896, effective June 29, 2011)

 

Section 340.1315  Identified Offenders

 

a)         The facility shall review the results of the criminal history background checks immediately upon receipt of these checks.

 

b)         The facility shall be responsible for taking all steps necessary to ensure the safety of residents while the results of a name-based background check or a fingerprint-based check are pending; while the results of a request for a waiver of a fingerprint-based check are pending; and/or while the Identified Offender Report and Recommendation is pending.

 

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

 

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

 

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

 

d)         The facility shall comply with all applicable provisions contained in the Uniform Conviction Information Act.

 

e)         All name-based and fingerprint-based criminal history record inquiries shall be submitted to the Department of State Police electronically in the form and manner prescribed by the Department of State Police.  The Department of State Police may charge the facility a fee for processing name-based and fingerprint-based criminal history record inquiries.  The fee shall be deposited into the State Police Services Fund.  The fee shall not exceed the actual cost of processing the inquiry. (Section 2-201.5(c) of the Act)

 

f)         If identified offenders are residents of  a facility, the facility shall comply with all of the following requirements:

 

1)         The facility shall inform the appropriate county and local law enforcement offices of the identity of identified offenders who are registered sex offenders or are serving a term of parole, mandatory supervised release or probation for a felony offense who are residents of the facility. If a resident of a licensed facility is an identified offender, any federal, State, or local law enforcement officer or county probation officer shall be permitted reasonable access to the individual resident to verify compliance with the requirements of the Sex Offender Registration Act, to verify compliance with the requirements of Public Act 94-163 and Public Act 94-752, or to verify compliance with applicable terms of probation, parole, or mandatory supervised release.  (Section 2-110(a-5) of the Act) Reasonable access under this provision shall not interfere with the identified offender's medical or psychiatric care.

 

2)         The facility staff shall meet with local law enforcement officials to discuss the need for and to develop, if needed, policies and procedures to address the presence of facility residents  who are registered sex offenders or are serving a term of parole, mandatory supervised release or probation for a felony offense, including compliance with Section 340.1380 of this Part.

 

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

 

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

 

B)         The notice shall include a statement that information regarding registered sex offenders may be obtained from the Illinois State Police website, www.isp.state.il.us, and that information regarding persons serving terms of parole or mandatory supervised release may be obtained from the Illinois Department of Corrections website, www.idoc.state.il.us. (Section 2-216 of the Act)

 

4)         If the identified offender is on probation, parole, or mandatory supervised release, the facility shall contact the resident's probation or parole officer, acknowledge the terms of release, update contact information with the probation or parole office, and maintain updated contact information in the resident's record. The record must also include the resident's criminal history record.

 

g)         Facilities shall maintain written documentation of compliance with Section 340.1305 of this Part.

 

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

 

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

 

j)          Upon admission of an identified offender to a facility or a decision to retain an identified offender in a facility, the facility, in consultation with the medical director and law enforcement, shall specifically address the resident's needs in an individualized plan of care.

 

k)         The facility shall incorporate the Identified Offender Report and Recommendation into the identified offender's care plan.  (Section 2-201.6(f) of the Act)

 

l)          If the identified offender is a convicted (see 720 ILCS 150/2) or registered (see 730 ILCS 150/3) sex offender or if the Identified Offender Report and Recommendation prepared pursuant to Section 2-201.6(a) of the Act reveals that the identified offender poses a significant risk of harm to others within the facility, the offender shall be required to have his or her own room within the facility subject to the rights of married residents under Section 2-108(e) of the Act. (Section 2-201.6(d) of the Act)

 

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

 

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

 

o)         Incident reports shall be submitted to the Division of Long-Term Care Field Operations in the Department's Office of Health Care Regulation  in compliance with Section 340.1330 of this Part. The facility shall review its placement determination of identified offenders based on incident reports involving the identified offender. In incident reports involving identified offenders, the facility shall identify whether the incident involves substance abuse, aggressive behavior, or inappropriate sexual behavior, as well as any other behavior or activity that would be reasonably likely to cause harm to the identified offender or others. If the facility cannot protect the other residents from misconduct by the identified offender, then the facility shall transfer or discharge the identified offender in accordance with Section 340.1470 of this Part.

 

p)         The facility shall notify the appropriate local law enforcement agency, the Illinois Prisoner Review Board, or the Department of Corrections of the incident and whether it involved substance abuse, aggressive behavior, or inappropriate sexual behavior that would necessitate relocation of that resident.

 

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

 

(Source:  Amended at 35 Ill. Reg. 11896, effective June 29, 2011)

 

Section 340.1316  Discharge Planning for Identified Offenders

 

a)         If, based on the security measures listed in the Identified Offender Report and Recommendation, a facility determines that it cannot manage the identified offender resident safely within the facility, it shall commence involuntary transfer or discharge proceedings pursuant to Section 3-402 of the Act and Section 340.1470 of this Part. (Section 2-201.6(g) of the Act)

 

b)         All discharges and transfers shall be pursuant to Section 340.1470 of this Part.

 

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

 

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

 

1)         The facility's inability to meet the needs of the resident, based on Section 340.1315 of this Part and subsection (a) of this Section;

 

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

 

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

 

e)         Discharge planning shall be included as part of the plan of care developed pursuant to Section 340.1315(k).

 

(Source:  Amended at 35 Ill. Reg. 11896, effective June 29, 2011)

 

Section 340.1317  Transfer of an Identified Offender

 

a)         If, based on the security measures listed in the Identified Offender Report and Recommendation, a facility determines that it cannot manage the identified offender resident safely within the facility, it shall commence involuntary transfer or discharge proceedings pursuant to Section 3-402 of the Act and Section 340.1470 of this Part. (Section 2-201.6(g) of the Act)

 

b)         All discharges and transfers shall be pursuant to Section 340.1470 of this Part.

 

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

 

d)         This notification shall include all of the documentation required under Section 340.1315 of this Part and subsection (a) of this Section, and the transferring facility shall provide this information to the receiving facility to complete the discharge planning.

 

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

 

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

 

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

 

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

 

4)         Reports of disciplinary infractions and dispositions;

 

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

 

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

 

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

 

(Source:  Amended at 35 Ill. Reg. 11896, effective June 29, 2011)

 

Section 340.1320  Disaster Preparedness

 

a)         For the purpose of this Section only, "disaster" means an occurrence, as a result of a natural force or mechanical failure such as water, wind or fire, or a lack of essential resources such as electrical power, that poses a threat to the safety and welfare of residents, personnel, and others present in the facility.

 

b)         Each facility shall have policies covering disaster preparedness, including a written plan for staff, residents and others to follow.  The plan shall include, but not be limited to, the following:

 

1)         Proper instruction in the use of fire extinguishers for all personnel employed on the premises;

 

2)         A diagram of the evacuation route, which shall be posted and made familiar to all personnel employed on the premises;

 

3)         A written plan for moving residents to safe locations within the facility in the event of tornado warning or severe thunderstorm warning; and

 

4)         An established means of facility notification when the National Weather Service issues a tornado or severe thunderstorm warning that covers the area in which the facility is located.  The notification mechanism shall be other than commercial radio or television.  Approved notification measures include being within range of local tornado warning sirens, an operable National Oceanic and Atmospheric Administration weather radio in the facility, or arrangements with local public safety agencies (police, fire, emergency management agency) to be notified if a warning is issued.

 

c)         Fire drills shall be held at least quarterly for each shift of facility personnel.  Disaster drills for other than fire shall be held twice annually for each shift of facility personnel.  Drills shall be held under varied conditions to:

 

1)         Ensure that all personnel on all shifts are trained to perform assigned tasks;

 

2)         Ensure that all personnel on all shifts are familiar with the use of the fire-fighting equipment in the facility; and

 

3)         Evaluate the effectiveness of disaster plans and procedures.

 

d)         Fire drills shall include simulation of the evacuation of residents to safe areas during at least one drill each year on each shift.

 

e)         The facility shall provide for the evacuation of physically handicapped persons, including those who are hearing or sight impaired.

 

f)         If the welfare of the residents precludes an actual evacuation of an entire building, the facility shall conduct drills involving the evacuation of successive portions of the building under conditions that assure the capability of evacuating the entire building with the personnel usually available, should the need arise.

 

g)         A written evaluation of each drill shall be submitted to the facility administrator and shall be maintained for one year.

 

h)         A written plan shall be developed for temporarily relocating the residents for any disaster requiring relocation and at any time that the temperature in residents' bedrooms falls below 55° F. for 12 hours or more.

 

i)          Reporting of Disasters

 

1)         Upon the occurrence of any disaster requiring hospital service, police, fire department or coroner, the facility administrator or designee shall provide a preliminary report to the Department either by using the nursing home hotline or by directly contacting the appropriate Department Regional Office during business hours.  This preliminary report shall include, at a minimum:

 

A)        The name and location of the facility;

 

B)        The type of disaster;

 

C)        The number of injuries or deaths to residents;

 

D)        The number of beds not usable due to the occurrence;

 

E)        An estimate of the extent of damages to the facility;

 

F)         The type of assistance needed, if any; and

 

G)        A list of other State or local agencies notified about the problem.

 

2)         If the disaster will not require direct Departmental assistance, the facility shall provide a preliminary report within 24 hours after the occurrence.  Additionally, the facility shall submit a full written account to the Department within seven days after the occurrence, which includes the information specified in subsection (i)(1) of this Section and a statement of actions taken by the facility after the preliminary report.

 

j)          Each facility shall establish and implement policies and procedures in a written plan to provide for the health, safety, welfare and comfort of all residents when the heat index/apparent temperature (see Section 340.Table A), as established by the National Oceanic and Atmospheric Administration, inside the facility exceeds 80° F.

 

k)         Coordination with Local Authorities

 

1)         Annually, each facility shall forward copies of all disaster policies and plans required under this Section to the local health authority and local emergency management agency having jurisdiction.

 

2)         Annually, each facility shall forward copies of its emergency water supply agreements, required under Section 340.2010(a)(5), to the local health authority and local emergency management agency having jurisdiction.

 

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

 

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

 

(Source:  Amended at 37 Ill. Reg. 2330, effective February 4, 2013)

 

Section 340.1330  Incidents and Accidents

 

a)         The facility shall maintain a file of all written reports of each incident and accident affecting a resident that is not the expected outcome of a resident's condition or disease process.  A descriptive summary of each incident or accident affecting a resident shall also be recorded in the progress notes or nurse's notes of that resident.

 

b)         The facility shall notify the Department of any serious incident or accident.  For purposes of this Section, "serious" means any incident or accident that causes physical harm or injury to a resident.

 

c)         The facility shall, by fax or phone, notify the Regional Office within 24 hours after each reportable incident or accident.  If a reportable incident or accident results in the death of a resident, the facility shall, after contacting local law enforcement pursuant to Section 340.1380, notify the Regional Office by phone only. For the purposes of this Section, "notify the Regional Office by phone only" means talk with a Department representative who confirms over the phone that the requirement to notify the Regional Office by phone has been met.  If the facility is unable to contact the Regional Office, it shall notify the Department's toll-free complaint registry hotline.  The facility shall send a narrative summary of each reportable accident or incident to the Department within seven days after the occurrence.

 

(Source:  Amended at 37 Ill. Reg. 2330, effective February 4, 2013)

 

Section 340.1335  Infection Control

 

a)         Policies and procedures for investigating, controlling, and preventing infections in the facility shall be established and followed.  The policies and procedures shall be consistent with and include the requirements of the Control of Communicable Diseases Code (77 Ill. Adm. Code 690) and Control of Sexually Transmissible Diseases Code (77 Ill. Adm. Code 693). Activities shall be monitored to ensure that these policies and procedures are followed.

 

b)         A group, i.e., an infection control committee, quality assurance committee, or other facility entity, shall periodically review the results of investigations and activities to control infections.

 

c)         Each facility shall adhere to the following guidelines of the Center for Infectious Diseases, Centers for Disease Control and Prevention, U.S. Public Health Service, Department of Health and Human Services (see Section 340.1010):

 

1)         Guideline for Prevention of Catheter-Associated Urinary Tract Infections.

 

2)         Guideline for Hand Hygiene in Health-Care Settings.

 

3)         Guidelines for Prevention of Intravascular Infections.

 

4)         Guideline for Prevention of Surgical Site Infection.

 

5)         Guideline for Prevention of Nosocomial Pneumonia.

 

6)         Guideline for Isolation Precautions in Hospitals.

 

7)                  Guidelines for Infection Control in Health Care  Personnel.

 

(Source:  Amended at 29 Ill. Reg. 12924, effective August 2, 2005)

 

Section 340.1337  Testing for Legionella Bacteria

 

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

 

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

 

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

 

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

 

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

 

(Source:  Added at 46 Ill. Reg. 10504, effective June 2, 2022)

 

Section 340.1340  Facility Record Requirements

 

a)         The facility shall maintain a file of reports of findings and recommendations from consultants.  Each report shall be dated and indicate each specific date and time the consultant was in the facility.

 

b)         The facility shall complete the Illinois Department of Public Health Annual Long Term Care (LTC) Facility Survey.

 

c)         The facility shall maintain a permanent chronological resident registry showing date of admission, name of resident and date of discharge or death.

 

Section 340.1350  Personnel Policies

 

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

 

b)         The facility shall document all arrangements for each consultant's services in a written agreement setting forth services to be provided.  These agreements shall be updated annually.

 

c)         Each facility shall develop and maintain written personnel policies that are followed in the operation of the facility.

 

d)         Employment application forms shall be completed for each employee and kept on file in the facility.  Completed forms shall contain, at a minimum, home address; social security number; educational background; and employment history, including dates, positions held, and reasons for leaving.  The date of employment and position held shall be documented in each file.

 

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

 

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

 

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

 

h)         The facility shall check the status of all applicants with the Nurse Aide Registry prior to hiring.

 

i)          All new employees, including student interns, shall complete an orientation program covering, at a minimum, the following:  general facility and resident orientation; job orientation, emphasizing allowable duties of the new employee; resident safety, including fire and disaster, emergency care and basic resident safety; and understanding and communicating with the type of residents being cared for in the facility.  In addition, all new direct care staff, including student interns, shall complete an orientation program covering the facility's policies and procedure for resident care services before being assigned to provide direct care to residents.  This orientation program shall include information on the prevention and treatment of decubitus ulcers and the importance of nutrition in general health care.

 

j)          All employees, except student interns, shall attend in-service training programs pertaining to their assigned duties at least annually.  These in-service training programs shall include the facility's policies, skill training, and ongoing education to enable all personnel to perform their duties effectively.  The in-service training sessions regarding personal care, nursing and restorative services shall include information on prevention and treatment of decubitus ulcers.  In-service training concerning dietary services shall include information on the effects of diet in treatment of various diseases or medical conditions and the importance of laboratory test results in determining therapeutic diets.  Written records of program content and personnel attending each session shall be kept.

 

k)         Every facility shall have a current employee time schedule.  This schedule shall contain the employee's name, job title, shift assignment, hours of work, and days off. The schedule shall be kept on file in the facility for one year after the week for which the schedule was used.

 

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

 

m)        Individual employee work performance evaluations shall be completed and maintained in the employee's file.

 

n)         The date and reason a person discontinues employment at the facility shall be noted in his/her file.

 

(Source:  Amended at 26 Ill. Reg. 10589, effective July 1, 2002)

 

Section 340.1351  Whistleblower Protection

 

a)         For the purposes of this Section, "retaliatory action" means the reprimand, discharge, suspension, demotion, denial of promotion or transfer, or change in the terms and conditions of employment of any employee of a facility that is taken in retaliation for the employee's involvement in a protected activity as set forth in Section 3-810 of the Act and this Section 340.1351.  (Section 3-810(a) of the Act)

 

b)         A facility shall not take any retaliatory action against an employee of the facility, including a nursing home administrator, because the employee does any of the following:

 

1)         Discloses or threatens to disclose to a supervisor or to a public body an activity, inaction, policy, or practice implemented by a facility that the employee reasonably believes is in violation of a law, rule, or regulation.

 

2)         Provides information to or testifies before any public body conducting an investigation, hearing, or inquiry into any violation of a law, rule, or regulation by a nursing home administrator.

 

3)         Assists or participates in a proceeding to enforce the provisions of the Act and this Part.  (Section 3-810(b) of the Act)

 

c)         A violation of the Act and this Section may be established only upon a finding that the employee of the facility engaged in conduct described in subsection (b) of Section 3-810 of the Act and this Section 340.1351 and this conduct was a contributing factor in the retaliatory action alleged by the employee.  There is no violation of this Section, however, if the facility demonstrates by clear and convincing evidence that it would have taken the same unfavorable personnel action in the absence of that conduct.  (Section 3-810(c) of the Act)

 

d)         The employee of the facility may be awarded all remedies necessary to make the employee whole and to prevent future violations of this Section.  Remedies imposed by the court may include, but are not limited to, all of the following:

 

1)         Reinstatement of the employee to either the same position held before the retaliatory action or to an equivalent position;

 

2)         Two times the amount of back pay;

 

3)         Interest on the back pay;

 

4)         Reinstatement of full fringe benefits and seniority rights; and

 

5)         Payment of reasonable costs and attorney's fees.  (Section 3-810(d) of the Act)

 

(Source:  Added at 35 Ill. Reg. 11896, effective June 29, 2011)

 

Section 340.1360  Initial Health Evaluation for Employees

 

a)         Each employee shall have an initial health evaluation, which shall be used to ensure that employees are not placed in positions that would pose undue risk of infection to themselves, other employees, residents, or visitors.

 

b)         The initial health evaluation shall include a health inventory.  This inventory shall be obtained from the employee and shall include the employee's immunization status and any available history of conditions that would predispose the employee to acquiring or transmitting infectious diseases in the course of performing anticipated job functions.  It shall include any history of exposure to, or treatment for, tuberculosis, any history of hepatitis, dermatologic conditions, chronic draining infections or open wounds.

 

c)         The initial health evaluation shall include a physical examination.  The examination shall include at a minimum any procedures needed in order to:

 

1)         Detect any unusual susceptibility to infection and any conditions that would increase the likelihood of the transmission of disease to residents, other employees, or visitors; and

 

2)         Determine that the employee appears to be physically able to perform the job functions that the facility intends to assign to the employee.

 

d)         The health inventory and physical examination shall be completed no more than 30 days prior to and no more than 30 days after the date of initial employment in the facility.

 

e)         The initial health evaluation shall include a tuberculin skin test, which is conducted in accordance with the requirements of Section 340.1520.  The test shall be completed no more than 90 days prior to or commenced no more than ten days after the date of initial employment in the facility.

 

Section 340.1370  Administrator

 

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

 

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

 

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

 

Section 340.1375  Personnel Requirements

 

a)         Supervision of Nursing Services

 

1)         The facility shall have a director of nursing service (DONS) who shall be a registered nurse.

 

A)        This person shall have knowledge and training in nursing service administration and restorative and rehabilitative nursing. This person shall also have some knowledge and training in the care of the type of residents for which the facility cares.

 

B)        This person shall be a full-time employee who is on duty a minimum of 36 hours, four days per week.

 

C)        A facility may, with written approval from the Department, have two nurses share the duties of this position if the facility is unable to obtain a full-time person.  Such an arrangement will be approved only through written documentation that the facility was unable to obtain the full-time services of a qualified individual to fill this position. Such documentation shall include, but not be limited to: an advertisement that has appeared in a newspaper of general circulation in the area for at least three weeks; the names, addresses and phone numbers of all persons who applied for the position and the reasons why they were not acceptable or would not work full time; and information about the numbers and availability of licensed nurses in the area. The Department will approve only when such documentation indicates that there were no qualified applicants who were willing to accept the job on a full-time basis, and the pool of nurses available in the area cannot be expected to produce, in the near future, a qualified person who is willing to work full time.

 

D)        In facilities of fewer than 50 beds, this person may also provide direct patient care, and this person's time may be included in meeting staff/resident ratio requirements.

 

2)         Facilities of 100 or more beds shall have a licensed nurse designated as the assistant director of nursing service. This person shall perform the duties of the DONS when the DONS is on vacation or extended sick leave. The assistant may provide direct patient care and be included in the staff to resident ratio calculations when not acting as the DONS.

 

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

 

B)        The assistant shall assist the DONS in carrying out the responsibilities of the DONS.

 

3)         The DONS shall oversee the nursing services of the facility. This person's duties shall include:

 

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

 

B)        Assuring that resident care plans are developed and maintained.

 

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

 

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

 

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

 

F)         Coordinating health services and nursing services with other resident care services such as medical, pharmaceutical, dietary activities, and any other restorative/rehabilitative services offered.

 

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

 

H)        Participating in the development and implementation of resident care policies and bringing resident care problems, requiring changes in policy, to the attention of the facility's policy development group.

 

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

 

b)         Nursing Personnel

 

1)         A licensed or registered nurse shall be on duty and designated as being in charge of nursing services on all shifts when neither the director of nursing service nor assistant director of nursing service is on duty.  If registered nurses and licensed practical nurses are on duty on the same shift, this charge nurse shall be the registered nurse.

 

2)         At least one registered nurse shall be on duty seven days per week for eight consecutive hours.  At least one registered nurse or licensed practical nurse shall be on duty on each floor housing residents.

 

3)         The need for licensed nurses on each nursing unit in a nursing facility will be determined on an individual case basis, dependent upon the individual situation. The need for an additional registered or licensed practical nurse to serve as a "house supervisor" will be determined on an individual basis.  If such additional staffing is required, the Department will inform the facility in writing of the kind and amount of additional staff time required, and the reason why it is needed.

 

4)         Nursing Assistants

 

A)        The facility shall assure that each person employed by the facility as a nursing assistant complies with one of the following conditions:

 

i)          Is approved on the Department's Nurse Aide Registry.  "Approved" means that the nursing assistant has met the training or equivalency requirements of Section 340.1376 of this Part and does not have a disqualifying criminal background check without a waiver.

 

ii)         Begins a Basic Nursing Assistant Training Program (see 77 Ill. Adm. Code 395) no later than 45 days after employment.  The nursing assistant shall successfully complete the training program within 120 days after the date of initial employment. A nursing assistant enrolled in a program approved in accordance with 77 Ill. Adm. Code 395.150(a)(2) shall not be employed more than 120 days prior to successfully completing the program.

 

iii)        Within 120 days after initial employment, submits documentation in accordance with Section 340.1376 of this Part to be registered on the Nurse Aide Registry.

 

B)        Each person employed by the facility as a nursing assistant shall meet each of the following requirements:

 

i)          Be at least 16 years of age, of temperate habits and good moral character, honest, reliable, and trustworthy.  (Section 3-206(a)(1) of the Act)

 

ii)         Be able to speak and understand the English language or a language understood by a substantial percentage of the facility's residents.  (Section 3-206(a)(2) of the Act)

 

iii)        Provide evidence of prior employment or occupation, if any, and residence for two years prior to present employment as a nursing assistant.  (Section 3-206(a)(3) of the Act)

 

iv)        Have completed at least eight years of grade school or provide proof of equivalent knowledge.  (Section 3-206(a)(4) of the Act)

 

C)        The facility shall certify to the Department the name and residence address of each nursing assistant employed by the facility, and that the employee subject to this Section meets all requirements of this Section.  Such certification shall be retained by the facility as part of the employee's personnel record. (Section 3-206(d) and (e) of the Act)

 

D)        A facility shall not employ an individual as a nursing assistant unless the facility has inquired of the Department as to information in the registry concerning the individual. (Section 3-206.01 of the Act) The Department shall advise the inquirer if the individual is on the Registry, has findings of abuse, neglect or misappropriation of property in accordance with Sections 3-206.01 and 3-206.02 of the Act, and if the individual has a current background check (see Section 340.1377 of this Part).

 

E)        Nursing assistants must be able to demonstrate competency in the principles, techniques, and procedures covered by the basic nursing assistant training program curriculum described in 77 Ill. Adm. Code 395.

 

c)         There shall be at least one person on duty at all times who has been properly trained to handle the medical emergencies listed in Section 340.1300(f) of this Part. This person may also be counted in fulfilling the requirements of other subsections of this Section.

 

d)         When a facility has only one employee on duty, that employee shall have been certified within the past 12 months in the provision of basic life support by an American Heart Association or American Red Cross certified training program. When there is more than one person on duty in the facility, at least two of the people on duty shall be so certified. A facility employee who is on duty serving in any capacity in the facility may be utilized to meet this requirement.

 

e)         Direct Care Staffing

 

1)         The facility must have adequate staff in numbers, training and supervision to meet all residents' nursing, personal care and psychosocial needs at all times.

 

2)         Staffing shall apply to hours of actual on duty time, not hours scheduled to be provided. The Director of Nursing Services time shall not be included to fulfill required hours except as allowed in subsection (a)(1)(D) of this Section. Direct care staff includes licensed nurses, certified nurse aides, social service staff, qualified mental retardation professionals, and activity personnel.

 

3)         Each resident shall be provided at least 2.0 direct care staff hours each day of which at least 20 percent must be licensed nurse time.

 

4)         In a facility whose residents participate in regularly scheduled therapeutic programs outside the facility, such as school or sheltered workshops, the minimum hours per day of direct care may be reduced proportionately as long as the facility meets the needs of the residents.

 

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

 

(Source:  Amended at 24 Ill. Reg. 17225, effective November 1, 2000)

 

Section 340.1376  Registry of Certified Nursing Assistants

 

a)         An individual will be placed on the Nurse Aide Registry when he/she has successfully completed a training program approved in accordance with the Long-Term Care Assistants and Aides Training Program Code (77 Ill. Adm. Code 395) and has met background check information required in Section 340.1377 of this Part, and when there are no findings of abuse, neglect, or misappropriation of property in accordance with Sections 3-206.01 and 3-206.02 of the Act.

 

b)         An individual will be placed on the Nurse Aide Registry if he/she has met background check information required in Section 340.1377 of this Part and submits documentation supporting one of the following equivalencies:

 

1)         Documentation of current registration from another state indicating that the requirements of 42 CFR 483.151 to 483.156 (October 1, 1997, no later amendments or editions included) have been met and that there are no documented findings of abuse, neglect, or misappropriation of property.

 

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

 

3)         Documentation of successful completion of a United States military training program that includes the content of the Basic Nursing Assistant Training Program (see 77 Ill. Adm. Code 395) and at least 40 hours of supervised clinical experience, as evidenced by a diploma, certification, DD-214, or other written verification and, within 120 days after employment, the written portion of the written portion of the Department-established nursing assistant competency test.

 

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

 

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

 

B)        Proof of application to the Department of Professional Regulation for licensure in Illinois;

 

C)        A copy of the Social Security card; and

 

D)        Visa or proof of citizenship.

 

c)         An individual shall notify the Nurse Aide Registry of any change of address within 30 days and of any name change within 30 days and shall submit proof of any name change to the Department. (Section 3-206.01 of the Act)

 

(Source:  Amended at 24 Ill. Reg. 17225, effective November 1, 2000)

 

Section 340.1377  Health Care Worker Background Check

 

A facility shall comply with the Health Care Worker Background Check Act [225 ILCS 46] and the Health Care Worker Background Check Code (77 Ill. Adm. Code 955).

 

(Source:  Amended at 29 Ill. Reg. 12924, effective August 2, 2005)

 

Section 340.1378  Resident Attendants

 

a)         As used in this Section, "resident attendant" means an individual who assists residents in a facility with the following activities:

 

1)         eating and drinking; and

 

2)         personal hygiene limited to washing a resident's hands and face, brushing and combing a resident's hair, oral hygiene, shaving residents with an electric razor, and applying makeup. (Section 3-206.03(a) of the Act)

 

b)         The term "resident attendant" does not include an individual who:

 

1)         is a licensed health professional or a registered dietitian;

 

2)         volunteers without monetary compensation;

 

3)         is a nursing assistant; or

 

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

 

c)         A facility may employ resident attendants to assist the nurse aides with the activities authorized under subsection (a) of this Section.  The resident attendants shall not count in the minimum staffing requirements under this Part. (Section 3-206.03(b) of the Act)

 

d)         Each person employed by the facility as a resident attendant shall meet the following requirements:

 

1)         Be at least 16 years of age; and

 

2)         Be able to speak and understand the English language or a language understood by a substantial percentage of the facility's residents.

 

e)         Resident attendants shall be supervised by and shall report to a nurse.

 

f)         The facility shall develop and implement policies and procedures concerning the duties of resident attendants in accordance with this Section, and shall document such duties in a written job description.

 

g)         As part of the comprehensive assessment, each resident shall be evaluated to determine whether the resident may or may not be fed, hydrated or provided personal hygiene by a resident attendant.  Such evaluation shall include, but not be limited to, the resident's level of care; the resident's functional status in regard to feeding, hydration, and personal hygiene; and the resident's ability to cooperate and communicate with staff.

 

h)         A facility may not use on a full-time or other paid basis any individual as a resident attendant in the facility unless the individual:

 

1)         has completed a Department-approved training and competency evaluation program encompassing the tasks the individual provides; and

 

2)         is competent to provide feeding, hydration, and personal hygiene services. (Section 3-206.03(c) of the Act)  The individual shall be deemed to be competent if he/she is able to perform a hands-on return demonstration of the required skills, as determined by a nurse.

 

i)          The facility shall maintain documentation of completion of the training program and determination of competency for each person employed as a resident attendant.

 

j)          A facility-based training and competency evaluation program shall be conducted by a nurse and/or dietician and shall include one or more of the following units:

 

1)         A feeding unit that is at least five hours in length and that is specific to the needs of the residents, and that includes the anatomy of digestion and swallowing; feeding techniques; developing an awareness of eating limitations; potential feeding problems and complications; resident identification; necessary equipment and materials; resident privacy; handwashing; use of disposable gloves; verbal and nonverbal communication skills; behavioral issues and management techniques; signs of choking; signs and symptoms of aspiration; and Heimlich maneuver;

 

2)         A hydration unit that is at least three hours in length and that includes the anatomy of digestion and swallowing; hydration technique; resident identification; necessary equipment and materials; potential hydration problems and complications; verbal and nonverbal communication skills; behavioral issues and management techniques; use of disposable gloves; signs of choking; signs and symptoms of aspiration; handwashing; and resident privacy;

 

3)         A personal hygiene unit that is at least five hours in length and includes oral hygiene technique, denture care; potential oral hygiene problems and complications; resident identification; verbal and nonverbal communication skills; behavioral issues and management techniques; resident privacy; handwashing; use of disposable gloves; hair combing and brushing; face and handwashing technique; necessary equipment and materials; shaving technique. (Section 3-206.03(d) of the Act)

 

k)         All training shall also include a unit in safety and resident rights that is at least five hours in length and that includes resident rights; fire safety, use of a fire extinguisher, evacuation procedures; emergency and disaster preparedness; infection control; and use of the call system.

 

l)          Each resident attendant shall be given instruction by a nurse or dietician concerning the specific feeding, hydration, and/or personal hygiene care needs of the resident whom he or she will be assigned to assist.

 

m)        Training programs shall be reviewed and approved by the Department every two years. (Section 3-206.03(d) of the Act)

 

n)         Training programs shall not be implemented prior to initial Department approval.

 

o)         Application for initial approval of facility-based and non-facility-based training programs shall be in writing and shall include:

 

1)         An outline containing the methodology, content, and objectives for the training program.  The outline shall address the curriculum requirements set forth in subsection (j) of this Section for each unit included in the program;

 

2)         A schedule for the training program;

 

3)         Resumes describing the education, experience, and qualifications of each program instructor, including a copy of any valid Illinois licenses, as applicable; and

 

4)         A copy or description of the tools that will be used to evaluate competency.

 

p)         The Department will evaluate the initial application and proposed program for conformance to the program requirements contained in this Section.  Based on this review, the Department will either:

 

1)         Grant approval of the proposed program for a period of two years;

 

2)         Grant approval of the proposed program contingent on the receipt of additional materials, or revision, needed to remedy any minor deficiencies in the application or proposed program, which would not prevent the program from being implemented, such as deficiencies in the number of hours assigned to cover different areas of content, which can be corrected by submitting a revised schedule or outline; or

 

3)         Deny approval of the proposed program based on major deficiencies in the application or proposed program, which would prevent the program from being implemented, such as deficiencies in the qualifications of instructors or missing areas of content.

 

q)         Programs shall be resubmitted to the Department for review within 60 days prior to expiration of program approval.

 

r)          If the Department finds that an approved program does not comply with the requirements of this Section, the Department will notify the facility in writing of non-compliance of the program and the reason for the finding.

 

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

 

t)          Any change in program content or objectives shall be submitted to the Department at least 30 days prior to program delivery.  The Department will review the proposed change based on the requirements of this Section and will either approve or disapprove the change.  The Department will notify the facility in writing of the approval or disapproval.

 

u)         A person seeking employment as a resident attendant is subject to the Health Care Worker Background Check Act (Section 3-206.03(f) of the Act) and Section 340.1377 of this Part.

 

(Source:  Added at 24 Ill. Reg. 17225, effective November 1, 2000)

 

Section 340.1379  Certified Nursing Assistant Interns

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

3)         Assign the work to the appropriate personnel; and

 

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

 

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

 

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

 

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

 

(Source:  Added at 48 Ill. Reg. 13825, effective August 28, 2024)

 

Section 340.1380  Contacting Local Law Enforcement

 

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

 

1)         "911" - an emergency answer and response system in which the caller need only dial 9-1-1 on a telephone to obtain emergency services, including police, fire, medical ambulance and rescue.

 

2)         Physical abuse - see Section 340.330.

 

3)         Sexual abuse - sexual penetration, intentional sexual touching or fondling, or sexual exploitation (i.e., use of an individual for another person's sexual gratification, arousal, advantage, or profit).

 

b)         The facility shall immediately contact local law enforcement authorities (e.g., telephoning 911 where available) in the following situations:

 

1)         Physical abuse involving physical injury inflicted on a resident by a staff member or visitor;

 

2)         Physical abuse involving physical injury inflicted on a resident by another resident, except in situations where the behavior is associated with dementia or developmental disability;

 

3)         Sexual abuse of a resident by a staff member, another resident, or a visitor;

 

4)         When a crime has been committed in a facility by a person other than a resident; or

 

5)         When a resident death has occurred other than by disease processes.

 

c)         The facility shall develop and implement a policy concerning local law enforcement notification, including:

 

1)         Ensuring the safety of residents in situations requiring local law enforcement notification;

 

2)         Contacting local law enforcement in situations involving physical abuse of a resident by another resident;

 

3)         Contacting police, fire, ambulance and rescue services in accordance with recommended procedure;

 

4)         Seeking advice concerning preservation of a potential crime scene;

 

5)         Facility investigation of the situation.

 

d)         Facility staff shall be trained in implementing the policy developed pursuant to subsection (c).

 

e)         The facility shall also comply with other reporting requirements of this Part.

 

(Source:  Added at 26 Ill. Reg. 4870, effective April 1, 2002)

SUBPART C: RESIDENT RIGHTS

 

Section 340.1400  Implementation of Resident Rights and Facility Responsibilities

 

a)         The facility shall establish written policies and procedures to implement the responsibilities and rights provided in Article II of the Act, Resident Rights and Facility Responsibilities.  The policies shall include the procedure for the investigation and resolution of resident complaints under the Act.  The policies shall be clear and unambiguous and shall be available for inspection by any person.  A summary of the policies and procedures, printed in not less than 12 point type, shall be distributed to each resident and representative.  (Section 2-210 of the Act)

 

b)         The facility shall provide copies of these policies and procedures upon request to next of kin, sponsoring agencies, representative payees and the public.

 

c)         Each resident and resident's guardian or other person acting for the resident shall be given a written explanation, prepared by the Office of the State Long Term Care Ombudsman, of all the rights enumerated in Part I of Article II And in Part 4 of Article III of the Act at the time of admission to a facility or as soon thereafter as the condition of the resident permits, but in no event later that 48 hours after admission, and again at least annually thereafter.  For residents of facilities participating in Title 18 or 19 of the Social Security Act, the explanation shall include an explanation of residents' rights enumerated in that Act.  If a resident is unable to read such written explanation, it shall be read to the resident in a language the resident understands.  In the case of a minor or a person having a guardian or other person acting for him, both the resident and the parent, guardian or other person acting for the resident shall be fully informed of these rights and responsibilities. (Section 2-211 of the Act)

 

d)         The resident, resident's representative, guardian, or parent of a minor resident shall acknowledge in writing the receipt from the facility of a copy of all resident rights set forth in Article II of the Act and a copy of all facility policies implementing such rights.

 

e)         The facility shall ensure that its staff is familiar with and observes the rights and responsibilities enumerated in the Act and this Part.  (Section 2-212 of the Act)

 

Section 340.1410  General

 

a)         No resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the Constitution of the State of Illinois, or the Constitution of the United States solely on account of their status as a resident of a facility.  (Section 2-101 of the Act)

 

b)         A resident shall be permitted the free exercise of religion. Upon a resident's request, and if necessary at his expense, the facility administrator shall make arrangements for a resident's attendance at religious services of the resident's choice. However, no religious beliefs or practices, or attendance at religious services, may be imposed upon any resident. (Section 2-109 of the Act)

 

c)         All facilities shall comply with the Election Code as it pertains to absentee voting for residents of licensed long-term care facilities.

 

d)         The facility shall immediately notify the resident's next of kin, representative and physician of the resident's death or when the resident's death appears to be imminent. (Section 2-208 of the Act)

 

e)         The facility shall also immediately notify the resident's family, guardian, representative, conservator and any private or public agency financially responsible for the resident's care whenever unusual circumstances such as accidents, sudden illness, disease, unexplained absences, extraordinary resident charges, billings, or related administrative matters arise.

 

f)         Where a resident, a resident's representative or a resident's next of kin believes that an emergency exists each or them, collectively or separately, may file a verified petition to the circuit court for the county in which the facility is located for an order placing the facility under the control of a receiver. (Section 3-503 of the Act) As used in Section 3-503 of the Act, "emergency" means a threat to the health, safety or welfare of a resident that the facility is unwilling or unable to correct. (Section 3-501 of the Act)

 

g)         The facility shall make reasonable efforts to prevent loss and theft of residents' property.  Those efforts shall be appropriate to the particular facility and may, for example, include, but are not limited to, staff training and monitoring, labeling property, and frequent property inventories. (Section 2-103 of the Act)

 

Section 340.1420  Contract Between Resident and Facility

 

a)         Contract Execution

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

m)        The contract shall specify the services to be provided under the contract and the charges for the services.  A paragraph shall itemize the services and products to be provided by the facility and express the cost of the itemized services and products to be provided either in terms of a daily, weekly, monthly or yearly rate, or in terms of a single fee.  (Section 2-202(g)(2) of the Act)

 

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

 

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

 

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

 

o)         The contract may provide that charges for services or products may be changed with 30 days advance written notice to the resident or the person executing the contract on behalf of the resident. The resident or any person executing the contract on behalf of the resident may either assent to the change or choose to terminate the contract at any time within 30 days of the receipt of the written notice of the change. The written notice shall become an addendum to the contract.

 

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

 

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

 

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

 

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

 

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

 

u)         All facilities which offer to provide a resident with nursing services, medical services or personal care services, in addition to maintenance services, conditioned upon the transfer of an entrance fee to the provider of such services in addition to or in lieu of the payment of regular periodic charges for the care and services involved, for a term in excess of one year or for life pursuant to a life care contract, shall meet all of the provisions of the Life Care Facilities Act (Ill. Rev. Stat. 1991, ch. 111½, par. 4161-1 et seq.) [210 ILCS 40], including the obtaining of a permit from the Department, before they may enter into such contracts.  (Section 2(c) of the Life Care Facilities Act)

 

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

 

1)         whether the facility accepts Medicaid clients;

 

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

 

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

 

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

 

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

 

Section 340.1430  Residents' Advisory Council

 

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

 

b)         The resident members shall be elected to the council by vote of their fellow residents, and the nonresident members shall be elected to the council by vote of the resident members of the council.

 

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

 

d)         No employee or affiliate of a facility shall be a member of any council.  Such persons may attend to discuss interests or functions of the non-members when invited by members of the residents' advisory council.  (Section 2-203(a) of the Act)

 

e)         The council shall meet at least once each month with the staff coordinator who shall provide assistance to the council in preparing and disseminating a report of each meeting to all residents, the administrator, and the staff. (Section 2-203(b) of the Act)

 

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

 

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

 

h)         The council shall be a forum for:

 

1)         Obtaining and disseminating information;

 

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

 

3)         Early identification of problems;

 

4)         Recommending orderly resolution of problems. (Section 2-203(e) of the Act)

 

i)          The council may present complaints on behalf of a resident to the Department, the Long-Term Care Facility Advisory Board created by Section 2-204 of the Act, or to any other person it considers appropriate. (Section 2-203(f) of the Act)

 

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

 

1)         the inclusion of community members such as volunteers, family members, residents' friends, residents' advocates, or community representatives, etc. on the resident advisory council;

 

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

 

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

 

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

 

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

 

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

 

(Source:  Amended at 31 Ill. Reg. 8841, effective June 6, 2007)

 

Section 340.1440  Abuse and Neglect

 

a)         An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident. (Section 2-107 of the Act)

 

b)         A facility employee or agent who becomes aware of abuse or neglect of a resident shall immediately report the matter to the facility administrator. (Section 3-610 of the Act)

 

c)         A facility administrator who becomes aware of abuse or neglect of a resident shall immediately report the matter by telephone and in writing to the  resident's representative. (Section 3-610 of the Act)

 

d)         A facility administrator, employee, or agent who becomes aware of abuse or neglect of a resident shall also report the matter to the Department. (Section 3-610 of the Act)

 

e)         Employee as perpetrator of abuse.  When an investigation of a report of suspected abuse of a resident indicates, based upon credible evidence, that an employee of a  long-term care facility is the perpetrator of the abuse, that employee shall immediately be barred from any further contact with residents of the facility, pending the outcome of any further investigation, prosecution or disciplinary action against the employee. (Section 3-611 of the Act)

 

f)         Resident as perpetrator of abuse.  When an investigation of a report of suspected abuse of a resident indicates, based upon credible evidence, that another resident of the long-term care facility is the perpetrator of the abuse, that resident's condition shall be immediately evaluated to determine the most suitable therapy and placement for the resident, considering the safety of that resident as well as the safety of other residents and employees of the facility. (Section 3-612 of the Act)

 

Section 340.1450  Communication and Visitation

 

a)         Every resident shall be permitted unimpeded, private and uncensored communication of his choice by mail, public telephone or visitation. (Section 2-108 of the Act)

 

b)         The facility administrator shall ensure that correspondence is conveniently received and mailed, and that telephones are reasonably accessible. (Section 2-108(a) of the Act)

 

c)         The facility administrator shall ensure that residents may have private visits at any reasonable hour unless such visits are not medically advisable for the resident as documented in the resident's clinical record by the resident's physician. (Section 2-108(b) of the Act)

 

d)         The facility shall allow daily visiting at least between 10 A.M. and 8 P.M.  Visiting hours shall be posted in plain view of visitors.

 

e)         The facility administrator shall ensure that space for visits is available and that facility personnel knock, except in an emergency, before entering any resident's room. (Section 2-108(c) of the Act)

 

f)         Unimpeded, private and uncensored communication by mail, public telephone, and visitation may be reasonably restricted by a physician only in order to protect the resident or others from harm, harassment or intimidation provided that the reason for any such restriction is placed in the resident's clinical record by the physician and that notice of probable causes of such restriction shall be given to all residents upon admission.  (Section 2-108(d) of the Act)

 

g)         Notwithstanding subsection (f) of this Section, all letters addressed by a resident to the Governor, members of the General Assembly, Attorney General, judges, state's attorneys, officers of the Department, or licensed attorneys at law shall be forwarded at once to the persons to whom they are addressed without examination by facility personnel. Letters in reply from the officials and attorneys mentioned above shall be delivered to the resident without examination by facility personnel. (Section 2-108(d) of the Act)

 

h)         Any employee or agent of a public agency, any representative of a community legal services program or any member of the general public shall be permitted access at reasonable hours to any individual resident or any facility, but only if there is neither a commercial purpose nor effect to such access and if the purpose is to do any of the following:

 

1)         Visit, talk with and make personal, social, and legal services available to all residents;

 

2)         Inform residents of their rights and entitlements and their corresponding obligations, under federal and State laws, by means of educational materials and discussions in groups and with individual residents;

 

3)         Assist residents in asserting their legal rights regarding claims for public assistance, medical assistance and Social Security benefits, as well as in all other matters in which residents are aggrieved.  Assistance any include counseling and litigation; or

 

4)         Engage in other methods of asserting, advising and representing residents so as to extend to them full enjoyment of their rights. (Section 2-110(a) of the Act)

 

i)          All persons entering a facility under  subsection (h) of this Section shall promptly notify appropriate facility personnel of their presence.  They shall, upon request, produce identification to establish their identity.  No person shall enter the immediate living area of any resident without first identifying himself and then receiving permission from the resident to enter.  The rights of other residents present in the room shall be respected. (Section 2-110(b) of the Act)

 

j)          A resident may terminate at any time a visit by a person having access to the resident's living area. (Section 2-110(b) of the Act)

 

Section 340.1460  Resident's Funds

 

a)         A resident shall be permitted to manage his own financial affairs unless he or his guardian or if the resident is a minor, his parent, authorizes the administrator of the facility in writing to manage such resident's financial affairs under subsections (b) through (n) of this Section.  (Section 2-102 of the Act)

 

b)         The facility shall at the time of admission, provide, in order of priority, each resident, or the resident's guardian, if any, or the resident's representative, if any, or the resident's immediate family member, if any, with a written statement explaining to the resident and to the resident's spouse their spousal impoverishment rights, as defined at Section 5-4 of the Illinois Public Aid Code, as now and hereafter amended, and at Section 303 of Title II of the Medicare Catastrophic Coverage Act of 1988 (P.L. 100-360), and the resident's rights regarding personal funds and listing the services for which the resident will be charged, and obtain a signed acknowledgment from each resident or the resident's guardian, if any, or the resident's representative, if any, or the resident's immediate family member, if any, that such person has received the statement.  (Section 2-201(1) of the Act)

 

c)         The facility may accept funds from a resident for safekeeping and managing, if it receives written authorization from, in order of priority, the resident or the resident's guardian, if any, or the resident's representative, if any, or the resident's immediate family member, if any; such authorization shall be attested to by a witness who has no pecuniary interest in the facility or its operations, and who is not connected in any way to facility personnel or the administrator in any manner whatsoever.  (Section 2-201(2) of the Act)

 

d)         The facility shall maintain and allow, in order of priority, each resident or the resident's guardian, if any, or the resident's representative, if any, or the resident's immediate family member, if any, access to a written record of all financial arrangements and transactions involving the individual resident's funds.  (Section 2-201(3) of the Act)

 

e)         The facility shall provide, in order of priority, each resident, or the resident's guardian, if any, or the resident's representative, if any, or the resident's immediate family member, if any, with a written itemized statement at least quarterly, of all financial transactions involving the resident's funds.  (Section 2-201(4) of the Act)

 

f)         The facility shall purchase a surety bond or otherwise provide assurance satisfactory to the Departments of Public Health and Insurance that all residents' personal funds deposited with the facility are secure against loss, theft, and insolvency. (Section 2-201(5) of the Act)

 

1)         If a surety bond is secured, it must be issued by a company licensed to do business in Illinois, the amount of bond must be equal to or greater than all resident funds managed by the facility, and the obligee named in the bond must be the Illinois Department of Public Health or its assignees.

 

2)         If an alternative to a surety bond is secured, the alternative must provide a protection equivalent to that afforded by a surety bond.  To be acceptable, the alternative must have a person(s) or entity(ies) designated who can collect in case of loss (e.g., residents, the Department).  The alternative must also provide a guarantee that lost funds will be repaid.  The guarantee may be made either by an independent entity (e.g., a bank) or the facility.  If the facility provides the guarantee, it must be backed by facility money at least equal to resident funds. This money must be reserved solely for the purpose of assuring the security of resident funds.  Two examples of acceptable alternatives to surety bonds are letters of credit and self-insurance.  Both surety bonds and alternatives must protect the full amount of residents' funds deposited with the facility.

 

3)         Any alternative to a surety bond shall be submitted to the Department for review and approval.

 

g)         The facility shall keep any funds received from a resident for safekeeping in an account separate from the facility's funds, and shall at no time withdraw any part or all of such funds for any purpose other than to return the funds to the resident upon the request of the resident or any other person entitled to make such request, to pay the resident his allowance, or to make any other payment authorized by the resident or any other person entitled to make such authorization.  (Section 2-201(6) of the Act)

 

h)         The facility shall deposit any funds received from a resident in excess of $100 in an interest bearing account insured by agencies of, or corporations chartered by, the State or federal government.  The account shall be in a form which clearly indicates that the facility has only a fiduciary interest in the funds and any interest from the account shall accrue to the resident.  (Section 2-201(7) of the Act)

 

i)          The facility may keep up to $100 of a resident's money in a non-interest bearing account or petty cash fund, to be readily available for the resident's current expenditures.  (Section 2-201(7) of the Act)

 

j)          The facility shall return to the resident, or the person who executed the written authorization required in subsection (c) of this Section, upon written request, all or any part of the resident's funds given the facility for safekeeping, including the interest accrued from deposits.  (Section 2-201(8) of the Act)

 

k)         The facility shall place any monthly allowance to which a resident is entitled in that resident's personal account, or give it to the resident, unless the facility has written authorization from the resident or the resident's guardian, or if the resident is a minor, his parent, to handle it differently.  The facility shall take all steps necessary to ensure that a personal needs allowance that is placed in a resident's personal account is used exclusively by the resident or for the benefit of the resident, and where such funds are withdrawn from the resident's personal account by any person other than the resident, require such person to whom funds constituting any part of a resident's personal needs allowance are released, to execute an affidavit that such funds shall be used exclusively for the benefit of the resident. (Section 2-201(9)(a) of the Act)  "Personal needs allowance", for the purposes of this subsection, refers to the monthly allowance allotted by the Illinois Department of Public Aid to public aid recipients.

 

l)          Unless otherwise provided by State law, the facility shall upon the death of a resident provide the executor or administrator of the resident's estate with a complete accounting of all the resident's personal property, including any funds of the resident being held by the facility.  (Section 2-201(10) of the Act)

 

m)        If an adult resident is incapable of managing his funds and does not have a resident's representative, guardian, or an immediate family member, the facility shall notify the Office of the State Guardian of the Guardianship and Advocacy Commission.  (Section 2-201(11) of the Act)

 

n)         If the facility is sold, the seller shall provide the buyer with a written verification by a public accountant of all residents' monies and properties being transferred, and obtain a signed receipt from the new owner.  (Section 2-201(12) of the Act)

 

Section 340.1470  Transfer or Discharge

 

a)         A resident may be discharged from a facility after the resident gives the administrator, a physician, or a nurse of the facility written notice of the resident's desire to be discharged.  If a guardian has been appointed for a resident or if the resident is a minor, the resident shall be discharged upon written consent of their guardian or if the resident is a minor, the resident's parent unless there is a court order to the contrary.  In such cases, upon the resident's discharge, the facility is relieved from any responsibility for the resident's care, safety or well-being. (Section 2-111 of the Act)

 

b)         A facility may involuntarily transfer or discharge a resident only for one or more of the following reasons:

 

1)         for medical reasons;

 

2)         for the resident's physical safety;

 

3)         for the physical safety of other residents, the facility staff or facility visitors; or

 

4)         for either late payment or nonpayment for the resident's stay, except as prohibited by Titles XVIII and XIX of the federal Social Security Act.  For purposes of this Section, "late payment" means non-receipt of payment after submission of a bill.  If payment is not received within 45 days after submission of a bill, a facility may send a notice to the resident and responsible party requesting payment within 30 days.  If payment is not received within such 30 days, the facility may thereupon institute transfer or discharge proceedings by sending a notice of transfer or discharge to the resident and responsible party by registered or certified mail.  The notice shall state, in addition to the requirements of Section 3-403 of the Act and subsection (e) of this Section, that the responsible party has the right to pay the amount of the bill in full up to the date the transfer or discharge is to be made and then the resident shall have the right to remain in the facility.  Such payment shall terminate the transfer or discharge proceedings.  This subsection (b) does not apply to those residents whose care is provided under the Illinois Public Aid Code.  (Section 3-401 of the Act)

 

c)         A facility participating in the Medical Assistance Program is prohibited from failing or refusing to retain as a resident any person because the resident is a recipient of, or an applicant for, the Medical Assistance Program under Article V of the Illinois Public Aid Code.  (Section 3-401.1(a) of the Act)  For the purposes of Section 3-401.1 of the Act, a recipient or applicant shall be considered a resident in the facility during any hospital stay totaling 10 days or less following a hospital admission.  (Section 3-401.1(a-10) of the Act)  The day on which a resident is discharged from the facility and admitted to the hospital shall be considered the first day of the 10-day period. 

 

d)         Involuntary transfer or discharge of a resident from a facility shall be preceded by the discussion required under Section 3-408 of the Act and subsection (j) of this Section and by a minimum written notice of 21 days, except in one of the following instances:

 

1)         When an emergency transfer or discharge is ordered by the resident's attending physician because of the resident's health care needs.  The State Long Term Care Ombudsman shall be notified at the time of the emergency transfer or discharge;  (Section 3-402(a) of the Act)

 

2)         When the transfer or discharge is mandated by the physical safety of other residents, the facility staff, or facility visitors as documented in the clinical record. The Department and the State Long Term Care Ombudsman shall be notified prior to any such involuntary transfer or discharge.  The Department will immediately offer transfer, or discharge and relocation assistance to residents transferred or discharged under this subsection (d), and the Department may place relocation teams as provided in Section 3-419 of the Act; or (Section 3-402(b) of the Act)

 

3)         When an identified offender is within the provisional admission period defined in Section 1-120.3 of the Act and Section 340.1000 of this Part.  If the Identified Offender Report and Recommendation prepared under Section 2-201.6 of the Act shows that the identified offender poses a serious threat or danger to the physical safety of other residents, the facility staff, or facility visitors in the admitting facility, and the facility determines that it is unable to provide a safe environment for the other residents, the facility staff, or facility visitors, the facility shall transfer or discharge the identified offender within 3 days after its receipt of the Identified Offender Report and Recommendation.  (Section 3-402(c) of the Act)

 

e)         For transfer or discharge made under subsection (d), the notice of transfer or discharge shall be made as soon as practicable before the transfer or discharge. The notice required by Section 3-402 of the Act and subsection (d) of this Section shall be on a form prescribed by the Department and shall contain all of the following:

 

1)         The stated reason for the proposed transfer or discharge; (Section 3-403(a) of the Act)

 

2)         The effective date of the proposed transfer or discharge; (Section 3-403(b) of the Act)

 

3)         A statement in not less than 12-point type, which reads: "You have a right to appeal the facility's decision to transfer or discharge you.  If you think you should not have to leave this facility, you may file a request for a hearing with the Department of Public Health within 10 days after receiving this notice.  If you request a hearing, it will be held not later than 10 days after your request, and you generally will not be transferred or discharged during that time.  If the decision following the hearing is not in your favor, you generally will not be transferred or discharged prior to the expiration of 30 days following receipt of the original notice of the transfer or discharge.  A form to appeal the facility's decision and to request a hearing is attached.  If you have any questions, call the Department of Public Health or the State Long Term Care Ombudsman at the telephone numbers listed below."; (Section 3-403(c) of the Act)

 

4)         A hearing request form, together with a postage paid, preaddressed envelope to the Department; and (Section 3-403(d) of the Act)

 

5)         The name, address, and telephone number of the person charged with the responsibility of supervising the transfer or discharge. (Section 3-403(e) of the Act)

 

f)         A request for a hearing made under Section 3-403 of the Act and subsection (e) of this Section shall stay a transfer pending a hearing or appeal of the decision, unless a condition which would have allowed transfer or discharge in less than 21 days as described under subsections (d)(1) and (2) of this Section develops in the interim. (Section 3-404 of the Act)

 

g)         A copy of the notice required by Section 3-402 of the Act and subsection (d) of this Section shall be placed in the resident's clinical record and a copy shall be transmitted to the Department, the State Long Term Care Ombudsman, the resident, and the resident's representative.  (Section 3-405 of the Act)

 

h)         When the basis for an involuntary transfer or discharge is the result of an action by the Department of Healthcare and Family Services with respect to a recipient of Title XIX and a hearing request is filed with the Department of Healthcare and Family Services, the 21-day written notice period shall not begin until a final decision in the matter is rendered by the Department of Healthcare and Family Services or a court of competent jurisdiction and notice of that final decision is received by the resident and the facility.  (Section 3-406 of the Act)

 

i)          When nonpayment is the basis for involuntary transfer or discharge, the resident shall have the right to redeem up to the date that the discharge or transfer is to be made and then shall have the right to remain in the facility.  (Section 3-407 of the Act)

 

j)          The planned involuntary transfer or discharge shall be discussed with the resident, the resident's representative and person or agency responsible for the resident's placement, maintenance, and care in the facility.  The explanation and discussion of the reasons for involuntary transfer or discharge shall include the facility administrator or other appropriate facility representative as the administrator's designee.  The content of the discussion and explanation shall be summarized in writing and shall include the names of the individuals involved in the discussions.  This summary shall be made a part of the resident's clinical record.  (Section 3-408 of the Act)

 

k)         The facility shall offer the resident counseling services before the transfer or discharge of the resident.  (Section 3-409 of the Act)

 

l)          A resident subject to involuntary transfer or discharge from a facility, the resident's guardian or if the resident is a minor, the resident's parent shall have the opportunity to file a request for a hearing with the Department within 10 days following receipt of the written notice of the involuntary transfer or discharge by the facility.  (Section 3-410 of the Act)

 

m)        The Department of Public Health, when the basis for involuntary transfer or discharge is other than action by the Department of Healthcare and Family Services with respect to the Title XIX Medicaid recipient, shall hold a hearing at the resident's facility not later than 10 days after a hearing request is filed, and render a decision within 14 days after the filing of the hearing request.  (Section 3-411 of the Act)

 

n)         The hearing before the Department provided under Section 3-411 of the Act and subsection (m) of this Section shall be conducted as prescribed under Section 3-703 of the Act.  In determining whether a transfer or discharge is authorized, the burden of proof in this hearing rests on the person requesting the transfer or discharge.  (Section 3-412 of the Act)

 

o)         If the Department determines that a transfer or discharge is authorized under Section 3-401 of the Act and subsection (b) of this Section, the resident shall not be required to leave the facility before the 34th day following receipt of the notice required under Section 3-402 of the Act and subsection (c) of this Section, or the 10^th day following receipt of the Department's decision, whichever is later, unless a condition which would have allowed transfer or discharge in less than 21 days as described under Section 3-402 of the Act and subsections (d)(1) and (2) of this Section develops in the interim. (Section 3-413 of the Act)

 

p)         The Department of Healthcare and Family Services shall continue Title XIX Medicaid funding during the appeal, transfer, or discharge period for those residents who are Title XIX recipients affected by Section 3-401 of the Act and subsection (c) of this Section.  (Section 3-414 of the Act)

 

q)         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 such part will require the transfer or discharge of more than 10% percent of the residents.  Such notice shall be given to the Department, to the office of the State Long-Term Care Ombudsman, to any resident who must be transferred or discharged, to the resident's representative, and to a member of the resident's family, where practicable.  If the Department suspends, revokes, or denies renewal of the facility's license, then notice shall be given no later than the date specified by the Department.  Notice shall state the proposed date of closing and the reason for closing.  The facility shall submit a closure plan to the Department for approval which shall address the process for the safe and orderly transfer of residents. The approved plan shall be included in the notice.  The facility shall offer to assist the resident in securing an alternative placement and shall advise the resident on available alternatives.  When the resident is unable to choose an alternate placement and is not under guardianship, the Department shall be notified of the need for relocation assistance.  A facility closing in its entirety shall not admit any new residents on or after the date written notice is submitted to the Department under the Act and this Part.  The facility shall comply with all applicable laws and regulations until the date of closing, including those related to transfer or discharge of residents.  The Department will place a relocation team in the facility as provided under Section 3-419 of the Act.  (Section 3-423 of the Act)

 

(Source:  Amended at 49 Ill. Reg. 832, effective December 31, 2024)

 

Section 340.1480  Complaint Procedures

 

a)         The facility shall develop procedures for investigating complaints concerning theft of resident's property and shall promptly investigate all such complaints.  (Section 2-103 of the Act)

 

b)         A resident shall be permitted to present grievances on behalf of himself and others to the administrator, the Long-term Care Facility Advisory Board, the residents' advisory council, State governmental agencies or other persons without threat of discharge or reprisal in any form or manner whatsoever. (Section 2-212 of the Act)

 

c)         The facility administrator shall provide all residents or their representatives with the name, address, and telephone number of the appropriate State governmental office where complaints may be lodged. (Section 2-212 of the Act)

 

d)         A person who believes that the Act or a rule promulgated under the Act may have been violated may request an investigation.  The request may be submitted to the Department in writing, by telephone, or by personal visit.  An oral complaint shall be reduced to writing by the Department. (Section 3-702(a) of the Act)

 

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

 

Section 340.1490  Private Right of Action

 

a)         Each resident shall have the right to maintain a private right of action against a facility as described in subsections (b) through (i) of this Section.

 

b)         The owner and licensee of a facility are liable to a resident for any intentional or negligent act or omission of their agents or employees which injures the resident. (Section 3-601 of the Act)

 

c)         The licensee shall pay three times the actual damages, or $500, whichever is greater, and costs and attorney's fees to a facility resident whose rights as specified in Part 1 of Article II of the Act are violated. (Section 3-602 of the Act)

 

d)         A resident may maintain an action under the Act and this Part for any other type or relief, including injunctive and declaratory relief, permitted by law. (Section 3-603 of the Act)

 

e)         Any damages recoverable under subsections (b) through (i) of this Section, including minimum damages as provided by this Part, may be recovered in any action which a court may authorize to be brought as a class action pursuant to part 8 of the Civil Practice Law (Ill. Rev. Stat. 1991, ch. 110, par. 2-801 et seq.) [735 ILCS 5]. The remedies provided in subsections (b) through (i) of this Section are in addition to and cumulative with any other legal remedies available to a resident. Exhaustion of any available administrative remedies shall not be required prior to commencement of a suit hereunder. (Section 3-604 of the Act)

 

f)         The amount of damages recovered by a resident in an action brought under subsections (b) through (i) of this Section shall be exempt for purposes of determining initial or  continuing eligibility for medical assistance under the Illinois Public Aid Code (Ill. Rev. Stat. 1991, ch. 23, par. 1-1 et seq.) [305 ILCS 5] as now or hereafter amended, and shall neither be taken into consideration nor required to be applied toward the payment or partial payment of the cost of medical care or services available under the Illinois Public Aid Code. (Section 3-605 of the Act)

 

g)         Any waiver by a resident or legal representative of the right to commence an action under subsections (b) through (i) of this Section, whether oral or in writing, shall be null and void, and without legal force or effect. (Section 3-606 of the Act)

 

h)         Any party to an action brought under subsections (b) through (i) of this Section shall be entitled to a trial by jury and any waiver of the right to a trial by jury, whether oral or in writing, prior to the commencement of an action, shall be null and void, and without legal force or effect. (Section 3-607 of the Act)

 

i)          A licensee or its agents or employees shall not transfer, discharge, evict, harass, dismiss, or retaliate against a resident, a resident's representative, or an employee or agent who makes a report of resident abuse or neglect, brings or testifies in a private right of action, or files a complaint, because of the report, testimony or complaint. (Section 3-608 of the Act)

 

Section 340.1491  Social Isolation

 

a)         For the purposes of this Section:

 

1)         "Assistive and supportive technology and devices" means computers, video conferencing equipment, distance-based communication technology, or other technological equipment, accessories, or electronic licenses as may be necessary to ensure that residents are able to engage in face-to-face, verbal-based, or auditory-based contact, communication, religious activity, or recreational activity with other facility residents and with family members, friends, loved ones, caregivers, and other external support systems, through electronic means, in accordance with the provisions of the Act and subsections (d)(2) and (3).

 

2)         "Religious and recreational activities" includes any religious, social, or recreational activity that is consistent with a resident's preferences and choosing, regardless of whether the activity is coordinated, offered, provided, or sponsored by facility staff or by an outside activities provider.

 

3)         "Resident's representative" has the same meaning as provided in Section 1-123 of the Act and Section 340.1000.

 

4)         "Social isolation" means a state of isolation wherein a resident of a long-term care facility is unable to engage in social interactions and religious and recreational activities with other facility residents or with family members, friends, loved ones, caregivers and external support systems.

 

5)         "Virtual visitation" means the use of face-to-face, verbal-based, or auditory-based contact through electronic means.  (Section 3-102.3(a) of the Act)

 

b)         Each facility shall adopt and implement written policies that provide for the availability of assistive and supportive technology and devices to facility residents.  Facilities shall ensure that appropriate staff are in place to help prevent the social isolation of facility residents.  (Section 3-102.3(b)(1) of the Act)

 

c)         The virtual visitation policies shall not be interpreted as a substitute for in-person visitation, but shall be wholly in addition to existing in-person visitation policies.  (Section 3-102.3(b)(2) of the Act)

 

d)         The social isolation prevention policies adopted by each long-term care facility pursuant to this Section shall be consistent with rights and privileges guaranteed to residents and constraints provided under Sections 2-108, 2-109, and 2-110 of the Act and this Subpart C, and shall include the following:

 

1)         Authorization and inclusion of specific protocols and procedures to encourage and enable residents of the facility to engage in in-person contact, communication, religious activity, and recreational activity with other facility residents and with family members, friends, loved ones, caregivers, and other external support systems, except when prohibited, restricted, or limited by federal or State statute, rule, regulation, executive order, or guidance;

 

2)         Authorization and inclusion of specific protocols and procedures to encourage and enable residents to engage in face-to-face, verbal-based, or auditory-based contact, communication, religious activity, and recreational activity with other facility residents and with family members, friends, loved ones, caregivers, and other external support systems through the use of electronic or virtual means and methods, including, but not limited to, computer technology, the Internet, social media, videoconferencing, videophone, and other innovative technological means or methods, whenever the resident is subject to restrictions that limit his or her ability to engage in in-person contact, communication, religious activity, or recreational activity as authorized by subsection (d)(1) and when the technology requested is not being used by other residents in the event of a limited number of items of technology in a facility;

 

3)         A mechanism for residents of the facility or the residents' representatives to request access to assistive and supportive technology and devices as may be necessary to facilitate the residents' engagement in face-to-face, verbal-based, or auditory-based contact, communication, religious activity, and recreational activity with other residents, family members, friends, and other external support systems, through electronic means, as provided by subsection (d)(2);

 

4)         Specific administrative policies, procedures, and protocols governing: 

 

A)        The acquisition, maintenance, and replacement of assistive and supportive technology and devices;

 

B)        The use of environmental barriers and other controls when the assistive and supportive technology and devices acquired pursuant to subsection (4)(A) are in use, especially in cases where the assistive and supportive technology and devices are likely to become contaminated with bodily substances, are touched frequently, or are difficult to clean; and

 

C)        The regular cleaning of the assistive and supportive technology and devices acquired pursuant to subsection (4)(A) and any environmental barriers or other physical controls used in association therewith; 

 

5)         A requirement that upon admission and at the request of a resident or the resident's representative, appropriate staff shall develop and update an individualized virtual visitation schedule while taking into account the individual's requests and preferences with respect to the residents' participation in social interactions and religious and recreational activities;

 

6)         A requirement that appropriate staff, upon the request of a resident or the resident's family members, guardian, or representative, shall develop an individualized virtual visitation schedule for the resident, which shall:

 

A)        Address the need for a virtual visitation schedule and establish a virtual visitation schedule if deemed to be appropriate;

 

B)        Identify the assessed needs and preferences of the resident and any preferences specified by the resident's representative, unless a preference specified by the resident conflicts with a preference specified by the resident's representative, in which case the resident's preference shall take priority;

 

C)        Document the facility's defined virtual hours of visitation and inform the resident and the resident's representative that virtual visitation pursuant to subsection (d)(2) will adhere to the defined visitation hours;

 

D)        Describe the location within the facility and assistive and supportive technology and devices to be used in virtual visitation; and

 

E)        Describe the respective responsibilities of staff, visitors, and the resident when engaging in virtual visitation pursuant to the individualized visitation plan;

 

7)         A requirement that, upon admission and at the request of the resident or the resident's representative, the facility provides notification to the resident and the resident's representative that they have the right to request of facility staff the creation and review of a resident's individualized virtual visitation schedule;

 

8)         A requirement that, upon admission and at the request of the resident or resident's representative, the facility provide, in writing to the resident or resident's representative, virtual visitation hours, how to schedule a virtual visitation, and how to request assistive and supportive technology and devices;

 

9)         Specific policies, protocols, and procedures governing a resident's requisition, use, and return of assistive and supportive technology and devices maintained pursuant to subsection (4)(A) and require appropriate staff to communicate those policies, protocols, and procedures to residents; and

 

10)         The designation of at least one member of the therapeutic recreation or activities department, or, if the facility does not have this department, the designation of at least one senior staff member, as determined by facility management, to train other appropriate facility employees, including, but not limited to, activities professionals and volunteers, social workers, occupational therapists, and therapy assistants, to provide direct assistance to residents upon request and on an as-needed basis, as necessary to ensure that each resident is able to successfully access and use, for the purposes specified in subsections (d)(2) and (3), the assistive and supportive technology and devices acquired pursuant to subsection (4)(A).  (Section 3-102.3(c) of the Act)

 

e)         A facility may apply to the Department for competitive civil monetary penalty fund grants for assistive and supportive technology and devices and may request other available federal and State funds.  (Section 3-102.3(d) of the Act)

 

f)         In addition to any other applicable penalties provided by law, a facility that fails to comply with the provisions of this Section or properly implement the written policies, protocols, and procedures adopted pursuant to subsection (b) shall be liable to pay an administrative penalty as a Type "C" violation, the amount of which shall be determined in accordance with subsections (f) and (g) of Section 340.1245.  (Section 3-102.3(e) of the Act)

 

g)         Implementation of an administrative penalty as a Type "C" violation under this subsection will not be imposed prior to January 1, 2023.  (Section 3-102.3(e) of the Act)

 

h)         This Section does not impact, limit, or constrict a resident's right to or usage of his or her personal property or electronic monitoring under Section 2-115 of the Act.  (Section 3-102.3(g) of the Act)

 

i)          Specific protocols and procedures shall be developed to ensure that the quantity of assistive and supportive technology and devices maintained on-site at the facility remains sufficient, at all times, to meet the assessed social and activity needs and preferences of each facility resident.  Residents' family members or caregivers shall be considered, as appropriate, in the assessment and reassessment.  (Section 3-102.3(h) of the Act)

 

j)          No administrative penalty shall be imposed against a facility for internet bandwidth limitations or internet access barriers beyond the control of the facility, such as a natural disaster.

 

k)         Nothing in this Section shall be interpreted to mean that addressing the issues of social isolation shall take precedence over providing for the health and safety of the residents.  (Section 3-102.3(k) of the Act)

 

(Source:  Added at 46 Ill. Reg. 14285, effective July 27, 2022)

SUBPART D: HEALTH SERVICES

 

Section 340.1500  Medical Care Policies

 

a)         The facility shall have a written program of medical services approved in writing by the advisory physician, which reflects the philosophy of care provided, the policies relating to this philosophy, and the procedures for implementation of the services.  The program shall include the entire complex of services provided by the facility and the arrangements to effect transfer to other facilities as promptly as needed.  The written program of medical services shall be followed in the operation of the facility.

 

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

 

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

 

2)         Documentation of the presence or absence of tuberculosis infection by tuberculin skin test in accordance with Section 340.1520.

 

3)         Documentation of the presence or absence of incipient or manifest decubitus ulcers (commonly known as bed sores), with grade, size and location specified, and orders for treatment, if present.  (A photograph of incipient or manifest decubitus ulcers is recommended on admission.)

 

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

 

c)         The facility shall notify the resident's physician of any accident, injury, or significant change in a resident's condition that threatens the health, safety or welfare of a resident, including, but not limited to, the presence of incipient or manifest decubitus ulcers or a weight loss or gain of five percent or more within a period of 30 days.  The facility shall obtain and record the physician's plan of care for the care or treatment of such accident, injury or change in condition at the time of notification.

 

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

 

e)         All medical treatment and procedures shall be administered as ordered by a physician.  All new physician orders shall be reviewed by the facility's director of nursing or charge nurse designee within 24 hours after such orders have been issued to assure facility compliance with such orders.  (Section 2-104(b) of the Act)

 

f)         Every resident shall be permitted to refuse medical treatment and to know the consequences of such action, unless such refusal would be harmful to the health and safety of others and such harm is documented by a physician in the resident's clinical record.  (Section 2-104(c) of the Act)

 

g)         All residents shall be permitted to participate in the planning of their total care and medical treatment to the extent that their condition permits.  (Section 2-104(a) of the Act)

 

h)         No resident shall be subjected to experimental research or treatment without first obtaining his informed, written consent.  The conduct of any experimental research or treatment shall be authorized and monitored by an institutional review committee appointed by the administrator of the facility where such research and treatment is conducted.  Any facility desiring to conduct an experimental program or do research that is in conflict with this Part shall submit a written request to the Department and secure prior approval.  Such approval will be granted only if the request will not create an unnecessary and unusual threat to the health, welfare, safety or rights of residents or staff.  (Section 2-104(a) of the Act)

 

i)          All residents shall be permitted respect and privacy in their medical and personal care program.  Every resident's case discussion, consultation, examination and treatment shall be confidential and shall be conducted discreetly, and those persons not directly involved in the resident's care must have the resident's permission to be present.  (Section 2-105 of the Act)

 

Section 340.1505  Medical, Nursing and Restorative Services

 

a)         Comprehensive resident care plan.  A facility, with the participation of the resident and the resident's guardian or representative, as applicable, must develop and implement a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment, which allow the resident to attain or maintain the highest practicable level of independent functioning, and provide for discharge planning to the least restrictive setting based on the resident’s care needs.  The assessment shall be developed with the active participation of the resident and the resident’s guardian or representative, as applicable. (Section 3-202.2a of the Act)

 

b)         The facility shall provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each resident's comprehensive resident care plan.  Adequate and properly supervised nursing care shall be provided to each resident to meet the total nursing care needs of the resident.

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

f)         If physical therapy, occupational therapy, speech therapy or any other specialized rehabilitative service is offered, it shall be provided by, or supervised by, a qualified professional in that specialty and upon the written order of the physician.

 

1)         In addition to the provision of direct services, any such qualified professional personnel shall be used as consultants to the total restorative program and shall assist with resident evaluation, resident care planning, and inservice education.

 

2)         Appropriate records shall be maintained by these personnel. Direct service to individual residents shall be documented on the individual clinical record as set forth in Section 340.1800(e) of this Part. A summary of program consultation and recommendations shall be documented.

 

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

 

(Source:  Amended at 35 Ill. Reg. 11896, effective June 29, 2011)

 

Section 340.1510  Communicable Disease Policies

 

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

 

b)         A resident who is suspected of or diagnosed as having any communicable, contagious or infectious disease, as defined in the Control of Communicable Diseases Code, shall be placed in isolation, if required, in accordance with the Control of Communicable Diseases Code. If the facility believes that it cannot provide the necessary infection control measures, it must initiate an involuntary transfer and discharge pursuant to Article III, Part 4 of the Act and Section 340.1310 of this Part. In determining whether a transfer or discharge is necessary, the burden of proof rests on the facility.

 

c)         All illnesses required to be reported under the Control of Communicable Diseases Code and Control of Sexually Transmissible Diseases Code (77 Ill. Adm. Code 693) shall be reported immediately to the local health department and to the Department.  The facility shall furnish all pertinent information relating to such occurrences.  In addition, the facility shall inform the Department of all incidents of scabies and other skin infestations.

 

(Source:  Amended at 29 Ill. Reg. 12924, effective August 2, 2005)

 

Section 340.1520  Tuberculin Skin Test Procedures

 

Tuberculin skin tests for employees and residents shall be conducted in accordance with the Control of Tuberculosis Code (77 Ill. Adm. Code 696).

 

(Source:  Amended at 23 Ill. Reg. 7931, effective July 15, 1999)

 

Section 340.1530  Physician Services

 

a)         A resident shall be permitted to retain the services of his own personal physician at his own expense under an individual or group plan of health insurance, or under any public or private assistance program providing such coverage. (Section 2-104(a) of the Act)

 

b)         The Department shall not prescribe the course of medical treatment provided to an individual resident by the resident's physician in a facility.  (Section 2-104(a) of the Act)

 

c)         The services of a physician licensed to practice medicine in Illinois shall be available to every resident of the facility.

 

d)         All residents shall be seen by their physician as often as necessary to assure adequate health care.

 

e)         All residents shall be permitted to obtain from their own physicians or the physician attached to the facility complete and current information concerning their medical diagnoses, treatment and prognoses in terms and language the residents can reasonably be expected to understand.  (Section 2-104(a) of the Act)

 

f)         All physician orders, plans of medical treatment, Medicare/Medicaid Certification and recertification statements must have the original written signature of the physician.  The use of a physician's rubber stamp signature with or without initials is not acceptable.

 

Section 340.1535  Dental Programs

 

a)         There shall be comprehensive treatment services for all residents which include, but are not limited to, the following:

 

1)         Provision for dental treatment;

 

2)         Provision for emergency treatment by a qualified dentist; and

 

3)         Assistance in arranging transportation to the dentist for treatment.

 

b)         The direct care staff shall receive inservice education annually. This will be provided by a dentist or a dental hygienist.

 

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

 

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

 

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

 

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

 

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

 

c)         The dental program shall provide for inservice education to residents and staff under direction of dental staff including, but not limited to, the following:

 

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

 

2)         Instruction in proper oral hygiene methods.

 

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

 

d)         The facility's dental program shall provide for each resident's proper daily personal dental hygiene, with the staff responsible for continuity of care that includes, but is not limited to, the following:

 

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

 

2)         Proper cleaning of dentures and partials, if applicable.

 

e)         If applicable, each facility shall have a denture and dental prosthesis marking system that takes into account the identification marking system contained in Section 49 of the Illinois Dental Practice Act (Ill. Rev. Stat. 1991, ch. 111, par. 2349). Policies and procedures shall be written and contained in the facility's policies and procedures manual. It shall include, at minimum, provision for:

 

1)         Marking individual dentures or dental prothesis, if not marked prior to admission to the facility, within ten days of admittance; and

 

2)         Individually marked denture cups for dental storage at night.

 

Section 340.1540  Life-Sustaining Treatments

 

a)         Every facility shall respect the residents' right to make decisions relating to their own medical treatment, including the right to accept, reject, or limit life-sustaining treatment. Every facility shall establish a policy concerning the implementation of such rights. Included within this policy shall be:

 

1)         implementation of Living Wills or Powers of Attorney for Health Care in accordance with the Living Will Act (Ill. Rev. Stat. 1991, ch. 110 ½, pars. 701 et seq.) [755 ILCS 35] and the Powers of Attorney for Health Care Law (Ill. Rev. Stat. 1991, ch. 110 ½, pars. 804-1 et seq.) [755 ILCS 45/Art. IV];

 

2)         the implementation of physician orders limiting resuscitation such as those commonly referred to as "Do-Not-Resuscitate" orders.  This policy may only prescribe the format, method of documentation and duration of any physician orders limiting resuscitation.  Any orders under this policy shall be honored by the facility;  (Section 2-104.2 of the Act)

 

3)         procedures for providing life-sustaining treatments available to residents at the facility;

 

4)         procedures detailing staff's responsibility with respect to the provision of life-sustaining treatment when a resident has chosen to accept, reject, or limit life-sustaining treatment, or when a resident has failed or has not yet been given the opportunity to make these choices; and

 

5)         procedures for educating both direct and indirect care staff in the application of those specific provisions of the policy for which they are responsible.

 

b)         For the purposes of this Section:

 

1)         "Agent" means a person acting under a Health Care Power of Attorney in accordance with the Powers of Attorney for Health Care Law;

 

2)         "Life-sustaining treatment" means any medical treatment, procedure, or intervention that, in the judgement of the attending physician, when applied to a resident, would serve only to prolong the dying process.  Those procedures can include, but are not limited to, cardiopulmonary resuscitation (CPR), assisted ventilation, renal dialysis, surgical procedures, blood transfusions, and the administration of drugs, antibiotics, and artificial nutrition and hydration.  Those procedures do not include performing the Heimlich maneuver or clearing the airway, as indicated;

 

3)         "Surrogate" means a surrogate decision maker acting in accordance with the Health Care Surrogate Act (Ill. Rev. Stat. 1991, ch. 110 ½, pars. 851-1 et seq.) [755 ILCS 40].

 

c)         Within 30 days of admission for new residents, and within one year of the effective date of this Section for all residents who were admitted prior to the effective date of this Section, residents, agents, or surrogates shall be given written information describing the facility's policies required by this Section and shall be given the opportunity to:

 

1)         execute a Living Will or Power of Attorney for Health Care in accordance with State law, if they have not already done so; and/or

 

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

 

d)         Any decision made by a resident, an agent, or a surrogate pursuant to subsection (c) above must be recorded in the resident's medical record.  Any subsequent changes or modifications must also be recorded in the medical record.

 

e)         The facility shall honor all decisions made by a resident, an agent, or a surrogate pursuant to subsection (c) above and may not discriminate in the provision of health care on the basis of such decision or will transfer care in accordance with the Living Will Act, the Powers of Attorney for Health Care Law, the Health Care Surrogate Act or the Right of Conscience Act (Ill. Rev. Stat. 1991, ch. 111 ½, pars. 5301 et seq.) [745 ILCS 70].

 

f)         The resident, agent, or surrogate may change his or her decision regarding life-sustaining treatments by notifying the treating facility of this decision change orally or in writing in accordance with State law.

 

g)         The physician shall confirm the resident's choice by writing appropriate orders in the patient record or will transfer care in accordance with the Living Will Act, the Powers of Attorney for Health Care Law, the Health Care Surrogate Act or the Right of Conscience Act.

 

h)         If no choice is made pursuant to subsection (c) above, and in the absence of any physician's order to the contrary, then the facility's policy with respect to the provision of life-sustaining treatment shall control until and if such a decision is made by the resident, agent, or surrogate in accordance with the requirements of the Health Care Surrogate Act.

 

Section 340.1550  Obstetrical and Gynecological Care

 

Every woman resident of child-bearing age shall receive routine obstetrical and gynecological evaluations as well as necessary prenatal care.  (Section 2-104(b) of the Act)  In addition, women residents shall be referred immediately for diagnosis whenever pregnancy is suspected.

 

a)         "Routine obstetrical evaluations" and "necessary prenatal care" shall include ata minimum, the following:

 

1)         Early diagnosis of pregnancy;

 

2)         A comprehensive health history, including menstrual history, methods of family planning that the patient has used, a detailed record of past pregnancies, and data on the current pregnancy that allow the physician to estimate the date of delivery;

 

3)         Identification of factors in the current pregnancy that help to identify the patient at high risk, such as maternal age, vaginal bleeding, edema, urinary infection, exposure to radiation and chemicals, ingestion of drugs and alcohol, and use of tobacco;

 

4)         A comprehensive physical examination, including an evaluation of nutritional status; determination of height, weight and blood pressure; examination of the head, breasts, heart, lungs, abdomen, pelvis, rectum, and extremities;

 

5)         The following laboratory tests, as early in pregnancy as possible. Findings obtained from the history and physical examination may determine the need for additional laboratory evaluations:

 

A)        Hemoglobin or hematocrit measurement;

 

B)        Urinalysis, including microscopic examination or culture;

 

C)        Blood group and Rh type determination;

 

D)        Antibody screen;

 

E)        Rubella antibody titer measurement;

 

F)         Syphilis screen;

 

G)        Cervical cytology; and

 

H)        Viral hepatitis (HBsAg) testing;

 

6)         A risk assessment that, based on the findings of the history and physical examination, should indicate any risk factors that may require special management, such as cardiovascular disease, maternal age more than 35 years, neurologic disorder, or congenital abnormalities;

 

7)         Return visits, the frequency of which will be determined by the resident's needs and risk factors.  A woman with an uncomplicated pregnancy shall be seen every four weeks for the first 28 weeks of pregnancy, every two to three weeks until 36 weeks of gestation, and weekly thereafter;

 

8)         Determinations of blood pressure, measured fundal height, fetal heart rate, and, in later months, fetal presentation, and urinalysis for albumin and glucose.  Hemoglobin or hematocrit level shall be measured again early in the third trimester.  Glucose screening is recommended for women who are 30 years of age or older;

 

9)         Evaluation and monitoring of nutritional status and habits;

 

10)         Education for health promotion and maintenance;

 

11)         Counseling concerning exercise and childbirth education programs; and

 

12)         Postpartum review and evaluation four to eight weeks after delivery, including determination of weight and blood pressure and assessment of status of breasts, abdomen, and external and internal genitalia.

 

b)         "Routine gynecological evaluations" shall include, at a minimum, the following:

 

1)         An initial examination, the basic components of which are:

 

A)        History; any present illnesses; menstrual, reproductive, medical, surgical, emotional, social, family, and sexual history; medications; allergies; family planning; and systems review;

 

B)        Physical examination, including height, weight, nutritional status, and blood pressure; head and neck, including thyroid gland; heart; lungs; breasts; abdomen; pelvis, including external and internal genitalia; rectum; extremities, including signs of abuse; lymph nodes; and

 

C)        Laboratory tests, including urine screen; hemoglobin or hematocrit determination and, if indicated, complete blood cell count; cervical cytology; rubella titer.

 

2)         Annual updates, including, but not limited to:

 

A)        History, including the purpose of the visit; menstrual history; interval history, including systems review; emotional history;

 

B)        Physical examination, including weight, nutritional status and blood pressure; thyroid gland; breasts; abdomen; pelvis, including external and internal genitalia; rectum; other areas as indicated by the interval history;

 

C)        Laboratory, including urine screen; cervical cytology, unless not indicated; hemoglobin or hematocrit determinations; and

 

D)        Additional laboratory tests, such as screening for sexually transmitted disease, shall be performed as warranted by the history, physical findings, and risk factors.

 

c)         When a resident is referred for a diagnosis of pregnancy and/or for prenatal care, the facility shall send the health care provider a copy of the resident's medical record, including a list of prescription medications taken by the resident; if known, the resident's use of alcohol, tobacco and illicit drugs; and any exposure of the resident to radiation or chemicals during the preceding three months.

 

d)         Cancer screening shall include the following:

 

1)         A periodic Pap test.  The frequency and administration of Pap tests shall be according to the guidelines set forth in the "Guidelines for Women's Health Care", published by the American College of Obstetricians and Gynecologists; and

 

2)         Mammography.  The frequency and administration of mammograms shall be according to the guidelines set forth in the "Guidelines for Women's Health Care".

 

(Source:  Amended at 35 Ill. Reg. 3442, effective February 14, 2011)

 

Section 340.1560  Nursing Personnel

 

a)         There shall be sufficient number of nursing and auxiliary personnel on duty each day to provide adequate and properly supervised nursing services to meet the nursing needs of the residents.

 

b)         There shall be at least one person awake, dressed and on duty at all times in each separate unit.

 

c)         Nursing service personnel at all levels of experience and competence shall only be assigned responsibilities in accordance with their qualifications.

 

Section 340.1570  Personal Care

 

a)         Personal care, as defined in Section 340.1000, shall be provided on a 24-hour, seven-day-a-week basis, as needed by the resident.  This shall include, but not be limited to, the following:

 

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

 

2)         Each resident shall have at least one complete bath and shampoo weekly and as many additional baths and shampoos as necessary for satisfactory personal hygiene.

 

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

 

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

 

b)         If clothing is provided to the resident by the facility it shall be of proper fit.  (Section 2-103 of the Act)

 

Section 340.1575  Care and Treatment of Sexual Assault Survivors

 

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

 

1)         Ambulance Provider – an individual or entity that owns and operates a business or service using ambulances or emergency medical services vehicles to transport emergency patients.

 

2)         Sexual Assault – an act of nonconsensual sexual conduct or sexual penetration, as defined in Section 12-12 of the Criminal Code of 1961 including, without limitation, acts prohibited under Sections 12-13 through 12-16 of the Criminal Code of 1961.

 

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

 

1)         Notify local law enforcement pursuant to the requirements of Section 340.1830;

 

2)         Call an ambulance provider if medical care is needed;

 

3)         Move the survivor, as quickly as reasonably possible, to a closed environment to ensure privacy while waiting for emergency or law enforcement personnel to arrive. The facility shall ensure the welfare and privacy of the survivor, including the use of incident code to avoid embarrassment; and

 

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

 

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

 

d)         The facility shall notify the Department and draft a descriptive summary of the alleged sexual assault pursuant to the requirements of Section 340.1330.

 

(Source:  Added at 35 Ill. Reg. 11896, effective June 29, 2011)

 

Section 340.1580  Restraints  

 

a)         The facility shall have written policies controlling the use of physical restraints, including but not limited to leg restraints, arm restraints, hand mitts, soft ties or vests, wheelchair safety bars and lap trays, and all facility practices that meet the definition of a restraint.  Such practices shall include, but not be limited to:  tucking in a sheet so tightly that a bed-bound resident cannot move; bed rails used to keep a resident from getting out of bed; chairs that prevent rising; or placing a resident who uses a wheelchair so close to a wall that the wall prevents the resident from rising. Adaptive equipment is not considered a restraint.  Wrist bands or devices on clothing that trigger electronic alarms to warn staff that a resident is leaving a room do not, in and of themselves, restrict freedom of movement and should not be considered as physical restraints.  The policies shall be followed in the operation of the facility and shall comply with the Act and this Part.  These policies shall be developed by the medical advisory committee or the advisory physician with participation by nursing and administrative personnel.

 

b)         No restraints with locks shall be used.

 

c)         Physical restraints shall not be used on a resident for the purposes of discipline or convenience.

 

d)         The use of chemical restraints is prohibited.

 

(Source:  Amended at 20 Ill. Reg. 12013, effective September 10, 1996)

 

Section 340.1590  Nonemergency Use of Physical Restraints

 

a)         Physical restraints shall only be used when required to treat the residents' medical symptoms or as a therapeutic intervention, as ordered by a physician, and based on:

 

1)         the assessment of the resident's capabilities and an evaluation and trial of less restrictive alternatives that could prove effective (Section 2-106(c) of the Act);

 

2)         the assessment of a specific physical condition or medical treatment, that requires the use of physical restraints,  and how the use of physical restraints will assist the resident in reaching his or her highest practicable physical, mental or psychosocial well being (Section 2-106(c) of the Act);

 

3)         consultation with appropriate health professionals, such as rehabilitative nurses and occupational or physical therapists, which indicates that the use of less restrictive measures or therapeutic interventions has proven ineffective; and

 

4)         demonstration by the care planning process that using a restraint as a therapeutic intervention will promote the care and services necessary for the resident to attain or maintain the highest practicable physical, mental or psychosocial well being.  (Section 2-106(c) of the Act, see P.A. 88-413, effective August 20, 1993)

 

b)         A physical restraint may be used only with the informed consent of the resident, the resident's guardian, or other authorized representative.  (Section 2-106(c) of the Act, see P.A. 88-413, effective August 20, 1993)  Informed consent includes information about potential negative outcomes of physical restraint use, including incontinence, decreased range of motion, decreased ability to ambulate, symptoms of withdrawal or depression, or reduced social contact.

 

c)         The informed consent may authorize the use of a physical restraint for a specified period of time. The effectiveness of the physical restraint in treating medical symptoms or as a therapeutic intervention, and any negative impact on the resident, shall be assessed by the facility throughout the period of time the physical restraint is used.

 

d)         After 50% of the period of restraint use authorized by the informed consent has expired but not less than five days before it has expired, information about the actual effectiveness of the restraint in treating the resident's medical symptoms or as a therapeutic intervention and about any actual negative impact on the resident shall be given to the resident, resident's guardian, or other authorized representative before the facility secures an informed consent for an additional period of time. Information about the effectiveness of the restraint program and about any negative impact on the resident shall be provided in writing.

 

e)         A physical restraint may be applied only by staff trained in the application of the particular type of restraint.  (Section 2-106(d) of the Act, see P.A. 88-413, effective August 20, 1993)

 

f)         Whenever a period of use of a physical restraint is initiated, the resident shall be advised of his or her right to have a person or organization of his or her choosing, including the Guardianship and Advocacy Commission, notified of the use of the physical restraint. A period of use is initiated when a physical restraint is applied to a resident for the first time under a new or renewed informed consent for the use of physical restraints.  A recipient who is under guardianship may request that a person or organization of his or her choosing be notified of the restraint, whether or not the guardian approves the notice.  If the resident so chooses, the facility shall make the notification within 24 hours, including any information about the period of time that the physical restraint is to be used.  Whenever the Guardianship and Advocacy Commission is notified that a resident has been restrained, it shall contact the resident to determine the circumstances of the restraint and whether further action is warranted.  (Section 2-106(e) of the Act, see P.A. 88-413, effective August 20, 1993) If the resident requests that the Guardianship and Advocacy Commission to be contacted, the facility shall provide the following information in writing to the Guardianship and Advocacy Commission:

 

1)         the reason the physical restraint was needed;

 

2)         the type of physical restraint that was used;

 

3)         the interventions utilized or considered prior to physical restraint and the impact of those interventions;

 

4)         the length of time the physical restraint was to be applied; and

 

5)         the name and title of the facility staff person who should be contacted for further information.

 

g)         Whenever a physical restraint is used on a resident whose primary mode of communication is sign language, the resident shall be permitted to have his or her hands free from restraint for brief periods each hour, except when this freedom may result in physical harm to the resident or others.  (Section 2-106(f) of the Act, see P.A. 88-413, effective August 20, 1993)

 

h)         The plan of care shall contain a schedule or plan of rehabilitative/habilitative training to enable the most feasible progressive removal of physical restraints or the most practicable progressive use of less restrictive means to enable the resident to attain or maintain the highest practicable physical, mental or psychosocial well being.

 

i)          A resident wearing a physical restraint shall have it released for a few minutes at least once every two hours, or more often if necessary.  During these times, residents shall be assisted with ambulation, as their condition permits, and provided a change in position, skin care and nursing care, as appropriate.

 

j)          No form of seclusion shall be permitted.

 

Section 340.1600  Emergency Use of Physical Restraints

 

a)         If a resident needs emergency care, physical restraints may be used for brief periods to permit treatment to proceed unless the facility has notice that the resident has previously made a valid refusal of the treatment in question.  (Section 2-106(c) of the Act, see P.A. 88-413, effective August 20, 1993)

 

b)         For this Section only, "emergency care" means the unforeseen need for immediate treatment inside or outside the facility that is necessary to:

 

1)         save the resident's life;

 

2)         prevent the resident from doing serious mental or physical harm to himself/herself; or

 

3)         prevent the resident from injuring another individual.

 

c)         If a resident needs emergency care and other less restrictive interventions have proved ineffective, a physical restraint may be used briefly to permit treatment to proceed.  The attending physician shall be contacted immediately for orders.  If the attending physician is not available, the facility's advisory physician or Medical Director shall be contacted.  If a physician is not immediately available, a nurse with supervisory responsibility may approve, in writing, the use of physical restraints.  A confirming order, which may be obtained by telephone, shall be obtained from the physician as soon as possible, but no later than eight hours after the physical restraint has been applied.  The effectiveness of the restraint in treating medical symptoms or as a therapeutic intervention, and any negative impact on the resident, shall be assessed by the facility throughout the period of time the restraint is used.  The resident must be in view of a staff person at all times until either the resident has been examined by a physician or the restraint is removed.  The resident's needs for toileting, ambulation, hydration, nutrition, repositioning, and skin care must be met while the physical restraint is being used.

 

d)         The emergency use of a physical restraint must be documented in the resident record, including:

 

1)         the behavior incident that prompted the use of the physical restraint;

 

2)         the date and times the physical restraint was applied and released;

 

3)         the name and title of the person responsible for the application and supervision of the physical restraint;

 

4)         the action by the resident's physician upon notification of the physical restraint use;

 

5)         the new or revised orders issued by the physician; and

 

6)         the effectiveness of the physical restraint in treating symptoms or as a therapeutic intervention, and any negative impact on the resident; and

 

7)         the date of the scheduled care planning conference or the reason a care planning conference is not needed, in light of the resident's emergency need for restraints.

 

e)         The facility's emergency use of physical restraints shall comply with Sections 340.1590 (e), (f), (g), and (j).

 

Section 340.1610  Unnecessary, Psychotropic, and Antipsychotic Drugs

 

a)         A resident shall not be given unnecessary drugs in accordance with Section 340.Table B. In addition, an unnecessary drug is any drug used:

 

1)         in an excessive dose, including in duplicative therapy;

 

2)         for excessive duration;

 

3)         without adequate monitoring;

 

4)         without adequate indications for its use; or

 

5)         in the presence of adverse consequences that indicate the drugs should be reduced or discontinued.  (Section 2-106.1(a) of the Act, see P.A. 88-413, effective August 20, 1993)

 

b)         Psychotropic medication shall not be prescribed without the informed consent of the resident, the resident's guardian, or other authorized representative.  (Section 2-106.1(b) of the Act, see P.A. 88-413, effective August 20, 1993) Informed consent includes information about potential negative outcomes of psychotropic medication use. Additional informed consent is not required for reduction in dosage level or deletion of a specific medication.

 

c)         Residents shall not be given antipsychotic drugs unless antipsychotic drug therapy is necessary, as documented in the resident's comprehensive assessment, to treat a specific or suspected condition as diagnosed and documented in the clinical record or to rule out the possibility of one of the conditions in accordance with Section 340.Table B, Guidelines for the Use of Various Drugs.

 

d)         Residents who use antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue these drugs in accordance with Section 340.Table B, Guidelines for the Use of Various Drugs.

 

e)         For the purposes of this Section:

 

1)         "Duplicative drug therapy" means any drug therapy that duplicates a particular drug effect on the resident without any demonstrative therapeutic benefit.  For example, any two or more drugs, whether from the same drug category or not, that have a sedative effect.

 

2)         "Psychotropic medication" means medication that is used for or listed as used for antipsychotic, antidepressant, antimanic or antianxiety behavior modification or behavior management purposes in the latest edition of the AMA Drug Evaluations or the Physician's Desk Reference or Drug Evaluation Subscription, American Medical Association, Vols. I-III, Summer 1993.  (Section 2-106.1(b) of the Act, see P.A. 88-413, effective August 20, 1993)

 

3)         "Antipsychotic Drug" means a neuroleptic drug that is helpful in the treatment of psychosis and has a capacity to ameliorate thought disorders.

 

Section 340.1620  Medication Administration (Repealed)

 

(Source:  Repealed at 27 Ill. Reg. 5903, effective April 01, 2003)

 

Section 340.1630  Self-Administration of Medication (Renumbered)

 

(Source:  Section 340.1630 renumbered to Section 340.1675 at 27 Ill. Reg. 5903, effective April 01, 2003)

 

Section 340.1640  Vaccinations

 

a)         A facility shall annually administer or arrange for a vaccination against influenza to each resident, in accordance with the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention that are most recent to the time of vaccination, unless the vaccination is medically contraindicated or the resident has refused the vaccine.  Influenza vaccinations for all residents age 65 and over shall be completed by November 30 of each year or as soon as practicable if vaccine supplies are not available before November 1.  Residents admitted after November 30, during the flu season, and until February 1 shall, as medically appropriate, receive an influenza vaccination prior to or upon admission or as soon as practicable if vaccine supplies are not available at the time of the admission, unless the vaccine is medically contraindicated or the resident has refused the vaccine.  (Section 2-213 of the Act)

 

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

 

c)         A facility shall provide or arrange for administration of a pneumococcal vaccination to each resident in accordance with the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, who has not received this immunization prior to or upon admission to the facility unless the resident refuses the offer for vaccination or the vaccination is medically contraindicated.  (Section 2-213 of the Act)

 

d)         A facility shall document in each resident's medical record that a vaccination against pneumococcal pneumonia was offered and administered, refused, or medically contraindicated.  (Section 2-213 of the Act)

 

(Source:  Amended at 39 Ill. Reg. 5482, effective March 25, 2015)

 

Section 340.1645  Language Assistance Services

 

A facility shall provide language assistance services in accordance with the Language Assistance Services Act [210 ILCS 87] and the Language Assistance Services Code (77 Ill. Adm. Code 940).

 

(Source:  Added at 29 Ill. Reg. 12924, effective August 2, 2005)

SUBPART E: MEDICATIONS

 

Section 340.1650  Medication Policies and Procedures

 

a)         Medication administration services are provided by a facility when medications are administered by facility staff.  Facilities that provide medication administration services shall adopt written policies and procedures for properly and promptly obtaining, dispensing, administering, returning, and disposing of drugs and medications.  These policies and procedures shall be consistent with the Act and this Part, shall be in compliance with all applicable federal, State, and local laws, and shall be followed by the facility.  These policies and procedures shall be developed with the advice of a pharmaceutical advisory committee that includes at least a pharmacist, a physician, the administrator and the director of nursing.  (This is not intended to limit the facility's organization of responsibilities.  Any group that includes at least these four members may approve these policies and procedures.)

 

b)         For the purpose of this Subpart, "licensed prescriber" means a physician;  a dentist; a podiatrist; an optometrist certified to use therapeutic ocular pharmaceutical agents; a physician assistant to whom prescriptive authority has been delegated by a supervising physician; or an advanced practice nurse practicing under a valid collaborative agreement.

 

c)         All legend medications maintained in the facility shall be on individual prescriptions or from the licensed prescriber's personal office supply, and shall be labeled as set forth in Section 340.1670.  A licensed prescriber who dispenses medication from his or her personal office supply shall comply with Sections 33 and 54.5 of the Medical Practice Act of 1987 [225 ILCS 60/33 and 54.5]; or Section 51 of the Illinois Dental Practice Act [225 ILCS 25/51]; or the Podiatric Medical Practice Act of 1987 [225 ILCS 100]; or Section 15.1 of the Illinois Optometric Practice Act of 1987 [225 ILCS 80/15.1]; or Section 15-20 of the Nursing and Advanced Practice Nursing Act [225 ILCS 65/15-20]; or Section 7.5 of the Physician Assistant Practice Act of 1987 [225 ILCS 95/7.5].

 

d)         No facility shall maintain a stock supply of controlled drugs or legend drugs, except for those in the emergency medication kits and convenience boxes, as described in this Section.

 

e)         A facility may stock drugs that are regularly available without prescription.  These shall be administered to a resident only upon written order of a licensed prescriber.  These medications shall be administered from the original containers, and shall be recorded in the resident's clinical record. Medications shall not be recorded as having been administered prior to their actual administration to the resident.

 

f)         A facility may keep "convenience boxes" containing medications to be used for initial doses.

 

1)         The contents and number of convenience boxes shall be determined by the pharmaceutical advisory committee.  The contents shall be listed on the outside of each box.

 

2)         Each convenience box shall be the property of and under the control of the pharmacy that supplies the contents of the box, and it shall be kept in a locked medicine room or cabinet.

 

3)         No Schedule II controlled substances shall be kept in convenience boxes.

 

g)         The contents and number of emergency medication kits shall be approved by the facility's pharmaceutical advisory committee, and shall be available for immediate use at all times in locations determined by the pharmaceutical advisory committee.

 

1)         Each emergency medication kit shall be sealed after it has been checked and refilled.

 

2)         Emergency medication kits shall also contain all of the equipment needed to administer the medications.

 

3)         The contents of emergency medication kits shall be labeled on the outside of each kit. The kits shall be checked and refilled by the pharmacy after use and as otherwise needed.  The pharmaceutical advisory committee shall review the list of substances kept in emergency medication kits at least quarterly. Written documentation of this review shall be maintained.

 

h)         The following requirements shall be met when controlled substances are kept as part of the emergency medication kits:

 

1)         If an emergency medication kit is not stored in a locked room or cabinet, or if the kit contains controlled substances that require refrigeration, then the controlled substances portion of the kit shall be stored separately in a locked cabinet or room (or locked refrigerator or locked container within a refrigerator, as appropriate) and labeled with a list of the substances and a statement that they are part of the emergency medication kit. The label of the emergency medication kit shall list the substances and the specific location where they are stored.

 

2)         Controlled substances for emergency medication kits shall be obtained from a federal Drug Enforcement Administration registered hospital, pharmacy, or licensed prescriber.

 

3)         Only the director of nursing, registered nurse on duty, licensed practical nurse on duty, consultant pharmacist or licensed prescriber shall have access to controlled substances stored in emergency medication kits.

 

4)         No more than ten different controlled substances shall be kept as part of an emergency medication kit, and there shall be no more than three single doses of any one controlled substance.

 

5)         Controlled substances in emergency medication kits may be administered only by persons licensed to administer medications, in compliance with 21 CFR 1306.11 and 1306.21 and the Illinois Controlled Substances Act [720 ILCS 570].

 

6)         A proof-of-use sheet shall be stored with each controlled substance.  Entries shall be made on the proof-of-use sheet by the nursing staff or licensed prescriber when any controlled substance from the kit is used.  The consultant pharmacist shall receive and file for two years a copy of all completed proof-of-use sheets.

 

7)         Whenever the controlled substance portion of an emergency medication kit is opened, the consultant pharmacist shall be notified within 24 hours. During any period when this kit is opened, a shift count shall be done on all controlled substances until the kit is closed or locked or the controlled substance is replaced.  Shift counts are not mandatory when the kit is sealed.  Forms for shift counts shall be kept with the controlled substances portion of the emergency medication kit.

 

8)         The consultant pharmacist shall check the controlled substances portions of emergency medication kits at least monthly and so document on the outside of each kit.

 

9)         Failure to comply with any provision of this Section or with any applicable provision of State or federal statutes or State regulations pertaining to controlled substances shall result in loss of the privilege of having or placing controlled substances in emergency medication kits until the facility can demonstrate that it is in compliance with such regulations.  This is in addition to the usual methods of corrective action available to the Department, such as fines and other penalties.

 

i)          Oxygen may be administered in a facility. The oxygen supply shall be stored and handled in accordance with the National Fire Protection Association (NFPA) Standard 99:  Standard for Health Care Facilities (2002, no later amendments or editions included) for nonflammable medical gas systems.  The facility shall comply with directions for use of oxygen systems as established by the manufacturer and the applicable provisions of the NFPA Life Safety Code (see Section 340.1010) and NFPA 99.

 

1)         Facilities shall store medical grade products separately from industrial grade products.  The storage area for medical grade products shall be well defined with one area for receiving full medical gas vessels and another for storing empty vessels.

 

2)         All personnel who will be handling medical gases shall be trained to recognize the various medical gas labels.  Personnel shall be trained to examine all labels carefully.

 

3)         If the facility's supplier uses 360-degree wrap-around labels to designate medical oxygen, personnel shall be specifically trained to make sure each vessel they connect to the oxygen system bears such a label.

 

4)         All facility personnel responsible for changing or installing medical gas vessels shall be trained to connect medical gas vessels properly.  Personnel shall understand how vessels are connected to the oxygen supply system and shall be alerted to the serious consequences of changing connections.

 

5)         If a medical gas vessel fitting does not seem to connect to the oxygen system fitting, the supplier shall be contacted immediately.  The vessel shall be returned to the supplier to determine the fitting or connection problem.

 

6)         Once a medical gas vessel has been connected to the oxygen supply system, but prior to introducing the product into the system, a trained facility staff member shall ensure that the correct vessel has been connected properly.

 

j)          Subsections (c), (d), (e), (f), (g) and (h) shall not apply to facilities served by an on-site licensed Division III pharmacy.

 

(Source:  Amended at 27 Ill. Reg. 5903, effective April 01, 2003)

 

Section 340.1655  Compliance with Licensed Prescriber's Orders

 

a)         All medications shall be given only upon the written, facsimile or electronic order of a licensed prescriber.  The facsimile or electronic orders of a licensed prescriber shall be authenticated by the licensed prescriber within 10 calendar days, in accordance with Section 340.1800.  All such orders shall have the handwritten signature (or unique identifier) of the licensed prescriber.  (Rubber stamp signatures are not acceptable.)  These medications shall be administered as prescribed by the licensed prescriber and at the designated time.

 

b)         Telephone orders may be taken by a registered nurse, licensed practical nurse or licensed pharmacist.  All such orders shall be immediately written on the resident's clinical record, or a telephone order form and signed by the nurse or pharmacist taking the order. These orders shall be countersigned by the licensed prescriber within ten calendar days.

 

c)         The staff pharmacist or consultant pharmacist shall review the medical record, including licensed prescriber's orders and laboratory test results, at least monthly and, based on their clinical experience and judgement, and Section 340.Table B, determine if there are irregularities that may cause adverse reactions, allergies, contraindications, medication errors or ineffectiveness.  This review shall be done at the facility and shall be documented in the clinical record.  Any irregularities noted shall be reported to the attending physician, the advisory physician, the director of nursing and the administrator and shall be acted upon.

 

d)         A medication order not specifically limiting the time or number of doses shall be automatically stopped in accordance with written policies approved by the pharmaceutical advisory committee.

 

e)         The resident's licensed prescriber shall be notified of medications about to be stopped so that the licensed prescriber may promptly renew such orders to avoid interruption of the resident's therapeutic regimen.

 

f)         The licensed prescriber shall approve the release of any medications to the resident, or person responsible for the resident's care, at the time of discharge or when the resident is going to be temporarily out of the facility at medication time.  Disposition of the medications shall be noted in the resident's clinical record.

 

(Source:  Amended at 27 Ill. Reg. 5903, effective April 01, 2003)

 

Section 340.1660  Administration of Medication

 

a)         All medications shall be administered only by personnel who are licensed to administer medications, in accordance with their respective licensing requirements.  Licensed practical nurses shall have successfully completed a course in pharmacology or have at least one year's full-time supervised experience in a health care setting if their duties include administering medications to residents.

 

b)         Medications shall be administered as soon as possible after doses are prepared at the facility and shall be administered by the same person who prepared the doses for administration, except under single unit dose packaged distribution systems.

 

c)         Each dose administered shall be properly recorded in the clinical record by the person who administered the dose.

 

d)         The facility shall have medication records that shall be used and checked against the licensed prescriber's orders to assure proper administration of medicine to each resident.  Medication records shall include or be accompanied by recent photographs or other means of easy, accurate resident identification.  Medication records shall contain the resident's name, diagnoses, known allergies, current medications, dosages, directions for use, and, if available, a history of prescription and non-prescription medications taken by the resident during the 30 days prior to admission to the facility.

 

e)         Medications prescribed for one resident shall not be administered to another resident.

 

f)         If, for any reason, a licensed prescriber's medication order cannot be followed, the licensed prescriber shall be notified as soon as is reasonable, depending upon the situation, and a notation made in the resident's record.

 

g)         Medication errors and drug reactions shall be immediately reported to the resident's physician, licensed prescriber if other than a physician, the consulting pharmacist and the dispensing pharmacist (if the consulting pharmacist and the dispensing pharmacist are not associated with the same pharmacy).  An entry shall be made in the resident's clinical record, and the error or reaction shall also be described in an incident report.

 

h)         Current medication references shall be available, such as the current edition of " Drug Facts and Comparisons", "Hospital Formulary", "USP-DI (United States Pharmacopeia – Drug Information", "Physician's Desk Reference" or other suitable references.

 

(Source:  Amended at 27 Ill. Reg. 5903, effective April 01, 2003)

 

Section 340.1665  Control of Medications

 

a)         All Schedule II controlled substances shall be stored so that two separate locks, using two different keys, must be unlocked to obtain these substances.  This may be accomplished by several methods, such as locked cabinets within locked medicine rooms; separately locked, securely fastened boxes (or drawers) within a locked medicine cabinet; locked portable medication carts that are stored in locked medicine rooms when not in use; or portable medication carts containing a separate locked area within the locked medication cart, when such cart is made immobile.

 

b)         All medications having an expiration date that has passed, and all medications of residents who have been discharged or who have died shall be disposed of in accordance with the written policies and procedures established by the facility in accordance with Section 340.1650.  Medications shall be transferred with a resident, upon the order of the resident's physician, when a resident transfers to another facility.  All discontinued medications, with the exception of those products regulated and defined as controlled substances under Section 802 of the federal Controlled Substances Act (21 UCS 802), shall be returned to the dispensing pharmacy.  Medications for any resident who has been temporarily transferred to a hospital shall be kept in the facility. Medications may be given to a discharged resident only upon the order of a licensed prescriber.

 

c)           Inventory Controls

 

1)         For all Schedule II substances, a controlled substances record shall be maintained that lists on separate sheets, for each type and strength of Schedule II substances, the following information:  date, time administered, name of resident, dose, licensed prescriber's name, signature of person administering dose, and number of doses remaining.

 

2)         The pharmaceutical advisory committee may also require that other medications shall be subject to such inventory records.

 

(Source:  Amended at 27 Ill. Reg. 5903, effective April 01, 2003)

 

Section 340.1670  Labeling and Storage of Medication

 

a)         The label of each individual multi-dose medication container filled by a pharmacist shall clearly indicate the resident's full name; licensed presriber's name; prescription number, name, strength and quantity of drug; date this container was last filled; the initials of the pharmacist filling the prescription; the name and address of the pharmacy; and any necessary special instructions.  If the individual multi-dose medication container is dispensed by a licensed prescriber from his or her own supply, the label shall clearly indicate all of the preceding information and the source of supply; it shall exclude identification of the pharmacy, pharmacist, and prescription number.

 

b)         Each single unit or unit dose package shall bear the proprietary or nonproprietary name of the drug, strength of dose and total contents delivered, lot or control number, and expiration date, if applicable.  The names of the resident and the licensed prescriber do not have to be on the label of the package, but they must be identified with the package in such a manner as to assure that the drug is administered to the right resident.  Appropriate accessory and cautionary statements and any necessary special instruction shall be included, as applicable.  Hardware for storing and delivering the medications shall be labeled with the identity of the dispensing pharmacy.  The pharmacist shall provide written verification of the date the medications were dispensed and the initials of the pharmacist who reviewed and verified the medications.  The pharmacist need not store such verification at the facility but shall readily make it available to the Department upon request.  The lot or control number need not appear on unit dose packages if the dispensing pharmacy has a system for identifying those doses recalled by the manufacturer/distributor or if the dispensing pharmacy will recall and destroy all dispensed doses of a recalled medication, irrespective of a manufacturer's/distributor's specifically recalled lot.

 

c)         Medication in containers having soiled, damaged, incomplete, illegible, or makeshift labels shall be returned to the issuing pharmacist, pharmacy, or dispensing licensed prescriber for relabeling or disposal. Medications whose directions for use have changed since the medication was originally dispensed and labeled may be retained for use at the facility in accordance with the licensed prescriber’s current medication order.  Medications in containers having no labels shall be destroyed in accordance with federal and State laws.

 

d)         The medications of each resident shall be kept and stored in their originally received containers.  Medications shall not be transferred between containers, except that a licensed nurse, acting as the agent of the resident, may remove previously dispensed medication from original containers and place it in other containers to be sent with a resident when the resident will be out of the facility at the time of scheduled administration of medication.  When medication is sent out of the facility with the resident, it shall be labeled by the nurse with the name of the resident, name and strength of the medication, instructions for administration, and any other appropriate information.

 

e)         All medications for external use shall be kept in a separate area in the medicine cabinet, medicine room, or mobile medication cart.

 

f)         All poisonous substances and other hazardous compounds shall be kept in a separate locked container away from medications.

 

g)         Biologicals or medications requiring refrigeration shall be kept in a separate, securely fastened locked box within a refrigerator or a locked refrigerator, at or near the nurses' station or in a refrigerator within a locked medication room.

 

h)         The key or access code to the medicine cabinet, medicine room, or mobile medication cart shall be the responsibility of, and in the possession of, the persons authorized to handle and administer medications, at all times.

 

i)          All medications for all residents shall be properly labeled and stored at, or near, the nurses' station, in a locked cabinet, a locked medication room, or one or more locked mobile medication carts of satisfactory design for such storage.

 

1)         These cabinets, rooms, and carts shall be well lighted and of sufficient size to permit storage without crowding.

 

2)         All mobile medication carts shall be under the visual control of the responsible nurse at all times when not stored safely and securely.

 

(Source:  Amended at 27 Ill. Reg. 5903, effective April 01, 2003)

 

Section 340.1675  Self-Administration of Medication

 

a)         A resident may self-administer medications, as approved in writing by the resident's personal licensed prescriber.

 

b)         All medications shall be properly labeled and stored in a locked area at all times.  Areas shall be well lighted and of sufficient size to permit storage without crowding.  This area may be a drawer, closet, cabinet or room.  The medication area shall not be used for any other purpose.  It shall not be located in residents' rooms, bathrooms or the kitchen, except as allowed in subsection (d) of this Section.  The key to the medication area shall be the responsibility of, and in the possession of, the staff persons responsible for overseeing the self-administration of medications by residents.

 

c)         If the facility medication policies permit residents to be totally responsible for their own medication, with written permission from the attending physician, the resident and attending physician shall be given written statements concerning what the responsibilities of the facility, the resident and the physician are if the resident, or any other person, suffers harm as a result of the resident's handling his or her own medications.

 

d)         Residents who are totally responsible for their own medication shall maintain possession of the key or combination of the lock to their own medication storage area, which may be a locked drawer or cabinet in the resident's room or private bathroom.  A duplicate key, or a copy of the combination, shall be kept by the facility in a secure place, for emergency use.

 

e)         Facility staff shall not administer medications unless they are properly licensed to administer medications, in accordance with their respective licensing requirements.  Unlicensed facility staff may assist in self-administration of medications as follows:

 

1)         They may prompt a resident that it is the time to take medication.

 

2)         They may assist a resident in the self-administration of medications by taking the medication from the locked area where it is stored and handing it to the resident. If the resident is physically unable to the open the container, a staff member may open the container for the resident.

 

3)         Facility staff may also assist physically impaired residents, such as those who have arthritis, cerebral palsy, or Parkinson's disease, in the removal of the medication from the container and in assisting the resident in consuming or applying the medication when requested to do so by the resident.  (For example, a staff member may place a dose of medicine in a container and place the container to the mouth of a resident who would not be able to do so himself without spilling it.)

 

(Source:  Section 340.1675 renumbered from Section 340.1630 and amended at 27 Ill. Reg. 5903, effective April 01, 2003)

SUBPART F: RESIDENT LIVING SERVICES

 

Section 340.1700  Recreational and Activity Programs

 

a)         The facility shall provide an ongoing program of recreational and activity services to meet the interests and preferences and physical, mental and psychosocial well-being of each resident, in accordance with the resident's comprehensive assessment.  These services shall be coordinated with other services and programs to make use of both community and facility resources and to benefit the residents.

 

b)         Activity personnel shall be provided to meet the needs of the residents and the program.  Activity staff time each week shall total not less than 45 minutes multiplied by the number of residents in the facility.  This time shall be spent in providing activity programming as well as planning and directing the program.  The time spent in the performance of other duties not related to the activity program shall not be counted as part of the required activity staff time.

 

1)         In a facility whose residents participate in regularly scheduled therapeutic programs outside the facility, such as school, employment or sheltered workshop, the minimum hours per week of activity staff time may be reduced.  The reduction shall be calculated by multiplying the number of residents in the facility who participate in such programs by the percentage of the day that these residents spend in such programs.

 

2)         Activity personnel working under the direction of the activity director shall have a minimum of 10 hours of in-service training per calendar or employment year, directly related to recreation/activities.  In-service training may be provided by qualified facility staff and/or consultants, or may be obtained from college or university courses, seminars and/or workshops, educational offerings through professional organizations, similar educational offerings or any combination thereof.

 

c)         Activity Director and Consultation

 

1)         A trained staff person shall be designated as activity director and shall be responsible for planning and directing the activities program.  This person shall be regularly scheduled to be on duty in the facility at least four days per week.

 

2)         If the activity director is not a Certified Therapeutic Recreation Specialist (CTRS), Occupational Therapist Registered and Licensed (OTR/L), or a Licensed Social Worker (LSW) or Licensed Clinical Social Worker (LCSW) who has specialized course work in social group work, the facility shall have a written agreement with a person from one of those disciplines to provide consultation to the activity director at least monthly, to ensure that the activity programming meets the needs of the residents of the facility.

 

3)         Any person designated as activity director hired after November 1, 2000, shall have a high school diploma or equivalent.

 

4)         Except for individuals qualified as a CTRS, OTR/L, LSW or LCSW as listed in subsection (c)(2) of this Section, any person hired as an activity director after November 1, 2000 shall have taken a 36-hour basic orientation course or shall register to take a 36-hour basic orientation course within 90 days after employment and shall complete the course within 180 days after employment.  This course shall be recognized by an accredited college or university or a nationally recognized continuing education sponsor following the guidelines of the International Association for Continuing Education and Training and include at least the following: resident rights; activity care planning for quality of life, human wellness and self-esteem; etiology and symptomatology of persons who are aged, developmentally disabled or mentally ill; therapeutic approaches; philosophy and design of activity programs; activity program resources; program evaluation; practitioner behavior and ethics; resident assessment and supportive documentation; standards and regulations concerning activity programs; management and administration.  Individuals who have previously taken a 36-hour basic orientation course, a 42-hour basic activity course or a 90-hour basic education course shall be considered to have met this requirement.

 

5)         The activity director shall have a minimum of ten hours of continuing education per year pertaining to activities programming.

 

6)         Consultation shall be required only quarterly when the activity director meets or exceeds the following criteria:

 

A)        High school diploma or equivalent, five years of full-time or 10,000 hours of part-time experience in activities, three years of experience as an activity director, and completion of a basic orientation course of at least 36 hours; or

 

B)        A two-year associate's degree, three years of full-time or 6,000 hours of part-time experience in activities, three years of experience as an activity director, and completion of a basic orientation course of at least 36 hours; or

 

C)        A four-year degree, one year full-time or 2,000 hours of part-time experience in activities, one year of experience as an activity director, and completion of a basic orientation course of at least 36 hours.

 

d)         Written permission, with any contraindications stated, shall be given by the resident's physician if the resident participates in the activity program.  Standing orders will be acceptable with individual contraindications noted.

 

e)         Activity program staff shall participate in the assessment of each resident, which shall include the following:

 

1)         Background information, including education level, cultural/social issues, and spiritual needs;

 

2)         Current functional status, including communication status, physical functioning, cognitive abilities, and behavioral issues; and

 

3)         Leisure functioning, including attitude toward leisure, awareness of leisure resources, knowledge of activity skills, and social interaction skills and activity interests, both current and past.

 

f)         The activity staff shall participate in the development of an individualized plan of care addressing needs and interests of the residents, including activity/recreational goals and/or interventions.

 

g)         The facility shall provide a specific, planned program of individual (including self-initiated) and group activities that are aimed at improving, maintaining, or minimizing decline in the resident's functional status, and at promoting well-being.  The program shall be designed in accordance with the individual resident's needs, based on past and present lifestyle, cultural/ethnic background, interests, capabilities, and tolerance.  Activities shall be daily and shall reflect the schedules, choices, and rights of the residents (e.g., morning, afternoon, evenings and weekends).  The residents shall be given opportunities to contribute to planning, preparing, conducting, concluding and evaluating the activity program.

 

h)         The activity program shall be multifaceted and shall reflect each individual resident's needs and be adapted to the resident's capabilities.  The activity program philosophy shall encompass programs that provide stimulation or solace; promote physical, cognitive and/or emotional health; enhance, to the extent practicable, each resident's physical and mental status; and promote each resident's self-respect by providing, for example, activities that support self-expression and choice.  Specific types of activities may include:

 

1)         Physical activity (e.g., exercise, fitness, adapted sports);

 

2)         Cognitive stimulation/intellectual/educational activity (e.g., discussion groups, reminiscence, guest speakers, films, trivia, quizzes, table games, puzzles, writing, spelling, newsletter);

 

3)         Spiritual/religious activity (e.g., religious services, spiritual study groups, visits from spiritual support groups);

 

4)         Service activity (e.g., volunteer work for the facility, other individuals and/or the community);

 

5)         Sensory stimulation (e.g., tactile, olfactory, auditory, visual and gustatory);

 

6)         Community involvement (e.g., community groups coming into the facility for intergenerational programs, special entertainment and volunteer visits; excursions outside the facility to museums, sporting events, entertainment, parks);

 

7)         Expressive and creative arts/crafts (adapted to the resident's capabilities), music, movement/dance, horticulture, pet-facilitated therapy, drama, literary programs, art, cooking;

 

8)         Family involvement (e.g., correspondence, family parties, holiday celebrations, family volunteers); and

 

9)         Social activity (e.g., parties and seasonal activities).

 

i)          If residents participate in regularly scheduled therapeutic programs outside the facility (e.g., school, employment, or sheltered workshop), the residents' needs for activities while they are in the facility shall be met .

 

j)          Residents' participation in and response to the activity program shall be documented at least quarterly and included in the clinical record.  The facility shall maintain current records of resident participation in the activity program.

 

(Source:  Amended at 24 Ill. Reg. 17225, effective November 1, 2000)

 

Section 340.1710  Social Services

 

If the staff member designated to provide social services is not a social worker, the facility shall have an effective arrangement with a social worker to provide social service consultation.

 

(Source:  Amended at 26 Ill. Reg. 10589, effective July 1, 2002)

 

Section 340.1720  Work Programs

 

a)         In-house facility work programs for individual residents shall be allowed only if oriented toward resident adjustment and therapeutic benefits.

 

1)         Documentation for each program shall include, but not be limited to, objectives, possible work assignment, duties, policies governing the program, agency involvement (where appropriate), and supervision.

 

2)         Residents involved in such programs shall meet all requirements of the Department for persons functioning in these positions.

 

3)         Residents shall not be used to replace employed staff.

 

4)         All such programs shall be in full compliance with all applicable regulations of both the State and Federal Departments of Labor.  Any program found by the Department not to be in compliance with State and Federal Departments of Labor regulations shall be terminated immediately.

 

b)         The facility should cooperate with State and community agencies in assisting individual residents to avail themselves of specialized work activity programs, prevocational and work adjustment training, sheltered workshop programs, and other similar programs that are provided outside of the facility.

 

c)         Appropriate records shall be maintained for residents functioning in these programs in the facility or outside the facility.  These shall show appropriateness of the program for the individual, resident's response to the program, and any other pertinent observations and shall become a part of the resident's record.

 

d)         A resident may refuse to perform labor for a facility.  (Section 2-113 of the Act)

 

Section 340.1730  Volunteer Program

 

a)         If the facility has a volunteer or auxiliary program, a facility staff person shall direct the program.  Community groups such as Boy and Girl Scouts, church groups and civic organizations that may occasionally present programs, activities, or entertainment in the facility shall not be considered volunteers for the purposes of this Section.

 

b)         Volunteers shall complete a standard orientation program, in accordance with their facility responsibilities and with the facility's policies and procedures governing the volunteer program.  The orientation shall include, but not be limited to:

 

1)         Residents' rights;

 

2)         Confidentiality;

 

3)         Disaster preparedness (i.e., fire, tornado);

 

4)         Emergency response procedures;

 

5)         Safety procedures/precautions;

 

6)         Infection control; and

 

7)         Body mechanics.

 

c)         Volunteers shall respect all aspects of confidentiality.

 

d)         Volunteers shall be informed of and shall implement medical and physical precautions related to the residents with whom they work.

 

e)         Volunteers shall not take the place of qualified staff (e.g., activity professionals, nursing assistants, or case workers).

 

(Source:  Added at 24 Ill. Reg. 17225, effective November 1, 2000)

SUBPART G: RESIDENT RECORDS

 

Section 340.1800  Resident Record Requirements

 

a)         Each facility shall designate an employee to be responsible for completing, maintaining and preserving the medical records.

 

b)         Each facility shall have a medical record system that retrieves information regarding individual residents.

 

c)         The facility shall keep an active medical record for each resident.  This resident record shall be kept current, complete, legible, and available at all times to those personnel authorized by the facility's policies and to the Department's representatives.

 

d)         Record entries shall meet the following requirements:

 

1)         Record entries shall be made by the person providing or supervising the service or observing the occurrence that is being recorded.

 

2)         All entries into the medical record shall be authenticated by the individual who made or authored the entry. "Authentication", for purposes of this Section, means identification of the author of a  medical record entry by that author and confirmation that the contents are what the author intended.

 

3)         Medical record entries shall include all notes, orders or observations made by direct resident care providers and any other individuals authorized to make such entries in the medical record, and written interpretive reports of diagnostic tests or specific  treatments including, but not limited to, radiologic or laboratory reports and other similar reports.

 

4)         Authentication shall include the initials of the signer's credentials. If the electronic signature system will not allow for the credential initials, the facility shall have a means of identifying the signer's credentials.

 

5)         Electronic Medical Records Policy.  The facility shall have a written policy on electronic medical records.  The policy shall address persons authorized to make entries, confidentiality, monitoring of record entries, and preservation of information.

 

A)        Authorized Users.  The facility shall develop a policy to assure that only authorized users make entries into medical records and that users identify the date and author of every entry in the medical records.  The policy should allow written signatures, written initials supported by a signature log, or electronic signatures with assigned identifiers, as authentication by the author that the entry made is complete, accurate and final.

 

B)        Confidentiality.  The facility policy shall include adequate safeguards to ensure confidentiality of patient medical records, including procedures to limit access to authorized users.  The authorized user must certify in writing that he or she is the only person with authorized user access to the identifier and that the identifier will not be shared or used by any other person.  A surveyor or inspector in the performance of a State-required inspection may have access to electronic information normally found in written patient records.  Additional summary reports, analyses, or cumulative statistics available through computerized records are the internal operational reports of the facility's Quality Assurance Committee.

 

C)        Monitoring.  The facility shall develop a policy to periodically monitor the use of identifiers and take corrective action as needed.  The facility shall maintain a master list of authorized users past and present and maintain a computerized log of all entries.  The logs shall include the date and time of access and the user ID under which access occurred.

 

D)        Preservation.  The facility shall develop a plan to ensure access to medical records over the entire record retention period for the particular piece of information.

 

e)         An ongoing resident record, including progression toward and regression from established resident goals, shall be maintained.

 

1)         The progress record shall indicate significant changes in the resident's condition. Any significant change shall be recorded upon occurrence by the staff person observing the change.

 

2)         Recommendations and findings of direct service consultants, such as providers of social, dental, dietary or rehabilitation services, shall be included in the resident's progress record when the recommendations pertain to an individual resident.

 

3)         The record shall include medically defined conditions and prior medical history, medical status, physical and mental functional status, sensory and physical impairments, nutritional status and requirements, special treatments and procedures, mental and psychosocial status, discharge potential, rehabilitation potential, cognitive status and drug therapy.

 

f)         A medication administration record shall be maintained, which contains the date and time each medication is given, name of drug, dosage, and by whom administered.  A medication administration record is not required for residents who have been approved to be fully responsible for their own medications in accordance with Section 340.1630(c).

 

g)         Treatment sheets shall be maintained recording all resident care procedures ordered by each resident's attending physician.  This does not prohibit the use of universal progress notes.

 

h)         Discharge information shall be completed within 48 hours after the resident leaves the facility.  Resident care staff shall record the date, time, condition of the resident, to whom released, and the resident's planned destination (home, another facility, undertaker).  This information may be entered onto the admission record form.  The discharge information shall also include reasons for discharge, diagnosis, individual habilitation plan, physical, pertinent medical and social histories, orders, and staff recommendations for immediate care to ensure the optimal continuity of care for the resident.

 

(Source:  Amended at 23 Ill. Reg. 7931, effective July 15, 1999)

 

Section 340.1810  Content of Medical Records

 

a)         No later than the time of admission, the facility shall enter the following information, as applicable, onto the identification or admission sheet for each resident.

 

1)         Name, sex, date of birth and Social Security Number;

 

2)         Marital Status, and the name of spouse;

 

3)         Date of admission to the facility;

 

4)         Date of current admission to the facility;

 

5)         State or country of birth;

 

6)         Home address;

 

7)         Religious affiliation;

 

8)         Name, address and telephone number of any referring agency, State hospital, zone center or hospital from which the resident has been transferred;

 

9)         Name and telephone number of the resident's personal physician;

 

10)         Name and telephone number of the resident's representative or guardian, if any;

 

11)         Name and telephone number of the resident's next of kin or responsible relative;

 

12)         Language understood or spoken;

 

13)         Race and origin;

 

14)         Most recent occupation;

 

15)         Whether the resident or the resident's spouse is a veteran;

 

16)         Father's name and mother's name;

 

17)         Name, address and telephone number of the resident's dentist; and

 

18)         The diagnosis applicable at the time of admission.

 

b)         In addition to the information that is specified above, each resident's medical record shall contain the following:

 

1)         Medical history and physical examination form that includes conditions for which medications have been prescribed, physician findings, all known diagnoses and restoration potential.  This shall describe those known conditions that the medical and resident care staff should be apprised of regarding the resident.  Examples of diagnoses and conditions that are to be included are allergies, epilepsy, diabetes and asthma.

 

2)         A physician's order sheet that includes orders for all medications, treatments, therapy and rehabilitation services, diet, activities and special procedures or orders required for the safety and well-being of the resident.

 

3)         Nurse's notes that describe the nursing care provided, observations and assessment of symptoms, reactions to treatments and medications, progression toward or regression from each resident's established goals, and changes in the resident's physical or emotional condition.

 

4)         An ongoing record of notations describing significant observations or developments regarding each resident's condition and response to treatments and programs.

 

A)        Physicians and other consultants who provide direct care or treatment to residents shall make notations at the time of each visit with a resident.

 

B)        Significant observations or developments regarding resident responses to activity programs, social services, dietary services and work programs shall be recorded as they are noted.  If no significant observations or developments are noted for three months, an entry shall be made in the record of that fact.

 

C)        Significant observations or developments regarding resident responses to nursing and personal care shall be recorded as they are noted.  If no significant observations or developments are noted for a month, an entry shall be made in the record of that fact.

 

D)        Significant behavior incidents, reactions to any family visits and contacts, attendance at programs.

 

5)         Any laboratory and x-ray reports ordered by the resident's physician.

 

6)         Documentation of visits to the resident by a physician and to the physician's office by the resident.  The physician shall record, or dictate and sign, the results of such visits, such as changes in medication, observations, and recommendations made by the physician during the visits, in the record.

 

7)         All psychological testing and multidisciplinary evaluations regarding each resident.

 

8)         Any correspondence pertaining to the resident's program.

 

9)         Appropriate authorizations and consents.

 

10)         Upon admission from a hospital or State facility, a hospital summary sheet or transfer form that includes the hospital diagnosis and treatment, and a discharge summary.  This transfer information, which may be included in the transfer agreement, shall be signed by the physician who attended the resident while in the hospital.

 

Section 340.1820  Records Pertaining to Resident's Property

 

a)         The facility shall maintain a record of any resident's belongings, including money, valuables and personal property, accepted by the facility for safekeeping. This record shall be initiated at the time of admission and shall be updated on an ongoing basis and made part of the resident's record.

 

b)         When purchases are made for a resident from the resident's personal monies, receipts shall be obtained and retained that verify the date, amount, and items purchased.

 

c)         A separate bookkeeping system shall be maintained by the facility, which accounts for all transactions affecting each resident's account.  Each individual resident, or the individual resident's representative, shall have access to the record of that individual resident's account.

 

Section 340.1830  Retention, Transfer, and Inspection of Records

 

a)         Each facility shall have a policy regarding the retirement and destruction of medical records.  This policy shall specify the time frame for retiring a resident's medical record, and the method to be used for record destruction at the end of the record retention period.

 

b)         Records of discharged residents shall be placed in an inactive file and retained as follows:

 

1)         Records for any resident who is discharged prior to being 18 years old shall be retained at least until the resident reaches the age of 23.

 

2)         Records of residents who are over 18 years old at the time of discharge shall be retained for a minimum of five years.

 

3)         After the death of a resident, the resident's record shall be retained for a minimum of five years.

 

4)         It is suggested that the administrator check with legal counsel regarding the advisability of retaining resident records for a longer period of time.

 

5)         If a facility ceases operation, procedures for handling resident records shall be developed by legal counsel.

 

c)         When a resident is transferred to another facility, the transferring facility shall send with the resident a reason for transfer, summary of treatment and results, laboratory findings, and orders for the immediate care of the resident.  This information may be presented in a transfer form or an abstract of the resident's medical record.

 

d)         The facility shall retain other records required by these standards for a minimum of three years.  Procedures to be followed in the event the facility ceases operation shall be developed by facility legal counsel.

 

e)         Each resident record is the property of the facility.  The facility shall be responsible for securing resident record information against loss, defacement, tampering or use by unauthorized persons.

 

f)         Every resident, resident's guardian, or parent (if the resident is a minor) shall be permitted to inspect and copy all of the resident's clinical and other records concerning the resident's care and maintenance kept by the facility or by the resident's physician.  (Section 2-104(d) of the Act)

 

Section 340.1840  Confidentiality of Resident's Records

 

a)         All information contained in a resident's record, including any information contained in an automated data bank, shall be considered confidential.  The facility shall permit the appropriate State and federal agencies (such as Illinois Departments of Public Aid, Public Health, Mental Health and Developmental Disabilities, and the U.S. Department of Health and Human Services and State and federal Department of Veterans' Affairs) to have access to resident records.

 

b)         The facility shall develop and implement written policies governing access to, duplication of, and dissemination of information from medical records.

 

c)         The facility shall obtain written consent of the resident, or the resident's guardian, prior to any release of any resident record information to persons not authorized to receive the information.

SUBPART H: FOOD SERVICE

 

Section 340.1900  Food Service Staff

 

a)         A full-time person who is a dietician or dietetic service supervisor shall be responsible for the total food and nutrition services of the facility.  The food service supervisor may assume cooking duties but only if these duties do not interfere with the responsibilities of management and supervision.

 

b)         If the person responsible for the food service is not a dietitian, the person shall have frequent and regularly scheduled consultation from a dietitian.  This consultation, given in the facility, shall include training, as needed, in areas such as menu planning and review, food preparation, food storage, food service, safety, sanitation and use of food equipment. Clinical management of therapeutic diets shall also be included in consulting, covering areas such as tube feeding; nutritional status and requirements of residents, including weight, height, hematologic and biochemical assessments; physical limitations; adaptive eating equipment; clinical observations of nutrition, nutritional intake, resident's eating habits and preferences, and dietary restrictions.

 

c)         A minimum of eight hours of consulting time per month shall be provided for facilities with 50 or fewer residents.  An additional five minutes of consulting time per month shall be provided per resident over 50 residents, based on the average daily census for the previous year.

 

d)         A sufficient number of food service personnel shall be employed and on duty to meet the dietary needs of all residents eating meals in the facility.  Food service staff working hours shall be scheduled to meet the total dietary needs of the residents.  All food service employees' time schedules and work assignments shall be posted in the kitchen. Dietary duties and job procedures shall be available in the food service for employees' information and use.

 

e)         Food service personnel shall be in good health and shall practice hygienic food handling techniques and good personal grooming.

 

(Source:  Amended at 23 Ill. Reg. 7931, effective July 15, 1999)

 

Section 340.1910  Diet Orders

 

a)         Two or more copies of a current diet manual shall be available and in use.  One copy shall be located in the kitchen for use by dietary personnel. Other copies shall be located at each nurses' station for use by physicians when prescribing diets.

 

b)         Physicians shall write a diet order, in the medical record, for each resident indicating whether the resident is to have a general or a therapeutic diet. The diet shall be served as ordered.

 

c)         A written diet order shall be sent to the food service department when each resident is admitted and each time that the resident's diet is changed. Each change shall be ordered by the physician.  The diet order shall include, at a minimum, the following information:  name of resident, room and bed number, type of diet, consistency if other than regular consistency, date diet order is sent to dietary, name of physician ordering the diet, and the signature of the person transmitting the order to the food service department.

 

d)         The resident shall be observed to determine acceptance of the diet, and these observations shall be recorded in the medical record.

 

e)         A therapeutic diet means a diet ordered by the physician as part of a treatment for a disease or clinical condition, to eliminate or decrease certain substances in the diet (e.g., sodium) or to increase certain substances in the diet (e.g., potassium), or to provide food in a form that the resident is able to eat (e.g., mechanically altered diet).

 

f)         All therapeutic diets shall be medically prescribed and shall be planned or approved by a dietitian.

 

g)         The kinds and variations of prescribed therapeutic diets shall be available in the kitchen.  If separate menus are not planned for each specific diet, diet information for each specific type, in a form easily understood by staff, shall be available in a convenient location in the kitchen.

 

h)         All oral liquid diets shall be reviewed every 48 hours.  Medical soft diets, sometimes known as transitional diets, shall be reviewed every three weeks. All other therapeutic and mechanically altered diets, including commercially  prepared formulas that are in liquid form and blenderized liquid diets, shall be reviewed as needed, or at least every three months.

 

(Source:  Amended at 23 Ill. Reg. 7931, effective July 15, 1999)

 

Section 340.1920  Meal Planning

 

Each resident shall be served food to meet the resident's needs and to meet the physician's orders. The facility shall use this Section to plan menus and purchase food in accordance with the following Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences.

 

a)         Milk and Milk Products Group: 16 ounces or more of Grade A whole or low fat pasteurized milk where milk is used for fluid consumption.  Calcium equivalents for eight ounces of milk:

 

1)         1½ ounces natural cheese,

 

2)         Two ounces processed cheese,

 

3)         One cup yogurt, or one cup frozen yogurt,

 

4)         One cup cottage cheese, or

 

5)         1½ cups ice cream or ice milk.

b)         Meat Group:  A total of 6 ounces (by weight) of good quality protein to provide 38 to 42 grams of protein daily.  To ensure variety, food items repeated within the same day shall not be counted as meeting a required serving. The following are examples of one serving:

 

1)         Three ounces (excluding bone, fat and breading) of any cooked meat such as whole or ground beef, veal, pork or lamb; poultry; organ meats such as liver, heart, kidney; prepared luncheon meats.

 

2)         Three ounces (excluding skin and breading) of cooked fish or shell fish or 1/2 cup canned fish.

 

3)         Three ounces of natural or processed cheese or ¾ cup cottage cheese.

 

4)         Three eggs (minimum weight of 21 ounces per dozen, considered a medium egg).  Note:  If one egg is served at a meal, a protein food of good quality may be reduced from six to five ounces for the remaining meals.  If two eggs are served at a meal, a minimum of two ounces of good quality protein shall be served at each of the remaining meals.

 

5)         1½ cups cooked dried peas or beans, six tablespoons of peanut butter, one cup nuts, not more than twice a week and provided that eggs, cheese, milk or lean meat is served at the same meal.

 

6)         Three ounces of soy protein containing not less than 21 grams of protein, or in combination with other sources of quality protein to equal 21 grams of protein, provided that it is acceptable to the resident population.

 

7)         Combinations of all above examples are acceptable, provided the minimum of six ounces of a good quality protein is served daily and provided that the combinations do not conflict with eye appeal or palatability.

 

8)         The content of meat alternative products shall be listed on the menu.

 

c)         Vegetable and Fruit Group:  Five or more servings of vegetables or fruits.

 

1)         A serving consists of:

 

A)        ½ cup chopped raw, cooked, canned or frozen fruit or vegetables;

 

B)        ¾ cup fruit or vegetable juice; or

 

C)        One cup raw leafy vegetable.

 

2)         The five or more servings shall consist of:

 

A)        Sources of vitamin C

 

i)          One serving of a good source of vitamin C (containing at least 60 mg of vitamin C); or

 

ii)         Two servings of a fair source of vitamin C.  This may be more than one food item and shall contain a total of at least 65 mg of vitamin C.

 

B)        One serving of a good source of vitamin A at least three times a week supplying at least 1000 micrograms retinol equivalent (RE) of vitamin A.

 

C)        Other fruits and vegetables, including potatoes, that may be served in ⅓ cup or larger portions.

 

3)         To ensure variety, food items repeated within the same day shall not be counted as meeting a required serving.

 

d)         Bread, Cereal, Rice and Pasta Group: Six or more servings of whole grain, enriched or restored products.  One serving equals:

 

1)         One slice of bread,

 

2)         ½ cup of cooked cereal, rice, pasta, noodles or grain product,

 

3)         ¾ cup of dry, ready-to-eat cereal,

 

4)         ½ hamburger or hotdog bun, bagel or English muffin,

 

5)         One 4-inch diameter pancake,

 

6)         One tortilla,

 

7)         Three to four plain crackers (small),

 

8)         ½ croissant (large), doughnut or danish (medium),

 

9)         1/16 cake,

 

10)       Two cookies,

 

11)       1/12 pie (2-crust, 8").

 

e)         Butter or Margarine: To be used as a spread and in cooking.

 

f)         Other foods shall be served to round out meals, satisfy individual appetites, improve flavor, and meet the individual's nutritional and caloric needs.

 

g)         Meals for the day shall be planned to provide a variety of foods, variety in texture and good color balance.  The following meal patterns shall be used.

 

1)         Three meals a day plan

 

A)        Breakfast:  Fruit or juice, cereal, meat (optional, but three to four times per week preferable), bread, butter or margarine, milk, and choice of additional beverage.

 

B)        Main Meal (may be served noon or evening):  Soup or juice (optional), entree (quality protein), potato or potato substitute, vegetable or salad, dessert (preferably fruit unless fruit is served as a salad or will be served at other meal), bread, butter or margarine, milk and choice of beverage.

 

C)        Lunch or Supper:  Soup or juice (optional), entree (quality protein), potato or potato substitute (optional if served at main meal), vegetable or salad, dessert, bread, butter or margarine, milk, and choice of additional beverage.

 

2)         Other meal patterns may be used if facilities are able to meet residents' needs using such plans.

 

i)          No more than 14 hours shall occur between the usual beginning of the evening meal and the usual beginning of the morning meal.

 

j)          Snacks of nourishing quality shall be offered at bedtime when there are four or more hours between the ending of the last meal and bedtime, or as otherwise indicated in the resident's plan of care.

 

k)         If a resident refuses food served, reasonable and nutritionally appropriate substitutes shall be served.

 

(Source:  Amended at 23 Ill. Reg. 7931, effective July 15, 1999)

 

Section 340.1930  Therapeutic Diets (Repealed)

 

(Source:  Repealed at 23 Ill. Reg. 7931, effective July 15, 1999)

 

Section 340.1940  Menus and Food Records

 

a)         Menus, including menus for "sack" lunches and between meal or bedtime snacks, shall be planned at least one week in advance.  Food sufficient to meet the nutritional needs of all the residents shall be prepared for each meal.  When changes in the menu are necessary, substitutions shall provide equal nutritive value and shall be recorded on the original menu, or in a notebook used for that purpose.  If a notebook is used to document substitutions, it shall include the date of the substitution; the meal at which the substitution was made; the menu as originally written; and the menu as actually served.

 

b)         The menu for the current week shall be dated and available in the kitchen.  Upon the request of the Department, sample menus shall be submitted for evaluation.

 

c)         Menus shall be different for the same day of consecutive weeks and adjusted for seasonal difference.

 

d)         All menus as actually served shall be kept on file at the facility for not less than 30 days.

 

e)         Food label information for purchased prepared food listing food composition and, when available, nutrient content shall be kept on file in the facility.

 

f)         Supplies of staple foods for a minimum of a one week period and of perishable foods for a minimum of a two day period shall be maintained on the premises. These supplies shall be appropriate to meet the requirements of the menu.

 

g)         Records of all food purchased shall be kept on file in the facility for not less than 30 days.

 

(Source:  Amended at 23 Ill. Reg. 7931, effective July 15, 1999)

 

Section 340.1950  Food Preparation and Service

 

a)         Every facility shall comply with the Department's rules entitled "Food Service Sanitation" (77 Ill. Adm. Code 750).

 

b)         Foods shall be prepared by appropriate methods that will conserve their nutritive value and enhance their flavor and appearance.  They shall be prepared according to standardized recipes, and a file of such recipes shall be available for the cook's use.

 

c)         Foods shall be attractively served at the proper temperatures and in a form to meet individual needs.

 

d)         Foods shall not be mixed for feeding so that residents may discriminate individual tastes.

 

e)         All residents shall be served in a dining room or multi-purpose room except for an individual with temporary illness, who is too ill, or for other valid reasons.  Residents shall be in an upright position during meal service unless contraindicated by the resident's condition.

 

Section 340.1960  Kitchen Equipment, Utensils, and Supplies

 

a)         Each facility shall provide an adequate number of dishes, glassware, and silverware of a satisfactory type to serve all the residents in the facility at each meal.

 

b)         Each facility shall have available for use a sufficient supply of adaptive food service equipment necessary to meet the need of each resident.

SUBPART I: PHYSICAL PLANT SERVICES, FURNISHINGS, EQUIPMENT, AND SUPPLIES

 

Section 340.2000  Maintenance

 

a)         Every facility shall have an effective written plan for maintenance, including sufficient staff, appropriate equipment, and adequate supplies.

 

b)         Each facility shall:

 

1)         Maintain the building in good repair, safe and free of the following: cracks in floors, walls, or ceilings; peeling wallpaper or paint; warped or loose boards; warped, broken, loose, or cracked floor covering, such as tile or linoleum; loose handrails or railings; loose or broken window panes; and any other similar hazards.

 

2)         Maintain all electrical, signaling, mechanical, water supply, heating, fire protection, and sewage disposal systems in safe, clean and functioning condition. This shall include regular inspections of these systems.

 

3)         Maintain all electrical cords and appliances in a safe and functioning condition.

 

4)         Maintain the interior and exterior finishes of the building as needed to keep it attractive, clean and safe (painting, washing, and other types of maintenance).

 

5)         Maintain all furniture and furnishings in a clean, attractive, and safely repaired condition.

 

6)         Maintain the grounds and other buildings on the grounds in a safe, sanitary, presentable condition, free of refuse and litter.

 

7)         Maintain the building and grounds free of any possible infestations of insects and rodents by: eliminating sites of breeding and harborage inside and outside the building; and eliminating sites of entry into the building with screens of not less than 16 mesh to the inch and repair of any breaks in construction.

 

8)         Maintain all plumbing fixtures and piping in good repair and proper functioning.

 

9)         Protect the potable water supply from contamination by providing and properly installing adequate backflow protection devices, or providing adequate air gaps on all fixtures that may be subject to backflow or back siphonage.

 

c)         Areas of a nursing home used by residents of the nursing home shall be air conditioned and heated by means of operable air-conditioning and heating equipment. The areas subject to this air-conditioning and heating requirement include, without limitation, bedrooms or common areas such as sitting rooms, activity rooms, living rooms, community rooms, and dining rooms. (Section 3-202(8) of the Act)

 

1)         The mechanical system shall be capable of maintaining a temperature of at least 75 degrees Fahrenheit, pursuant to the requirements of Section 340.1320(j).

 

2)         The air conditioning system shall be capable of maintaining an ambient air temperature of between 75 degrees Fahrenheit and 80 degrees Fahrenheit, pursuant to the requirements of Section 340.1320(j).

 

(Source:  Amended at 35 Ill. Reg. 3442, effective February 14, 2011)

 

Section 340.2010  Water Supply, Sewage Disposal and Plumbing

 

a)         Water Supply

 

1)         Each facility shall be served by water from a municipal public water supply when available.

 

2)         When a municipal public water supply is not available, the water supply shall comply with the Department's rules entitled "Drinking Water Systems" (77 Ill. Adm. Code 900).

 

3)         If water is supplied by a well that is not part of a municipal system, the well shall be constructed and maintained in accordance with the Department's rules entitled "Illinois Water Well Construction Code" (77 Ill. Adm. Code 920) and "Water Well Pump Installation Code" (77 Ill. Adm. Code 925).

 

4)         Each water supply shall comply with all applicable State and local codes and ordinances.

 

5)         Each facility shall have a written agreement with a water company, dairy, or other water purveyor to provide an emergency supply of potable water for drinking and culinary purposes.

 

b)         Sewage Disposal

 

1)         All sewage and liquid wastes shall be discharged into a public sewage system when available.

 

2)         When a public sewage system is not available, sewage and liquid wastes shall be collected, treated, and disposed of in a private sewage disposal system.  The design, construction, maintenance, and operation of the system shall comply with the Department's rules entitled "Private Sewage Disposal Code" (77 Ill. Adm. Code 905).

 

3)         All sewage disposal systems shall comply with all applicable State and local codes and ordinances.

 

c)         Plumbing

 

1)         Each plumbing system shall comply with the Department's rules entitled "Illinois Plumbing Code" (77 Ill. Adm. Code 890) effective at the time of construction or approved acceptance by the Department.

 

2)         All plumbing systems shall comply with all applicable State and local codes and ordinances.

 

Section 340.2020  Housekeeping

 

a)         Every facility shall have an effective plan for housekeeping including sufficient staff, appropriate equipment, and adequate supplies.  Each facility shall:

 

1)         Keep the building in a clean, safe, and orderly condition.  This includes all rooms, corridors, attics, basements, and storage areas.

 

2)         Keep floors clean, as nonslip as possible, and free from tripping hazards including throw or scatter rugs.

 

3)         Control odors within the housekeeping staff's areas of responsibility by effective cleaning procedures and by the proper use of ventilation systems.  Deodorants shall not be used to cover up persistent odors caused by unsanitary conditions or poor housekeeping practices.

 

b)         Attics, basements, stairways, and similar areas shall be kept free of accumulations of refuse, discarded furniture, old newspapers, boxes, discarded equipment, and other items.

 

c)         Bathtubs, shower stalls, and lavatories shall not be used for laundering, janitorial, or storage purposes.

 

d)         All cleaning compounds, insecticides, and all other potentially hazardous compounds or agents shall be stored in locked cabinets or rooms.

 

Section 340.2030  Laundry Services

 

a)         Every facility shall have an effective means of supplying an adequate amount of clean linen for operation, either through an in-house laundry or a contract with an outside service.

 

1)         An adequate supply of clean linen shall be defined as the three sets of sheets, draw sheets, and pillow cases required to provide for the residents' needs. Additional changes of linen may be required in consideration of the time involved for laundering and transporting soiled linens.

 

2)         If an in-house laundry service is provided, then the following conditions shall exist:

 

A)        The laundry area shall be maintained and operated in a clean, safe and sanitary manner.  No part of the laundry shall be used as a smoking or dining area.

 

B)        Written operating procedures shall be developed, posted and implemented that provide for the handling, transport and storage of clean and soiled linens.

 

C)        Laundry personnel must be in good health and practice good personal grooming.  Employees must thoroughly wash their hands and exposed portions of their arms with soap and warm water before starting work, during work as often as necessary to keep them clean, and after smoking, eating, drinking, using the toilet, and handling soiled linens.

 

D)        Clean linen shall be protected from contamination during handling, transport, and storage.

 

E)        Soiled linen shall be handled, transported, and stored in a manner that protects facility residents and personnel.

 

F)         If supplies and equipment not directly connected with the operation of the laundry are stored in the laundry or its accessory storage and handling areas, they shall be protected from contamination by the soiled linens and shall not contribute to contamination of the clean linens.

 

b)         If an outside laundry service is used, it shall comply with the requirements of in-house laundries and shall provide for protection of clean linens during transport back to the facility.

 

c)         If the facility provides laundry service for residents' personal clothing, it must be handled, transported, and stored in a manner that will not allow contamination of clean linen or allow contamination by soiled linen.  The facility shall assure that the personal clothing of each resident is returned to that individual resident after laundering.

 

Section 340.2040  Furnishings

 

a)         Each resident shall be provided, if he or she does not wish to provide his or her own, furniture and furnishings for his or her bedroom.  These items shall be well constructed, of a satisfactory design, and appropriate to meet the needs of the resident.  This shall include, but not be limited to:

 

1)         a bed of a size appropriate to the resident;

 

2)         a clean, firm, comfortable mattress and pillow;

 

3)         accessible in-room storage for folded clothing, such as a dresser or chest of drawers;

 

4)         accessible in-room storage for hanging clothes, such as a closet or wardrobe;

 

5)         an area to hang the resident's towel and washcloth;

 

6)         a reading light at an in-room location convenient to the resident, such as at bedside or near a chair;

 

7)         a location to keep nursing and personal care items that are appropriate for in-room storage, such as a bedside cabinet;

 

8)         comfortable in-room seating.

 

b)         The facility administrator shall ensure that married residents residing in the same facility be allowed to reside in the same room within the facility unless there is no room available in the facility or it is deemed medically inadvisable by the resident's attending physician and so documented in the resident's medical records.  (Section 2-108(e) of the Act) A double bed shall be provided for married couples if they request this arrangement and there are no medical contraindications.

 

c)         There shall be additional pillows available to satisfactorily meet the needs of the residents.

 

d)         A resident shall be permitted to retain and use or wear his personal property in his immediate living quarters, unless deemed medically inappropriate by a physician and so documented in the resident's clinical record.  (Section 2-103 of the Act)

 

e)         The facility shall provide adequate storage space for the personal property of the resident.  (Section 2-103 of the Act)

 

f)         The facility shall provide a means of safeguarding small items of value for its residents in their rooms or in any other part of the facility so long as the residents have daily access to such valuables.  (Section 2-103 of the Act)

 

g)         Each bedroom exterior window shall have a device (e.g., blinds, curtains, window shades) to ensure privacy and light control.

 

h)         There shall be at least one privacy screen available in the facility for emergency use when resident privacy is needed.

 

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

 

j)          Residents over the age of six years occupying the same bedroom shall be of the same sex unless otherwise individually approved by the interdisciplinary team.

 

k)         Each bedroom shall be provided with a mirror, unless there is a mirror in a bathroom opening into this bedroom.  Each lavatory shall be provided with a mirror.

 

l)          Each living room for resident use shall be provided with an adequate number of reading lamps, tables, and chairs or settees.  These furnishings shall be well constructed and of satisfactory design to meet the needs of the residents.

 

m)        Dining room furnishings shall be provided for each resident that are well constructed, comfortable, in good repair, and of satisfactory design for the residents.  There shall be a sufficient number of tables, of a type that can be used by wheelchair residents, to accommodate all such residents in the facility.  A sufficient number of tables that can be rolled over the resident's bed or that can be placed next to the bed shall be provided for residents who cannot, or do not, eat in the dining room or area.

 

n)         Office spaces, nurses' stations, treatment rooms, and other areas shall be satisfactorily furnished with desks, chairs, lamps, cabinets, benches, work tables, and other furnishings essential to the proper use of the area.

 

Section 340.2050  Equipment and Supplies

 

a)         There shall be an adequate supply of nursing equipment to meet the needs of the residents.

 

b)         There shall be a sufficient quantity of resident care equipment of satisfactory design and in good condition to meet each resident's needs.

 

c)         A sufficient quantity of suction machines shall be provided to meet the needs of all residents who need suctioning.

 

d)         According to the resident's needs, the facility shall assist the resident in obtaining special equipment for an individual resident's exclusive use.

 

e)         There shall be a first-aid kit or emergency box in every facility.  This shall contain bandages, sterile gauze dressing, bandage scissors, tape, sling, burn ointment, and other equipment deemed necessary by the advisory physician or the medical advisory committee.

 

f)         Every facility shall follow an acceptable plan to provide for sterile equipment and supplies, such as needles, syringes, catheters, and dressings, such as:

 

1)         Use of an autoclave located in a central sterilization area, clean utility area, or nurses' station.

 

2)         Use of individually wrapped sterile dressing, disposable syringes, needles, catheters, and gloves, which shall be disposed of after a single use.

 

3)         Formal plan with another facility for the autoclaving of equipment and supplies.

 

4)         Other alternative methods when approved on an individual basis in writing from the Department based on a written request from the facility, giving in detail the method proposed to be used and which method meets equivalent criteria for proper sterilization for these items to be sterilized.

 

g)         Every facility shall sanitize bed pans, urinals, wash basins, emesis basins, enema equipment, and similar patient care utensils as follows:

 

1)         Individual bedpans, urinals, wash basins, and similar equipment shall be washed and rinsed after each use, and be sanitized at least weekly.  If individual equipment is not provided, the equipment shall be washed, rinsed, and sanitized after each use.

 

2)         Utensils shall be pre-flushed prior to washing.  Utensils shall be washed in a hot detergent solution that is maintained clean.  After washing, utensils shall be rinsed free of detergents with clean water.

 

3)         Utensils shall be sanitized, either mechanically or manually, through the use of steam, hot water, or chemicals approved by the U.S. Environmental Protection Agency, formulated for the sanitization of patient care utensils, and shall be used in accordance with label instructions.

 

4)         Patient care utensil sanitization shall be completed in the soiled utility room.







Section 340.TABLE A   Heat Index Table/Apparent Temperature

 

 

Air Temperature (degrees Fahrenheit)

(Relative Humidity Percent)		70	75	80	85	90	95	100	105	110	115	120	125	130	135
	5	64	69	74	79	84	88	93	97	102	107	111	116	122	128
	10	65	70	75	80	85	90	95	100	105	111	116	123	131
	15	65	71	76	81	86	91	97	102	108	115	123	131
	20	66	72	77	82	87	93	99	105	112	120	130	141
	25	66	72	77	83	88	94	101	109	117	127	139
	30	67	73	78	84	90	96	104	113	123	135	148
	35	67	73	79	85	91	98	107	118	130	143
	40	68	74	79	86	93	101	110	123	137	151
	45	68	74	80	87	95	104	115	129	143
	50	69	75	81	88	96	107	120	135	150
	55	69	75	81	89	98	110	126	142
	60	70	76	82	90	100	114	132	149
	65	70	76	83	91	102	119	138
	70	70	77	85	93	106	124	144
	75	70	77	86	95	109	130
	80	71	78	86	97	113	136
	85	71	78	87	99	117
	90	71	79	88	102	122
	95	71	79	89	105

 

(Table is from the National Oceanic and Atmospheric Administration)

 

(Source:  Amended at 22 Ill. Reg. 7162, effective April 15, 1998)




Section 340.TABLE B   Guidelines for the Use of Various Drugs

 

A.        Long-Acting Benzodiazepine Drugs

Long-acting benzodiazepine drugs should not be used in residents unless an attempt with a shorter-acting drug (i.e., those listed under subsection B. Benzodiazepine or Other Anxiolytic/Sedative Drugs, and under subsection C. Drugs Used for Sleep Induction) has failed.

 

After an attempt with a shorter-acting benzodiazepine drug has failed, a long-acting benzodiazepine drug should be used only if:

 

1.         Evidence exists that other possible reasons for the resident's distress have been considered and ruled out;

 

2.         Its use results in maintenance or improvement in the resident's functional status;

 

3.         Daily use is less than four continuous months unless an attempt at a gradual dose reduction is unsuccessful; and

 

4.         Its use is less than, or equal to, the following listed total daily doses unless higher doses (as evidenced by the resident's response and/or the resident's clinical record) are necessary for the maintenance of, or improvement in, the resident's functional status.

 

EXAMPLES OF LONG-ACTING BENZODIAZEPINES (not maximum doses)
Generic	Brand	Daily Oral Dosage
Flurazepam	(Dalmane)	15mg
Clordiazepoxide	(Librium)	20mg
Clorazepate	(Tranxene)	15mg
Diazepam	(Valium)	5mg
Clonazepam	(Klonopin)	1.5mg
Quazepam	(Doral)	7.5mg
Halazepam	(Paxipam)	40mg

 

NOTES:

When diazepam is used for neuromuscular syndromes (e.g., cerebral palsy, tardive dyskinesia or seizure disorders), this Guideline does not apply.

 

When long-acting benzodiazepine drugs are being used to withdraw residents from short-acting benzodiazepine drugs, this Guideline does not apply.

 

When clonazepam is used in bi-polar disorders, management of tardive dyskinesia, nocturnal myoclonus or seizure disorders, this Guideline does not apply.

 

The daily doses listed under Long-Acting Benzodiazepines are doses (usually administered in divided doses) for "geriatric" or "elderly" residents.  The facility is encouraged to initiate therapy with lower doses and when necessary only gradually increase doses.  The facility may exceed these doses if it provides evidence to show why it was necessary for the maintenance or improvement in the resident's functional status.

 

For drugs in this category, a gradual dose reduction should be attempted at least twice within one year before one can conclude that the gradual dose reduction is "clinically contraindicated."

 

B.        Benzodiazepine or other Anxiolytic/Sedative Drugs

Use of the Anxiolytic/Sedative drugs for purposes other than sleep induction should only occur if:

 

1.         Evidence exists that other possible reasons for the resident's distress have been considered and ruled out;

 

2.         Use results in a maintenance or improvement in the resident's functional status;

 

3.         Daily use (at any dose) is less than four continuous months unless an attempt at a gradual dose reduction is unsuccessful;

 

4.         Use is for one of the following indications as defined by the Diagnostic and Statistical Manual of Mental Disorders; Fourth Edition (DSM-IV):

 

Generalized anxiety disorder;

 

Organic mental syndromes (now called dementia, delirium, and amnestic and other "cognitive disorders" by DSM-IV) with associated agitated states which are quantitatively and objectively documented, which are persistent and not due to preventable reasons and which constitute sources of distress or dysfunction to the resident or represent a danger to the resident or others;

 

Panic disorder;

 

Symptomatic anxiety that occurs in residents with another diagnosed psychiatric disorder (e.g., depression, adjustment disorder); and

 

5.         Use is equal to or less than the following listed total daily doses, unless higher doses (as evidenced by the resident response and/or the resident's clinical record) are necessary for the improvement or maintenance in the resident's functional status.

 

EXAMPLES OF SHORT-ACTING BENZODIAZEPINES (not maximum doses)

 

Generic	Brand	Daily Oral Dosage
Lorazepam	(Ativan)	2mg
Oxazepam	(Serax)	30mg
Alprazolam	(Xanax)	0.75mg

 

EXAMPLES OF OTHER ANXIOLYTIC AND SEDATIVE DRUGS
Generic	Brand	Daily Oral Dosage
Diphenhydramine	(Benadryl)	50mg
Hydroxyzine	(Atarax, Vistaril)	50mg
Chloral Hydrate	(Many Brands)	750mg

 

NOTES:

This documentation is often referred to as "behavioral monitoring charts" and is necessary to assist in:  (a) assessing whether the resident's behavioral symptom is in need of some form of intervention, (b) determining whether the behavioral symptom is transitory or permanent, (c) relating the behavioral symptom to other events in the resident's life in order to learn about potential causes (e.g., death in the family, not adhering to the resident's customary daily routine), (d) ruling out environmental causes such as excessive heat, noise, overcrowding, etc., (e) ruling out medical causes such as pain, constipation, fever, infection.

 

The daily doses listed under Short-Acting Benzodiazepines are doses (usually administered in divided doses) for "geriatric" or "elderly" residents.  The facility is encouraged to initiate therapy with lower doses and when necessary only gradually increase doses.  The facility may exceed these doses if it provides evidence to show why it was necessary for the maintenance or improvement in the resident's functional status.

 

For drugs in this category, a gradual dose reduction should be attempted at least twice within one year before one can conclude that a gradual dose reduction is "clinically contraindicated."

 

Diphenhydramine, hydroxyzine and chloral hydrate are not necessarily drugs of choice for treatment of anxiety disorders.  They are only listed here in the event of their potential use.

 

C.        Drugs Used for Sleep Induction

Drugs used for sleep induction should only be used if:

 

1.         Evidence exists that other possible reasons for insomnia (e.g., depression, pain, noise, light, caffeine) have been ruled out;

 

2.         The use of a drug to induce sleep results in the maintenance or improvement of the resident's functional status;

 

3.         Daily use of the drug is less than ten continuous days unless an attempt at a gradual dose reduction is unsuccessful;

 

4.         The dose of the drug is equal to or less than the following listed doses unless higher doses (as evidenced by the resident response and/or the resident's clinical record) are necessary for maintenance or improvement in the resident's functional status.

 

EXAMPLES OF HYPNOTIC DRUGS (not maximum doses)
Generic	Brand	Oral Dosage
Temazepam	(Restoril)	7.5mg
Triazolam	(Halcion)	0.125mg
Lorazepam	(Ativan)	1mg
Oxazepam	(Serax)	15mg
Alprazolam	(Xanax)	0.25mg
Estazolam	(ProSom)	0.5mg
Diphenhydramine	(Benadryl)	25mg
Hydroxyzine	(Atarax, Vistaril)	50mg
Chloral Hydrate	(Many Brands)	50mg
Zolipiden	(Amien)	5mg

 

NOTES:

Diminished sleep in the elderly is not necessarily pathological.

 

The doses listed are doses for "geriatric" or "elderly" residents.  The facility is encouraged to initiate therapy with lower doses and when necessary only gradually increase doses.  The facility may exceed these doses if it provides evidence to show why it was necessary for the maintenance or improvement in the resident's functional status.

 

Diphenhydramine, hydroxyzine, and chloral hydrate are not necessarily drugs of choice for sleep disorders.  They are listed here only in the event of their potential use.

 

For drugs in this category, a gradual dose reduction should be attempted at least three times within six months before one can conclude that a gradual dose reduction is "clinically contraindicated."

 

D.        Miscellaneous Hypnotic/Sedative/Anxiolytic Drugs

The initiation of the following hypnotic/sedative/anxiolytic drugs should not occur in any dose for any resident.  (See Notes for exceptions.)  Residents currently using these drugs or residents admitted to the facility while using these drugs should receive gradual dose reductions as part of a plan to eliminate or modify the symptoms for which they are prescribed.  A gradual dose reduction should be attempted at least twice within one year before one can conclude that the gradual dose reduction is clinically contraindicated.  Newly admitted residents using these drugs may have a period of adjustment before a gradual dose reduction is attempted.

 

(Caution:  The Rapid withdrawal of these drugs might result in severe physiological withdrawal symptoms.)

 

EXAMPLES OF BARBITURATES
Generic	Brand
Amobarbital	(Amytal)
Amobarbital-Secobarbital	(Tuinal)
Butabarbital	(Butisol, others)
Pentobarbital	(Nembutal)
Secobarbital	(Seconal)
Phenobarbital	(Many Brands)
Barbiturates with	(e.g., Fiorinal)
other drugs

 

EXAMPLES OF MISCELLANEOUS HYPNOTIC/SEDATIVE/ANXIOLYTICS
Generic	Brand
Ethchlorvynol	(Placidyl)
Glutethimide	(Doriden)
Meprobamate	(Equinal, Miltown)
Methprylon	(Noludar)
Paraldehyde	(Many Brands)

 

NOTES:

Any sedative drug is excepted from this Guideline when used as a single dose sedative for dental or medical procedures.

 

Phenobarbital is excepted from this Guideline when used in the treatment of seizure disorders.

 

When Miscellaneous Hypnotic/Sedative/Anxiolytic Drugs are used outside these Guidelines, they may be unnecessary drugs as a result of inadequate indications for use.

 

E.         Antipsychotic Drugs

The following examples of antipsychotic drugs should not be used in excess of the listed doses for residents with organic mental syndromes (now called dementia, delirium, and amnestic and other "cognitive disorders" by DSM-IV) unless higher doses (as evidenced by the resident's response or the resident's clinical record) are necessary to maintain or improve the resident's functional status.

 

EXAMPLES OF ANTIPSYCHOTIC DRUGS FOR RESIDENTS
WITH ORGANIC MENTAL SYNDROMES (not maximum dose)
Generic	Brand	Daily Oral Dosage
Clorpromazine	(Thorazine)	75mg
Promazine	(Sparine)	150mg
Triflupromazine	(Vesprin)	20mg
Thioridazine	(Mellaril)	75mg
Mesoridazine	(Serentil)	25mg
Acetophenazine	(Tindal)	20mg
Perphenazine	(Trilafon)	8mg
Fluphenazine	(Prolixin, Permitil)	4mg
Trifluoperazine	(Stelazine)	8mg
Chlorprothixene	(Taractan)	75mg
Thiothixene	(Navane)	7mg
Haloperidol	(Haldol)	4mg
Molindone	(Moban)	10mg
Loxapine	(Loxitane)	10mg
Clozapine	(Clozaril)	50mg
Prochlorperazine	(Compazine)	10mg
Risperidone	(Resperdal)	4mg

 

NOTES:

The doses listed are daily doses (usually administered in divided doses) for residents with organic mental syndromes (now called dementia, delirium, and amnestic and other "cognitive disorders" by DSM-IV).  The facility is encouraged to initiate therapy with lower doses and when necessary only gradually increase doses.  The facility may exceed these doses if it provides evidence to show why it is necessary for the maintenance or improvement in the resident's functional status.

 

The "specific conditions" for use of antipsychotic drugs are listed under this Guideline G.

 

The dose of prochlorperazine may be exceeded for short term (seven day) treatment of nausea and vomiting.  Residents with nausea and vomiting secondary to cancer or cancer chemotherapy can also be treated with higher doses for longer periods of time.

 

When antipsychotic drugs are used outside these Guidelines, they may be deemed unnecessary drugs as a result of excessive doses.

 

F.         Monitoring for Antipsychotic Drug Side Effects

The facility assures that residents who are undergoing antipsychotic drug therapy receive adequate monitoring for significant side effects of such therapy with emphasis on the following:

 

1.         Tardive dyskinesia;

 

2.         Postural (orthostatic) hypotension;

 

3.         Cognitive/behavior impairment;

 

4.         Akathisia; and

 

5.         Parkinsonism.

 

When antipsychotic drugs are used without monitoring for these side effects, they may be unnecessary drugs because of inadequate monitoring.

 

G.        Use of Antipsychotic Drugs

 

Antipsychotic drugs should not be used unless the clinical record documents that the resident has one or more of the following "specific conditions":

 

1.         Schizophrenia;

 

2.         Schizo-affective disorder;

 

3.         Delusional disorder;

 

4.         Psychotic mood disorders (including mania and depression with psychotic features);

 

5.         Acute psychotic episodes;

 

6.         Brief reactive psychosis;

 

7.         Schizophreniform disorder;

 

8.         Atypical psychosis;

 

9.         Tourette's disorder;

 

10.         Huntington's disease;

 

11.         Organic mental syndromes (now called dementia, delirium, and amnestic and other "cognitive disorders" by DSM-IV) with associated psychotic and/or agitated behaviors:

 

Which have been quantitatively (number of episodes) and objectively (e.g., biting, kicking, scratching) documented.  This documentation is necessary to assist in:  (a) assessing whether the resident's behavioral symptom is in need of some form of intervention, (b) determining whether the behavioral symptom is transitory or permanent, (c) relating the behavioral symptom to other events in the resident's life in order to learn about potential causes (e.g., death in the family, not adhering to the resident's customary daily routine), (d) ruling out environmental causes such as excessive heat, noise, overcrowding, (e) ruling out medical causes such as pain, constipation, fever, infection;

 

Which are persistent;

 

Which are not caused by preventable reasons; and

 

Which are causing the resident to:

 

Present a danger to her/himself or to others,

 

Continuously cry, scream, yell, or pace if these specific behaviors cause an impairment in functional capacity, or

 

Experience psychotic symptoms (hallucinations, paranoia, delusions) not exhibited as dangerous behaviors or as crying, screaming, yelling, or pacing but which cause the resident distress or impairment in functional capacity; or

 

12.        Short term (seven days) symptomatic treatment of hiccups, nausea, vomiting or pruritus.  Residents with nausea and vomiting secondary to cancer or cancer chemotherapy can also be treated with higher doses for longer periods of time.

 

Antipsychotics should not be used if one or more of the following is/are the only indication:

 

1.         Wandering,

 

2.         Poor self care,

 

3.         Restlessness,

 

4.         Impaired memory,

 

5.         Anxiety,

 

6.         Depression (without psychotic features),

 

7.         Insomnia,

 

8.         Unsociability,

 

9.         Indifference to surroundings,

 

10.         Fidgeting,

 

11.         Nervousness,

 

12.         Uncooperativeness, or

 

13.         Agitated behaviors which do not represent danger to the resident or others.

 

H.        Antipsychotic Drug Gradual Dose Reduction

Residents must, unless clinically contraindicated, have gradual dose reductions of the antipsychotic drug.  The gradual dose reduction should be under close supervision.  If the gradual dose reduction is causing an adverse effect on the resident and the gradual dose reduction is discontinued, documentation of this decision and the reasons for it should be included in the clinical record.  Gradual dose reductions consist of tapering the resident's daily dose to determine if the resident's symptoms can be controlled by a lower dose or to determine if the dose can be eliminated altogether.

 

"Behavioral interventions" means modification of the resident's behavior or the resident's environment, including staff approaches to care, to the largest degree possible to accommodate the resident's behavioral symptoms.

 

"Clinically contraindicated" means that a resident need not undergo a "gradual dose reduction" or "behavioral intervention" if the resident has a "specific condition" (as listed in these Guidelines under subsection G, 1-11) and has a history of recurrence of psychotic symptoms (e.g., delusions, hallucinations) which have been stabilized with a maintenance dose of an antipsychotic drug without incurring significant side effects (e.g., tardive dyskinesia).  In residents with organic mental syndromes (now called dementia, delirium, and amnestic and other cognitive disorders by DSM-IV), "clinically contraindicated" means that a gradual dose reduction has been attempted twice in one year and that attempt resulted in the return of symptoms for which the drug was prescribed to a degree that a cessation in the gradual dose reduction, or a return to previous dose levels was necessary.  The resident's physician provides a justification why the continued use of the drug and the dose of the drug is clinically appropriate.  This justification should include:  (a) a diagnosis, but not simply a diagnostic label or code, but the description of symptoms, (b) a discussion of the differential psychiatric and medical diagnosis (e.g., why the resident's behavioral symptom is thought to be a result of a dementia with associated psychosis and/or agitated behaviors, and not the result of an unrecognized painful medical condition or a psychosocial or environmental stressor), (c) a description of the justification for the choice of a particular treatment or treatments, and (d) a discussion of why the present dose is necessary to manage the symptoms of the resident.  This information need not necessarily be in the physician's progress notes, but must be a part of the resident's clinical record.

 

I.          Antidepressant Drugs

The facility is not required to use behavioral monitoring charts when antidepressant drugs are used.  "Behavioral monitoring charts" include such records as quantitative evidence (number of episodes) and objective evidence (e.g., withdrawn behavior such as the resident staying in his/her room, refusal to speak, etc.) of patient behavior necessitating the use of the antidepressant drug.  The following is a list of commonly used antidepressant drugs:

 

EXAMPLES OF ANTIDEPRESSANT DRUGS
Generic	Brand
Amitriptyline	(Elavil)
Amoxapine	(Asendin)
Desipramine	(Norpramin, Pertofrane)
Doxepin	(Sinequan)
Imipramine	(Tofranil)
Maprotiline	(Ludiomil)
Nortriptyline	(Aventyl, Panelor)
Protriptyline	(Vivactil)
Trimipramine	(Surmontil)
Fluoxetine	(Prozac)
Sertaline	(Zoloft)
Trazodone	(Desyrel)
Clomipramine	(Anafranil
Paroxetine	(Paxil)
Bupropion	(Wellbutrin)
Isocarboxazid	(Marplan)
Phenelzine	(Nardil)
Tranylcypromine	(Parnate)
Venlafaxine	(Effexor)
Nefazadone	(Serzone)
Fluvoxamine	(Luvox)

 

J.          Exceptions to These Guidelines

The facility shall have the opportunity to provide a rationale for the use of drugs prescribed  outside these Guidelines.  The facility may not justify the use of a drug prescribed outside these Guidelines solely on the basis of "the doctor ordered it."  The rationale must be based on sound risk-benefit analysis of the resident's symptoms and potential adverse effects of the drug.

 

The unnecessary drug criterion of "adequate indications for use" does not simply mean that the physician's order must include a reason for using the drug (although such order writing is encouraged).  It means that the resident lacks a valid clinical reason for use of the drug as evidenced by the evaluation of some, but not necessarily all, of the following:  resident assessment, plan of care, reports of significant change, progress notes, laboratory reports, professional consults, drug orders, observation and interview of the resident, and other information.

 

In determining whether an antipsychotic drug is without a "specific condition" or that "gradual dose reduction and behavioral interventions" have not been performed, the facility shall justify why using the drug outside these Guidelines is in the best interest of the resident.

 

Examples of evidence that would support a justification of why a drug is being used outside these Guidelines but in the best interests of the resident may include, but are not limited to:

 

1.         A physician's note indicating, for example, that the dosage, duration, indication, and monitoring are clinically appropriate, and the reasons why they are clinically appropriate; this note should demonstrate that the physician has carefully considered the risk/benefit to the resident in using drugs outside these Guidelines;

 

2.         A medical or psychiatric consultation or evaluation (e.g., Geriatric Depression Scale) that confirms the physician's judgment that use of a drug outside those Guidelines is in the best interest of the resident;

 

3.         Physician, nursing, or other health professional documentation indicating that the resident is being monitored for adverse consequences or complications of the drug therapy;

 

4.         Documentation confirming that previous attempts at dosage reduction have been unsuccessful;

 

5.         Documentation (such as MDS documentation) showing resident's subjective or objective improvement, or maintenance of function while taking the medication;

 

6.         Documentation showing that a resident's decline or deterioration is evaluated by the interdisciplinary team to determine whether a particular drug, or a particular dose, or duration of therapy, may be the cause;

 

7.         Documentation showing why the resident's age, weight, or other factors would require a unique drug dose or drug duration, indication, monitoring;

 

8.         Other evidence which may be appropriate.