Section 102.5  Applicability

 

This Part pertains to the use and regulation of the Department's State-operated mental health and developmental disability centers and programs.

 

(Source:  Added at 26 Ill. Reg. 8520, effective May 30, 2002)

 

Section 102.6  Definitions

 

For the purposes of this Part, the following terms are defined:

 

            "Administrator" means the chief administrator of a State-operated mental health center.

 

            "Assistant Associate Director" means the Assistant Associate Director for Mental Health or Assistant Associate Director for State-operated Developmental Center (SODC) Operations, as appropriate for the center/program.

 

            "Center/program" means a State-operated developmental disabilities facility or a State-operated mental health facility as defined by Sections 1-107 and 1-114 of the Mental Health and Developmental Disabilities Code [405 ILCS 5/1-107 and 1-114].

 

            "Director" means the chief administrator of a State-operated developmental disabilities facility or program.

 

            "Individual" means a recipient of services as defined in Section 1-123 of Mental Health and Developmental Disabilities Code [405 ILCS 5/1-123].

 

            "Voluntary organization" or "organization" means private or not-for-profit organizations that have, as a purpose, the review or promotion of treatment or habilitation services to persons with mental disabilities.  Voluntary organization does not include organizations or agencies authorized to have access to centers/programs pursuant to either the Guardianship and Advocacy Act [20 ILCS 3955] or the Protection and Advocacy for Developmentally Disabled Persons Act [405 ILCS 40].

 

(Source:  Added at 26 Ill. Reg. 8520, effective May 30, 2002)

 

Section 102.10  Use of Department Campuses and Property

 

a)         Site visitations

 

1)         The Department may provide visiting privileges to voluntary organizations that wish to review living conditions and the nature of publicly-sponsored services.

 

2)         Voluntary organizations shall request authorization for visiting privileges in writing.  The request shall be made to the Assistant Associate Director of the Office of Mental Health or the Assistant Associate Director of SODC Operations, as appropriate and shall specify the center/program to be visited.  If the organization agrees to the conditions set out in subsection (a)(2)(A) of this Section, the request shall contain those agreements.

 

A)        The Assistant Associate Director shall authorize an organization to make visits to one or more centers/programs for a period of one year if:

 

i)          The organization agrees that its visits will not interfere with the center's/program's treatment or habilitation programs;

 

ii)         The organization agrees to abide by the provisions of the Mental Health and Developmental Disabilities Confidentiality Act (Confidentiality Act) [740 ILCS 110] concerning records and communications of individuals served; and

 

iii)        The organization provides evidence that volunteers have received training on the topics specified in subsection (a)(3) of this Section within 12 months prior to the date of the application for authorization.  Such evidence shall, at a minimum, include a list of the training sessions and instructors and any documents distributed as part of the training session.

 

B)        The Assistant Associate Director shall revoke his or her authorization or not renew the authorization if he or she has information that the organization has not abided by the conditions set out in subsection (a)(2)(A) or complied with the requirements of this Section. Any person having information that the organization has not abided by the conditions or complied with the requirements shall submit that information in writing to the appropriate Assistant Associate Director's office.  Within 30 calendar days after the receipt of such information, the Assistant Associate Director shall decide whether to revoke or renew the authorization.

 

C)        When the Assistant Associate Director denies, revokes or does not renew an authorization, he or she shall send written notice of the decision to the agency within 30 calendar days after receipt of the application or receipt of information as set out in subsection (a)(2)(B) of this Section.  The notice shall include the appeal procedure and time in which the agency must appeal.

 

D)        Any organization whose authorization has been revoked or not renewed may appeal the decision within 30 calendar days after receiving the notice.  The organization must submit its request for review in writing to the Secretary, and may submit any other documents in support of its appeal with the request for review.  The Secretary shall review the decision and the documents and accept or reverse the decision within 30 calendar days.  The Secretary shall uphold the decision if he or she finds that the organization has not abided by the agreements as set out in subsection (a)(2)(A) of this Section or complied with the requirements of subsection (a) of this Section.

 

3)         Organization site visits shall be conducted in a manner that is consistent with center/program operating needs in compliance with the Confidentiality Act and be authorized by the Assistant Associate Director of the Office of Mental Health or the Assistant Associate Director of SODC Operations, as appropriate to the center/program.  Disruption of individuals and their programs shall be minimized.  Except as set by prior agreement with the appropriate Assistant Associate Director, visitation groups shall not exceed five persons on a given unit on any one day.  The Assistant Associate Director shall allow more than five persons on a unit if, after consulting with the Director or Administrator, he or she determines that the proposed number of visitors would not interfere with the center's/program's treatment or habilitation plans and would not violate the individuals' privacy. Directors or Administrators who receive requests for visitation privileges shall either forward them to the Assistant Associate Director or advise the organization to send a written request to the Assistant Associate Director.  The purpose of the authorization process is to ensure that organization members have received training and orientation concerning the Department's service delivery system with a focus on mental health services and/or developmental disability services, advocacy services, and legal issues such as the rights of individuals and confidentiality.  The Assistant Associate Director shall distribute to centers/programs a listing of organizations that are authorized to conduct site visits.  Although visitation privileges shall be authorized annually, organizations meeting the standards of this subsection (a) (3) may be included in the listing at any time during the year.

 

4)         Site visits shall be announced 48 hours in advance to the Director or Administrator and shall occur between 9:00 a.m. and 9:00 p.m.  Following two scheduled visits to any center/program, voluntary organizations may make unannounced visits to any center/program.

 

5)         Before conducting any site visit, organization visitors shall report their presence to the Director or Administrator or the unit administrator on duty, who shall confirm the visitors' identity and authorization and make available a staff member to escort the visitors.  All organization visitor's must produce a valid photo identification, such as a driver's license, passport, identification card issued by the Secretary of State to non-drivers, student identification or identification card issued by the visitor's organization or employer before the visitor will be permitted to enter the unit.

 

6)         All visitation activities shall conform to the Confidentiality Act.  Clinical records of individuals shall be examined during site visits only in accordance with the Confidentiality Act.  During the visit, visitors may request and receive verbal authorization from individuals for interviews with the individuals.  If center/program staff are to be included in the interviews or are to be questioned separately in regard to a specific individual, a written consent for release of information shall be obtained from that individual prior to or during the visit. The release shall be filed in the individual's clinical record.  Unless a release is obtained, center/program staff shall not participate in the interview or respond to such questions.

 

7)         Authorized visitors shall be permitted access to individuals' living units and program areas, except when, in the Director's, Administrator's or Unit Administrator's clinical judgment, such access poses a threat to their or the individuals' security, or constitutes an interference with individuals' programming.  Before visitors are permitted access to living units or program areas, the Director or Administrator shall give individuals advance notice. Before inspecting an individual's room, visitors shall obtain the individual's written or verbal permission.  The center/program staff member shall document the verbal permission or receive the written permission and file it in the individual's clinical record.

 

8)         The organization shall  provide a written report of its findings to the Director or Administrator within 14 calendar days after the visit.  If no negative findings were noted during the visit, the organization should document this finding.  The Director or Administrator shall provide the Assistant Associate Director, the Associate Director and the Department Secretary with a copy of all written reports within 48 hours and shall provide a written response to all exit reports within five working days after receipt to the visitors with a copy to the Assistant Associate Director, the Associate Director and the Department Secretary.  If the organization has not received a response 15 working days after it submitted its report, it shall notify the Assistant Associate Director, who shall inform the Director or Administrator.

 

b)         Sales or solicitation

            The Director or Administrator shall not permit organizations or individuals to solicit funds or memberships, other than union memberships, nor sell or take orders for goods or services from employees in the buildings or on the campuses or property of Department centers/programs without the Secretary's prior approval.  The Secretary may approve these activities if they do not interfere with the employees' job duties and if the activities are not directed toward individuals.

 

c)         Game preserve

 

1)         All Department center/program campuses and property shall be closed as game reservations and posted accordingly.  The Director or Administrator may, however, grant fishing privileges to individuals at centers/programs where fishing is possible.

 

2)         No hunting or trapping shall be permitted on the campuses or property of any Department center/program.

 

d)         Liquor, controlled substances, cannabis, firearms and other weapons

 

1)         Sale or gift of alcoholic beverages, liquor, controlled substances or cannabis to employees or individuals on center/program campuses or property is prohibited. Visitors or employees who show signs of intoxication or a drug-induced state shall not be admitted to center/program campuses or property.

 

2)         Firearms or other weapons such as bludgeons, metal knuckles, tear gas, broken bottles or glass, knives, hatchets or bombs of any sort shall not be brought or permitted on center/program campuses or property.  Armed law enforcement officials are allowed on the center/program campus or property when responding to an emergency situation.  An  emergency occurs when there is a threat of bodily harm that could result in the death or serious injury of individuals served or center/program staff.  The delivery of an individual by a law enforcement official to a center/program for admission does not constitute an emergency.  The Director or Administrator shall request that law enforcement officials secure their weapons in a locked squad car or store their weapons in a locked safe upon arrival at the center/program except during an emergency.

 

e)         Center/program access

            Only persons on official business, such as employees, authorized visitors, persons providing required goods and services shall have access to center/program campuses and property.

 

f)         Identification of employees and visitors

            The Director or Administrator shall develop and implement written policies and procedures to ensure that employees and visitors are properly identified at all times while they are on the center/program campus or property.  Employees shall have on their person an employee identification card.  All visitors must produce a photo identification as described in subsection (a)(5), and  shall have on their person a visitor identification card. No Department employee shall wear a badge such as those issued to sworn law enforcement officials.   The requirement of identification shall not hinder or preclude unannounced visits by voluntary organizations pursuant to this Section.

 

g)         Traffic rules

            All persons driving on center/program campuses or property shall operate their vehicles consistent with the Illinois Vehicle Code [625 ILCS 5] and shall observe the traffic rules established by the Director or Administrator that include, but are not limited to, the use of designated parking areas, observance of posted stop signs, speed limits, reckless driving, failure to yield to individuals, employees, and other persons crossing roadways, failure to display a decal, and leaving unattended vehicles unlocked.  The Director or Administrator may bar vehicles from the center/program campus or property after notice is given for three violations of this subsection.  Traffic rules shall be prominently posted.

 

(Source:  Amended at 26 Ill. Reg. 8520, effective May 30, 2002)

 

Section 102.30  Fire Protection in Department Centers/Programs

 

The Department adopts the rules of the Office of the State Fire Marshal at 41 Ill. Adm. Code 100 (Fire Prevention and Safety), 41 Ill. Adm. Code 140 (Policy and Procedures Manual for Fire Protection Personnel), 41 Ill. Adm. Code 160 (Storage, Transportation, Sale and Use of Gasoline and Volatile Oils: Rules and Regulations Relating to General Storage), 41 Ill. Adm. Code 170 (Storage, Transportation, Sale and Use of Petroleum and Other Regulated Substances), 41 Ill. Adm. Code 180 (Storage, Transportation, Sale and Use of Gasoline and Volatile Oils), 41 Ill. Adm. Code 200 (Storage, Transportation, Sale and Use of Liquified Petroleum Gas), 41 Ill. Adm. Code 250 (Fire Equipment Distributor and Employee Standards), and 41 Ill. Adm. Code 300 (Furniture Fire Safety Regulations).

 

a)         General provisions

            Each Department center/program shall have a master fire plan that shall include, at a minimum, that:

 

1)         fire regulations are posted and communicated;

 

2)         sprinkler systems, fire hoses, fire detection and alarm devices, and other fire safety equipment, are maintained in a fully functional condition at all times;

 

3)         fire detection and protection systems are inspected, tested and serviced as required for compliance with the standards of the Office of the State Fire Marshal and the Illinois Department of Public Health;

 

4)         interim life safety measures are implementing to compensate for the temporary interruption of fire safety systems and installations during periods of system failure and construction;

 

5)         evacuation procedures protect the safety and well-being of all persons at all times;

 

6)         employees are instructed in fire notification procedures and the use of alarm and signal systems;

 

7)         situations when employees are to attempt to contain fires are identified;

 

8)         there is advance planning for evacuation of non-ambulatory individuals in a prompt and safe manner; and

 

9)         there is a displacement plan for the temporary housing of individuals and staff in the event there is a fire that hinders the center's/program's ability to provide for safe occupancy in any portion of the center/program.

 

b)         Training

            All employees shall be trained in:

 

1)         Procedures to be followed in the master fire plan.

 

2)         The general principles of portable fire extinguisher use and the hazards involved with incipient stage fire fighting.

 

c)         Evacuation

 

1)         Fire exiting drills shall be held at intervals to be set by the Director or Administrator, but shall be conducted at least once per shift, quarterly.  Fire exiting drills do not require building evacuation.

 

2)         Primary and secondary evacuation routes and the location of fire alarm activation stations and portable fire extinguishers shall be posted in all occupied structures.

 

3)         In the event of fire or other emergencies, employees who serve non-ambulatory individuals shall be assisted by employees from other units who have been assigned to provide evacuation assistance.

 

4)         Security staff and local law enforcement authorities, if requested, shall assist in the evacuation of individuals who present a risk of unauthorized absence or serious harm to others.

 

d)         Prevention

 

1)         Smoking shall not be permitted in areas other than those designated as smoking areas by the Director or Administrator.

 

2)         The burning of candles, incense, and similar items with open flames/embers shall not be permitted inside buildings where centers/programs are located.  This does not prohibit the use of such items as part of religious services.

 

e)         Hazard surveillance

 

1)         Every center/program shall develop a system of self-inspections to identify and eliminate fire hazards.

 

2)         Employees shall report to their supervisors any potential fire hazards they identify.  Information regarding the identified hazard shall be provided to the center/program safety officer or other person designated to act on such findings.

 

3)         The center/program safety officer or other designated person shall conduct regularly scheduled inspections of all areas of the center/program.

 

4)         In addition to life safety inspections conducted by other State agencies, the Department's environmental health and safety manager is responsible for conducting periodic hazard surveillance rounds of treatment and sleeping areas.

 

f)         Reporting

 

1)         The center/program shall maintain records and reports of fire safety inspections, fire drills and fire evacuations.  The center/program shall document specific actions taken to correct deficiencies noted in these reports. Inspection reports from external sources and the plan for correcting the reported deficiencies shall be forwarded to the Department's Office of Environmental Health and Safety on the same date it is submitted to the inspecting agency.

 

2)         Each center/program shall prepare, within 24 hours after each fire-related incident or injury, a fire incident report form, provided by the State Fire Marshal, and shall submit the form the 15th day of the following month to the Deputy State Fire Marshal for Fire Prevention of the Office of the State Fire Marshal and the Department's Office of Environmental Health and Safety.

 

3)         Each center/program shall prepare an annual narrative report of the fires at the center/program during the previous calendar year.  This summary report shall contain such information as the total number of fires by unit, total dollar amount of damages, any injuries or deaths that occurred, the primary cause of the fires, and any steps taken to reduce the number of fires or to increase fire safety.  The Director or Administrator shall forward these reports to the Department's Office of Environmental Health and Safety.

 

(Source:  Amended at 26 Ill. Reg. 8520, effective May 30, 2002)

 

Section 102.40  Emergency/Disaster Response Plans

 

In the event of an emergency or disaster, such as an earthquake, tornado, flood, fire or man-made occurrence that threatens the safety and well-being of individuals, centers/programs shall comply with their emergency/disaster response plans.

 

(Source:  Added at 26 Ill. Reg. 8520, effective May 30, 2002)