TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1000 DEFINITIONS
Section 340.1000 Definitions
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
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 or
Satisfactory or Sufficient − enough in either quantity or quality, as
determined by a reasonable person familiar with the professional standards of
the subject under review, to meet the needs of the residents of a facility
under the particular set of circumstances in existence at the time of review.
Administrative
Warning − a notice to a facility issued by the Department under Section 340.1225
and Section 3-303.2 of the Act that indicates that a situation, condition, or
practice in the facility violates the Act or the Department's rules, but is not
a Type AA, Type A, Type B, or Type C violation.
Administrator −
a person who is charged with the general administration and supervision of a
facility and licensed, if required, under the Nursing Home Administrators
Licensing and Disciplinary Act. (Section 1-105 of the Act)
Advocate −
a person who represents the rights and interests of an individual as though
they were the person's own, in order to realize the rights to which the
individual is entitled, obtain needed services, and remove barriers to meeting
the individual's needs.
Affiliate −
means:
With
respect to a partnership, each partner thereof.
With
respect to a corporation, each officer, director and stockholder thereof.
With
respect to a natural person: any person related in the first degree of kinship
to that person; each partnership and each partner thereof of which that person
or any affiliate of that person is a partner; and each corporation in which
that person or any affiliate of that person is an officer, director or
stockholder. (Section 1-106 of the Act)
Aide −
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.
Approved –
acceptable to the authority having jurisdiction.
Assessment −
the use of an objective system with which to evaluate the physical, social,
developmental, behavioral, and psychosocial aspects of an individual.
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 U.S. Department of Health and Human Services or the Department of Healthcare
and Family Services verifying compliance with applicable statutory or
regulatory requirements for the purposes of participation as a provider of care
and service in a specific federal or State health program.
Certified
Nursing Assistant – any person who meets the requirements of 77 Ill. Adm. Code
395 and who provides nursing care or personal care to residents of facilities,
regardless of title, and who is not otherwise licensed, certified or registered
by the Department of Financial and Professional Regulation to render medical
care. Nursing assistants shall function under the supervision of a licensed
nurse.
Charge Nurse −
a registered professional nurse or a licensed practical nurse in charge of the
nursing activities for a specific unit or floor during a shift.
Chemical
Restraint − any drug that is used for discipline or convenience and is
not required to treat medical symptoms or behavior manifestations of mental
illness. (Section 2-106 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.
Dentist −
any person licensed to practice dentistry, including persons holding a
Temporary Certificate of Registration, as provided in the Illinois Dental
Practice Act.
Department
− the Department of Public Health. (Section 1-109 of the Act)
Developmental
Disability − means a severe, chronic disability of a person which:
is
attributable to a mental or physical impairment or combination of mental and
physical impairments, such as intellectual disability, cerebral palsy, epilepsy,
or autism;
is
manifested before the person attains age 22;
is likely
to continue indefinitely;
results in
substantial functional limitations in 3 or more of the following areas of major
life activity:
self-care,
receptive
and expressive language,
learning,
mobility,
self-direction,
capacity
for independent living, and
economic
self-sufficiency; and
reflects
the person's need for combination and sequence of special, interdisciplinary or
generic care, treatment or other services which are of lifelong or extended
duration and are individually planned and coordinated. (Section 3-801.1 of
the Act)
Dietetic
Service Supervisor − a person who:
is a
dietitian; or
is a graduate
of a dietetic and nutrition school or program authorized by the Accreditation
Council for Education in Nutrition and Dietetics;
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 that included
consultation from a dietitian;
has
successfully completed an Association of Nutrition & Foodservice
Professionals-approved Certified Dietary Manager or Certified Food Protection
Professional course;
is certified
as a Certified Dietary Manager or Certified Food
Protection Professional by the Association of Nutrition & Foodservice
Professionals; or
has training
and experience in food service supervision and management in a military service
equivalent in content to the programs in the second, third or fourth paragraph
of this definition.
Dietitian −
a person who is credentialed by the Commission on Dietetic Registration as a
Registered Dietitian and is a licensed dietitian nutritionist as defined in the
Dietitian Nutritionist Practice Act.
Direct
Supervision − under the guidance and direction of a supervisor who is
responsible for the work, who plans work and methods, who is available on short
notice to answer questions and deal with problems that are not strictly
routine, who regularly reviews the work performed, and who is accountable for
the results.
Director −
the Director of Public Health or designee. (Section 1-110 of the Act)
Director of
Nursing Service − the full-time Professional Registered Nurse who is
directly responsible for the immediate supervision of the nursing services.
Discharge −
the full release of any resident from a facility. (Section 1-111 of the
Act)
Discipline −
any action taken by the facility for the purpose of punishing or penalizing
residents.
Distinct Part −
an entire, physically identifiable unit consisting of all of the beds within
that unit and having facilities meeting the standards applicable to the levels
of service to be provided. Staff and services for a distinct part are
established as set forth in the respective regulations governing the levels of
services approved for the distinct part.
Emergency −
a situation, physical condition or one or more practices, methods or operations
that present imminent danger of death or serious physical or mental harm
to residents of a facility and are clinically documented in the resident's
medical record. (Section 1-112 of the Act)
Facility or
Long-term Care Facility − A private home, institution, building,
residence, or any other place, whether operated for profit or not, or a county
home for the infirm and chronically ill operated pursuant to Division 5-21 or
5-22 of the Counties Code, or any similar institution operated by a political
subdivision of the State of Illinois, which provides, through its ownership or
management, personal care, sheltered care or nursing for three or more
persons, not related to the applicant or owner by blood or marriage. It
includes skilled nursing facilities and intermediate care facilities as those
terms are defined in Title XVIII and Title XIX of the federal Social Security
Act (42 U.S.C. 1395 et seq. and 1936 et seq.). It also includes homes,
institutions, or other places operated by or under the authority of the
Illinois Department of Veterans' Affairs. A "facility" may
consist of more than one building as long as the buildings are on the same
tract or adjacent tracts of land. However, there shall be no more than one
"facility" in any one building. "Facility" does not
include the following:
A home,
institution, or other place operated by the federal government or agency
thereof, or by the State of Illinois other than homes, institutions, or other
places operated by or under the authority of the Illinois Department of
Veterans' Affairs;
A hospital,
sanitarium, or other institution whose principal activity or business is the
diagnosis, care, and treatment of human illness through the maintenance and
operation as organized facilities therefor, which is required to be licensed
under the Hospital Licensing Act;
Any
"facility for child care" as defined in the Child Care Act of 1969;
Any "Community
Living Facility" as defined in the Community Living Facilities Licensing
Act;
Any nursing
home or sanatorium operated solely by and for persons who rely exclusively upon
treatment by spiritual means through prayer, in accordance with the creed or
tenets of any well-recognized church or religious denomination. However, such
nursing home or sanatorium shall comply with all local laws and rules relating
to sanitation and safety;
Any
facility licensed by the Department of Human Services as a
community-integrated living arrangement as defined in the Community-Integrated
Living Arrangements Licensure and Certification Act;
Any "supportive
residence" licensed under the Supportive Residences Licensing Act;
Any "supportive
living facility" in good standing with the program established under
Section 5-5.01a of the Illinois Public Aid Code, except only for
purposes of the employment of persons in accordance with Section 3-206.01
of the Act;
Any
assisted living or shared housing establishment licensed under the Assisted
Living and Shared Housing Act, except only for purposes of the
employment of persons in accordance with Section 3-206.01 of the Act;
An
Alzheimer's disease management center alternative health care model licensed
under the Alternative Health Care Delivery Act;
A facility licensed under the ID/DD
Community Care Act;
A facility licensed under the
Specialized Mental Health Rehabilitation Act of 2013;
A facility
licensed under the MC/DD Act; or
A medical foster home, as
defined in 38 CFR 17.73, that is under the oversight of the United States
Department of Veterans Affairs. (Section 1.113 of the Act)
Full-time −
on duty a minimum of 36 hours, four days per week.
Goal −
an expected result or condition that involves a relatively long period of time
to achieve, that is specified in behavioral terms in a statement of relatively
broad scope, and that provides guidance in establishing specific, short-term
objectives directed toward its attainment.
Guardian
– a person appointed as a guardian of the person or guardian of the estate,
or both, of a resident under the "Probate Act of 1975." (Section
1-114 of the Act)
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, 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
Is 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 of the Act)
Immediate
family – the spouse, an adult child, a parent, an adult brother or sister, or
an adult grandchild of a person. (Section 1-114.1 of the Act)
Intellectual
Disability – subaverage general intellectual functioning originating during the
developmental period and associated with maladaptive behavior.
Interdisciplinary
Team − a group of persons that represents those professions, disciplines,
or service areas that are relevant to identifying an individual's strengths and
needs, and designs a program to meet those needs. This team shall include at
least a physician, a nurse with responsibility for the resident, the resident,
the resident's guardian, the resident's primary service providers, including
staff most familiar with the resident, and other appropriate professionals and
caregivers as determined by the resident's needs. The resident or their
guardian may also invite other individuals to meet with the Interdisciplinary
Team and participate in the process of identifying the resident's strengths and
needs.
Licensed
Practical Nurse − a person with a valid Illinois license to practice as a
practical nurse.
Licensee
− the individual or entity licensed by the Department to operate the
facility. (Section 1-115 of the Act)
Life Care
Contract − a contract through which a facility agrees to provide
maintenance and care for a resident throughout the remainder of the resident's
life.
Maintenance
− food, shelter, and laundry services. (Section 1-116 of the Act)
Misappropriation
of a Resident's Property – the deliberate misplacement, exploitation, or
wrongful temporary or permanent use of a resident's belongings or money without
the resident's consent or the consent of a resident's guardian or
representative. Misappropriation of a Resident's Property includes failure to
return valuables after a resident's discharge, failure to refund money after
death, or discharge when there is an unused balance in the resident's personal
account. (Section 1-116.5 of the Act)
Monitor −
a qualified person placed in a facility by the Department to observe operations
of the facility, assist the facility by advising it on how to comply with the
State regulations, and 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.
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 −
with regard to the term "owner," any individual, partnership,
corporation, association, municipality, political subdivision, trust, estate or
other legal entity.
Personal
Care − assistance with meals, dressing, movement, bathing or other
personal needs or maintenance, or general supervision and oversight of the
physical and mental well-being of an individual who is incapable of maintaining
a private, independent residence or who is incapable of managing their
person, whether or not a guardian has been appointed for that
individual. (Section 1-120 of the Act)
Pharmacist, Licensed
− a person who holds a license as a pharmacist, a local registered
pharmacist or a registered assistant pharmacist under the Pharmacy Practice
Act.
Physical
Restraint − any manual method or physical or mechanical device, material,
or equipment attached or adjacent to a resident's body that the resident cannot
remove easily and that restricts freedom of movement or normal access to
one's body. (Section 2-106 of the Act)
Physical
Therapist − a person who is licensed as a physical therapist under the
Illinois Physical Therapy Act.
Physical
Therapist Assistant − a person who has graduated from a two-year college
level program approved by the American Physical Therapy Association.
Physician −
any person licensed to practice medicine in all its branches as provided in the
Medical Practice Act of 1987.
Provisional Admission Period –
the time between the admission of an identified offender as defined in Section
1-114.01 of the Act and this Section, and 3 days following the admitting
facility's receipt of an Identified Offender Report and Recommendation in
accordance with Section 2-201.6 of the Act. (Section 1-120.3 of the
Act)
Psychiatric Services Rehabilitation
Aide – an individual employed by a long-term care facility to provide, for
mentally ill residents, at a minimum, crisis intervention, rehabilitation, and
assistance with activities of daily living. (Section 1-120.7 of the Act)
Psychiatrist −
a physician who has had at least three years of formal training or primary
experience in the diagnosis and treatment of mental illness.
Psychologist −
a person who is licensed to practice clinical psychology under the Clinical
Psychologist Licensing Act.
Qualified
Professional − a person who meets the educational, technical and ethical
criteria of a health care profession, as evidenced by eligibility for
membership in an organization established by the profession for the purpose of
recognizing those persons who meet this criteria; and is licensed, registered,
or certified by the State of Illinois, if required.
Reasonable Hour
− any time between the hours of 10 a.m. and 8 p.m. daily. (Section
1-121 of the Act)
Registered
Nurse − a person with a valid license to practice as a registered
professional nurse under the Nurse Practice Act.
Repeat
Violation − for purposes of assessing fines under Section 3-305 of
the Act and this Part, a violation that has been cited during one
inspection of the facility for which a subsequent inspection indicates that
an accepted plan of correction was not complied with, within a period of
not more than 12 months from the issuance of the initial violation, or a new
citation of the same rule if the licensee is not substantially addressing the
issue routinely throughout the facility. (Section 3-305(7) of the Act)
Resident
− a person receiving personal or medical care, including but not limited
to mental health treatment, psychiatric rehabilitation, physical
rehabilitation, and assistance with activities of daily living, from a
facility. (Section 1-122 of the Act)
Resident
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 not related to the
resident, or an agent or employee of a facility not related to the resident,
designated in writing by a resident to be their representative, or the
resident's guardian. (Section 1-123 of the Act)
Restorative Services
− services 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.
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 Illinois State Fire Marshal, who serves as the executive
director of the Office of the State Fire Marshal. (Section 1 of the State
Fire Marshal Act)
Sterilization −
the act or process of destroying completely all forms of microbial life,
including viruses.
Stockholder
of a Corporation − any person who, directly or indirectly, beneficially
owns, holds or has the power to vote, at least five percent of any class of
securities issued by the corporation. (Section 1-125 of the Act)
Student Intern − any
person whose total term of employment in any facility during any 12-month period
is equal to or less than 90 continuous days, and whose term of employment:
is an academic credit
requirement in a high school or undergraduate institution;
immediately succeeds a full
quarter, semester, or trimester of academic enrollment in either a high school
or undergraduate or graduate institution, provided that such person is
registered for another full quarter, semester, or trimester of academic
enrollment in either a high school or undergraduate or graduate institution
which quarter, semester, or trimester will commence immediately following the
term of employment; or
immediately succeeds graduation
from the high school or undergraduate or graduate institution. (Section
1-125.1 of the Act)
Substantial
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 term as used in Section 340.1130(b)(1).
Supervision −
authoritative guidance by a qualified person for the accomplishment of a
function or activity within their sphere of competence. 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.
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 that creates a condition or occurrence
relating to the operation and maintenance of a facility that proximately caused
a resident's death. (Section 1-128.5 of the Act)
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 49 Ill.
Reg. 6539, effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1010 INCORPORATED AND REFERENCED MATERIALS
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 online at: https://www.scribd.com/document/359258258/american-college-of-obstetricians-and-gynecologists-guidelines-for-women-s-health-care-a-resource-manual.
(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.
C) The
Prescribers' Digital Reference (PDR) database, which may be accessed at: www.pdr.net.
D) The
UpToDate Lexidrug online database, which may be accessed at: www.wolterskluwer.com/en/solutions/uptodate/enterprise/lexidrug.
E) The American Society of Health-System Pharmacists (ASHP)
database, which may be accessed at: www.ashp.org.
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/infection-control/media/pdfs/guideline-cauti-h.pdf?CDC_AAref_Val=https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf
(June 6, 2019);
ii) Guideline for Hand Hygiene in Health-Care Settings, available
at: https://www.cdc.gov/infection-control/media/pdfs/Guideline-Hand-Hygiene-P.pdf
(October 25, 2002);
iii) Guidelines for Prevention of Intravascular Catheter-Related Infections,
2011, available at: https://www.cdc.gov/infection-control/media/pdfs/guideline-bsi-h.pdf?CDC_AAref_Val=https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf
(October 2017);
iv) Guideline for Prevention of Surgical Site Infection, 2017, available
at: https://jamanetwork.com/journals/jamasurgery/fullarticle/2623725 (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/infection-control/media/pdfs/guideline-isolation-h.pdf?CDC_AAref_Val=https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf
(September 2024);
vii) Infection Control in Healthcare
Personnel, available in two parts: Infrastructure and Routine Practices for
Occupational Infection Prevention and Control Services, available at: https://www.cdc.gov/infection-control/media/pdfs/Guideline-Infection-Control-HCP-H.pdf
(October 25, 2019) and Epidemiology and Control of Selected Infections Transmitted
Among Healthcare Personnel and Patients, available at: https://www.cdc.gov/infection-control/media/pdfs/Guideline-IC-HCP-H.pdf
(October 22, 2024).
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/control-legionella/media/pdfs/Control-Toolkit-All-Modules.pdf.
3) Federal regulations:
A) Definitions (38 CFR 51.2, effective July 1, 2024);
B) Resident rights (38 CFR 51.70, effective July 1, 2024);
C) Admission, transfer and discharge rights (38 CFR 51.80,
effective July 1, 2024);
D) Resident behavior and facility practices (38 CFR 51.90,
effective July 1, 2024);
E) Quality of life (38 CFR 51.100, effective July 1, 2024);
F) Resident assessment (38 CFR 51.110, effective July 1, 2024);
G) Quality of care (38 CFR 51.120, effective July 1, 2024);
H) Nursing services (38 CFR 51.130, effective July 1, 2024);
I) Dietary services (38 CFR 51.140, effective July 1, 2024);
J) Physician services (38 CFR 51.150, effective July 1, 2024);
K) Specialized rehabilitative services (38 CFR 51.160, effective July
1, 2024);
L) Dental services (38 CFR 51.170, effective July 1, 2024);
M) Pharmacy services (38 CFR 51.180, effective July 1, 2024);
N) Infection control (38 CFR 51.190, effective July 1, 2024);
O) Physical environment (38 CFR 51.200, effective July 1, 2024);
P) Administration (38 CFR 51.210, effective July 1, 2023);
Q) Prescriptions (21 CFR 1306, effective April 1, 2024).
R) Medical Foster Homes - General (38 CFR 17.73, effective July 1,
2024)
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 U.S.C. 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
Disease 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, Powers Of Attorney For Health Care [755 ILCS 45/Art.
IV];
37) Specialized
Mental Health Rehabilitation Act of 2013 [210 ILCS 49];
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];
44) Sex
Offender Management Board Act [20 ILCS 4026];
45) MC/DD
Act [210 ILCS 46];
46) ID/DD
Community Care Act [210 ILCS 47];
47) Alzheimer's
Disease and Related Dementias Services Act [410 ILCS 406];
48) Illinois
Uniform Conviction Information Act [20 ILCS 2635];
49) Illinois
Controlled Substances Act [720 ILCS 570];
50) Home
Health, Home Services, and Home Nursing Agency Licensing Act [210 ILCS 55];
51) Community-Integrated
Living Arrangements Licensure and Certification Act [210 ILCS 135];
52) Methamphetamine
Control and Community Protection Act [720 ILCS 646];
53) Department
of Veterans' Affairs Act [20 ILCS 2805];
54) Authorized
Electronic Monitoring in Long-Term Care Facilities Act [210 ILCS 32];
55) Illinois
Emergency Management Agency Act [20 ILCS 3305];
56) Language
Assistance Services Act [210 ILCS 87];
57) Mental
Health Treatment Preference Declaration Act [755 ILCS 43].
c) The following State of Illinois rules are referenced:
1) Department of Public Health, Control of Notifiable Diseases and
Conditions 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 Public Health, Authorized Electronic Monitoring in Long-Term Care Facilities
Code (77 Ill. Adm. Code 389);
15) Department of Public Health, Alzheimer's Disease and Related
Dementias Services Code (77 Ill. Adm. Code 973);
16) Department
of Public Health, Illinois Controlled Substances Act (77 Ill. Adm. Code 3100);
17) Department of Financial and Professional Regulation, Illinois Controlled
Substances Act (77 Ill. Adm. Code 3100);
18) Department of Human Services, Alcoholism and Substance Abuse
Treatment and Intervention Licenses (77 Ill. Adm. Code 2060);
19) 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 49 Ill.
Reg. 6539, effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1110 GENERAL REQUIREMENTS
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.
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, the licensee's name, the facility name and address, and 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 establishing, constructing or modifying a long-term
care facility or portion thereof shall obtain the required permit from the Health
Facilities and Services Review Board to be eligible for licensure for that
facility or portion thereof.
f) No person shall:
1) Willfully file any false, incomplete or intentionally
misleading information required to be filed under this Act, or willfully fail
or refuse to file any required information (Section 3-318(a)(6) of the
Act); or
2) Open or operate a facility without a license. (Section
3-318(a)(7) of the Act)
g) A violation of subsection (f) is a business offense,
punishable by a fine not to exceed $10,000, except as otherwise provided in
subsection (2) of Section 3-103 of the Act and subsection 350.120(c) as
to submission of false or misleading information in a license application.
(Section 3-318(b) of the Act)
h) Each facility shall notify the Department electronically at
DPH.StrikePlan@illinois.gov within 24 hours after receiving a notice of
impending strike of staff providing direct care. The facility shall submit a
strike contingency plan to the Department no later than three calendar days
prior to the impending strike.
i) A facility shall have a facility-specific email address and
shall provide that email address to the Department. The facility shall not
change the email address without prior notice to the Department.
(Source: Amended at 49 Ill. Reg. 6539, effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1115 FEDERAL VETERANS' REGULATIONS
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1120 APPLICATION FOR LICENSE
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1125 ALZHEIMER'S SPECIAL CARE DISCLOSURE
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1130 CRITERIA FOR ADVERSE LICENSURE ACTIONS
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1140 DENIAL OF INITIAL LICENSE
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1150 REVOCATION OR DENIAL OF RENEWAL OF LICENSE
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1160 INSPECTIONS, SURVEYS, EVALUATIONS, AND CONSULTATIONS
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 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. (Section 3-213 of the Act) A facility
may charge the Department for such photocopying at a rate determined by the
facility not to exceed the rate in the Freedom of Information Act.
b) No person shall:
1) Intentionally
prevent, interfere with, or attempt to impede in any way any duly authorized
investigation and enforcement of the Act or this Part;
2) Intentionally
prevent or attempt to prevent any examination of any relevant books or records
pertinent to investigations and enforcement of the Act or this Part;
3) Intentionally
prevent or interfere with the preservation of evidence pertaining to any
violation of the Act or this Part;
4) Intentionally
retaliate or discriminate against any resident or employee for contacting or
providing information to any state official, or for initiating, participating
in, or testifying in an action for any remedy authorized under the Act or
this Part (Section 3-318(a) of the Act);
c) A violation of subsection (b) is a business offense,
punishable by a fine not to exceed $10,000, except as otherwise provided in
subsection (2) of Section 3-103 of the Act and Section 300.120(e) as to
submission of false or misleading information in a license application.
(Section 3-318(b) of the Act)
d) 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.
(Source: Amended at 49 Ill. Reg. 6539, effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1170 PRESENTATION OF FINDINGS BY THE DEPARTMENT
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.
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1190 OWNERSHIP DISCLOSURE
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1200 MONITOR AND RECEIVERSHIP
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.
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1210 DETERMINATION OF A VIOLATION
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1220 DETERMINATION OF THE LEVEL OF A VIOLATION
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1225 ADMINISTRATIVE WARNING
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1230 PLANS OF CORRECTION AND REPORTS OF CORRECTION
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) No person shall intentionally fail to correct or interfere
with the correction of a Type "AA", Type "A", or Type
"B" violation within the time specified on the notice or approved
plan of correction under the Act as the maximum period given for
correction, unless an extension is granted pursuant to subsection (c)
and the corrections are made before expiration of extension. A violation of
this subsection is a business offense, punishable by a fine not to
exceed $10,000, except as otherwise provided in subsection (2) of Section 3-103
of the Act and Section 340.1130(b)(8) as to submission of false
or misleading information in a license application. (Section 3-318 (a)(1)
and (b) of the Act)
e) 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.
f) 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 the 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.
g) Submission of a plan of correction or report of correction will
not be considered an admission by the facility that the violation has occurred.
h) 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, 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.
i) 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)
j) If a facility fails to submit a plan or report of correction
or modified plan meeting the criteria in subsection (f) within the prescribed
time periods in subsections (a) and (b) or subsection (j), 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 49 Ill.
Reg. 6539, effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1240 CALCULATION OF PENALTIES (REPEALED)
Section 340.1240 Calculation
of Penalties (Repealed)
(Source: Repealed at 35 Ill.
Reg. 11896, effective June 29, 2011)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1245 CONDITIONS FOR ASSESSMENT OF PENALTIES
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1250 REDUCTION OR WAIVER OF PENALTIES
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1255 SUPPORTED CONGREGATE LIVING ARRANGEMENT DEMONSTRATION (REPEALED)
Section 340.1255 Supported
Congregate Living Arrangement Demonstration (Repealed)
(Source: Repealed at 49 Ill. Reg. 6539, effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1260 WAIVERS
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1265 COMPLIANCE WITH THE ALZHEIMER'S DISEASE AND RELATED DEMENTIAS SERVICES ACT
Section 340.1265 Compliance
with the Alzheimer's Disease and Related Dementias Services Act
A facility shall comply with the
Alzheimer's Disease and Related Dementias Services Act and the Alzheimer's
Disease and Related Dementias Services Code.
(Source: Added at 49 Ill. Reg. 6539,
effective April 22, 2025)
SUBPART B: POLICIES AND FACILITY RECORDS
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1300 FACILITY POLICIES
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1305 REQUEST FOR RESIDENT CRIMINAL HISTORY RECORD INFORMATION
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1310 ADMISSION, RETENTION AND DISCHARGE POLICIES
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1314 CRIMINAL HISTORY BACKGROUND CHECKS FOR PERSONS WHO WERE RESIDENTS ON MAY 10, 2006 (REPEALED)
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1315 IDENTIFIED OFFENDERS
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1316 DISCHARGE PLANNING FOR IDENTIFIED OFFENDERS
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1317 TRANSFER OF AN IDENTIFIED OFFENDER
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1320 DISASTER PREPAREDNESS
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1327 WORKPLACE VIOLENCE PREVENTION PROGRAM
Section 340.1327 Workplace
Violence Prevention Program
a) A
veterans' home is subject to the Health Care Violence Prevention Act. (Section
2.7 of the Department of Veterans' Affairs Act)
b) A
facility shall display a notice, either by physical or electronic means,
stating that verbal aggression will not be tolerated and physical assault will
be reported to law enforcement. (Section 15(c) of the Health Care Violence
Prevention Act)
c) A
facility shall create a workplace violence prevention program that complies
with the Occupational Safety and Health Administration (OSHA) Guidelines for
Preventing Workplace Violence for Healthcare and Social Service Workers. In
addition, the workplace violence prevention program shall include:
1) The
following classification of workplace violence as one of 4 possible types:
A) "Type
1 violence" – workplace violence committed by a person who has no
legitimate business at the work site and includes violent acts by anyone who
enters the workplace with the intent to commit a crime;
B) "Type
2 violence" – workplace violence directed at employees by customers,
clients, patients, students, inmates, visitors, or other individuals
accompanying a patient;
C) "Type
3 violence" – workplace violence against an employee by a present or
former employee, supervisor, or manager; or
D) "Type
4 violence" – workplace violence committed in the workplace by someone who
does not work there, but has or is known to have had a personal relationship
with an employee.
2) Management
commitment and worker participation, including, but not limited to, nurses;
3) Worksite analysis
and identification of potential hazards;
4) Hazard prevention
and control;
5) Safety
and health training that includes annual completion of one of the following
online courses:
A) Preventing
Workplace Violence in Healthcare, available at:
https://www.oshatrain.org/courses/mods/776e.html; or
B) Workplace
Violence Prevention for Nurses, available at: https://www.cdc.gov/niosh/topics/violence/;
and
6) Recordkeeping
and evaluation of the violence prevention program. (Section 20 of the
Health Care Violence Prevention Act)
d) A facility workplace
violence prevention program shall also include:
1) An overview
of the incidence and prevalence of sexual assault and sexual violence;
2) Strategies and
approaches to prevent sexual violence;
3) Intervention procedures
to report sexual violence;
4) Contact
information for local programs and services to assist victims of sexual
violence; and
5) Additional
training and education resources regarding the prevention and reporting of
sexual violence, including, but not limited to, the Centers for Disease Control
and Prevention's STOP SV: A Technical Package to Prevent Sexual Violence,
available at:
https://www.cdc.gov/violenceprevention/pdf/SV-Prevention-Technical-Package.pdf.
(Source: Added at 49 Ill. Reg. 6539,
effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1330 INCIDENTS AND ACCIDENTS
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1335 INFECTION CONTROL
Section 340.1335 Infection
Control
a) Each facility shall establish and follow policies and
procedures for investigating, controlling, and preventing infections in the
facility. The policies and procedures shall be consistent with and include the
requirements of the Control of Communicable Diseases Code and Control of
Sexually Transmissible Infections Code. 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 and
toolkits of the Center for Infectious Diseases, Centers for Disease Control and
Prevention, U.S. Public Health Service, Department of Health and Human Services,
and Agency for Healthcare Research and Quality (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 Catheter-Related Infections.
4) Guideline for Prevention of Surgical Site Infection.
5) Guideline for Prevention of Healthcare-Associated Pneumonia,
2023.
6) 2007 Guideline for Isolation Precautions: Preventing
Transmission of Infectious Agents in Healthcare Settings.
7) Infection
Control in Healthcare Personnel, available in two parts: Infrastructure and
Routine Practices for Occupational Infection Prevention and Control Services
and Epidemiology and Control of Selected Infections Transmitted Among
Healthcare Personnel and Patients.
8) Toolkit for Controlling
Legionella in Common Sources of Exposure.
d) The
facility shall establish an infection prevention and control program (IPCP)
that shall include, at a minimum, an antibiotic stewardship program that
includes antibiotic use protocols and a system to monitor antibiotic use.
(Source: Amended at 49 Ill. Reg. 6539,
effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1337 TESTING FOR LEGIONELLA BACTERIA
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1340 FACILITY RECORD REQUIREMENTS
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.
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1350 PERSONNEL POLICIES
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 Financial
and Professional Regulation to verify that the individual's license is active.
A copy of the license shall be placed in the individual's personnel file.
h) The facility shall check the status of all applicants with the
Health Care Worker 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 their file.
(Source: Amended at 49 Ill. Reg. 6539, effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1351 WHISTLEBLOWER PROTECTION
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1360 INITIAL HEALTH EVALUATION FOR EMPLOYEES
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.
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1370 ADMINISTRATOR
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.
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1375 PERSONNEL REQUIREMENTS
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. At least 50 percent of this person's
hours shall be regularly scheduled between 7 a.m. and 7 p.m.
C) A facility may, with written approval from the Department, have
two registered nurses share the duties of this position if the facility is
unable to obtain a full-time person. Such an arrangement will be approved only
through written documentation that the facility was unable to obtain the
full-time services of a qualified individual to fill this position. Such
documentation shall include, but not be limited to: an advertisement that has
appeared in a newspaper of general circulation in the area for at least three
weeks; the names, addresses and phone numbers of all persons who applied for
the position and the reasons why they were not acceptable or would not work
full time; and information about the numbers and availability of licensed
nurses in the area. The Department will 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 registered
professional 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 in-service 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.
c) Nursing
Assistants
1) The facility shall ensure that each person employed by the
facility as a nursing assistant complies with one of the following conditions:
A) Is approved on the Department's Health Care Worker 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.
B) Begins a Department-approved nurse aide 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 shall not be employed more
than 120 days prior to successfully completing the program.
C) Within 120 days after initial employment, submits documentation
in accordance with Section 340.1376 of this Part to be registered on the Health
Care Worker Registry.
2) The facility shall ensure that each person employed by the
facility as a nursing assistant or habilitation aide has met each of the
following requirements:
A) Is 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)
B) Is able to speak and understand the English language or a
language understood by a substantial percentage of the facility's residents.
(Section 3-206(a)(2) of the Act)
C) Has provided evidence of prior employment or
occupation, if any, and residence for two years prior to present
employment as a nursing assistant or habilitation aide. (Section
3-206(a)(3) of the Act)
D) Has completed at least eight years of grade school or
provide proof of equivalent knowledge. (Section 3-206(a)(4) of the Act)
E) Is familiar with and has general skills related to
resident care. (Section 3-206(a)(6) of the Act)
F) Has completed the training or equivalency requirements for nursing
assistants, habilitation aides, or has begun a current course of
training for nursing assistants, habilitation aides, or child care aides,
approved by the Department, within 45 days of initial employment in the
capacity of a nursing assistant, habilitation aide, or child care aide at any
facility. Such courses of training shall be successfully completed within 120
days of initial employment in the capacity of nursing assistant, habilitation
aide, or child care aide at a facility, except as follows:
i) Nursing assistants, habilitation aides, and child care
aides who are enrolled in approved courses in community colleges or other
educational institutions on a term, semester, or trimester basis, shall be
exempt from the 120-day completion time limit. During a statewide public
health emergency, as defined in the Illinois Emergency Management Agency Act,
all nursing assistants, habilitation aides, and child-care aides shall, to the
extent feasible, complete the training.
ii) The Department may accept comparable training in lieu of
the 120-hour course for student nurses, foreign nurses, military personnel, or
employees of the Department of Human Services. (Section 3-206(a)(5) of the
Act)
3) The facility shall maintain in the personnel folder of the
employee, proof of compliance by each employee with the requirements set
out in Section 3-206(d) of the Act.
4) The facility shall obtain access to the Health Care Worker
Registry's web application, maintain the employment and demographic information
relating to each employee, and verify by the category and type of employment
that each employee meets all the requirements of Section 3-206(e) of the
Act.
5) A facility shall not employ an individual as a nursing
assistant, habilitation aide, home health aide, psychiatric services
rehabilitation aide, or child care aide, or newly hired as an individual who
may have access to a resident, a resident's living quarters, or a resident's
personal, financial, or medical records, unless the facility has inquired of
the Department's Health Care Worker Registry and the individual is listed on
the Health Care Worker Registry as eligible to work for a health care employer.
(Section 3-206.01 (a) of the Act)
6) Nursing assistants and habilitation aides shall 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.
d) 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(g) of this Part. This person may also be counted in fulfilling the
requirements of other subsections of this Section.
e) 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.
f) 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 2.5 hours per patient
per 24 hours, 7 days per week in accordance with 38 CFR 51.130.
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 staffing may be
reduced proportionately for the hours the residents are not in the facility as
long as the facility meets the needs of the residents.
g) 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 ensure 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.
h) A
facility shall designate a person or persons as Infection Prevention and
Control Professionals (IP) to develop and implement policies governing
control of infections and communicable diseases. The IPs shall be qualified
through education, training, experience, or certification or a combination of these
qualifications. The IP's qualifications shall be documented and shall be made
available for inspection by the Department. (Section 2-213(d) of the Act)
1) IPs
shall complete, or provide proof of completion of initial infection control and
prevention training provided by CDC or equivalent training, covering topics
listed in subsection (h)(2)(A) to the facility, within 30 days after accepting
an IP position. Documentation of required initial infection control and
prevention training shall be maintained in the employee file.
2) A
qualified IP candidate shall:
A) Have
completed at least 19 hours of training in infection prevention and control
including, but not limited to, training in the following areas:
i) Principles of Standard
Precautions
ii) Principles of
Transmission-Based Precautions
iii) Prevention of
Healthcare-Associated Infections
iv) Hand Hygiene
v) Environmental
Cleaning, Sterilization, Disinfection, and Asepsis
vi) Environment of Care and
Water Management
vii) Employee/Occupational
Health
viii) Surveillance and
Epidemiological Investigations
ix) Antimicrobial
Stewardship
B) Have
clinical work experience related to infection prevention and control in health care settings including, but not limited to,
hospitals or long-term care settings.
3) A
facility shall have at least one IP on-site for a minimum of 20 hours per week
to develop and implement policies governing prevention and control of
infectious diseases.
4) Facilities
with more than 100 licensed beds or facilities that offer high-acuity services,
including but not limited to on-site dialysis, infusion therapy, or ventilator
care shall have at least one IP on-site for a minimum of 40 hours per week to
develop and implement policies governing control of infectious diseases. For
the purposes of this subsection (h)(4), "infusion therapy" refers to
parenteral, infusion, or intravenous therapies that require ongoing monitoring
and maintenance of the infusion site (e.g., central, percutaneously inserted
central catheter, epidural, and venous access devices).
5) A facility's IP shall coordinate with the facility group
listed in Section 340.1335(b) to ensure compliance with Section 340.1335.
(Source: Amended at 49 Ill. Reg. 6539, effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1376 HEALTH CARE WORKER REGISTRY
Section 340.1376 Health Care
Worker Registry
a) An individual will be included on the Health Care Worker
Registry as a certified nursing assistant when the individual has successfully
completed a training program approved in accordance with the Long-Term Care
Assistants and Aides Training Program Code, successfully completes the required
proficiency examination, and meets background check information required in
Section 340.1377 of this Part.
b) An individual who has not completed a Department-approved
nurse aide training program in Illinois will be included on the Health Care
Worker Registry as a certified nursing assistant if the individual has met
background check information required in Section 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 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 a Department-approved
nurse aide training program as provided in 77 Ill. Adm. Code 395, at least 40
hours of supervised clinical experience, as evidenced by a diploma,
certification, DD-214, or other written verification, and, within 120 days
after employment, successful completion of the written portion of the
Department-established 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 Financial and 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 Health Care Worker Registry of
any change of address within 30 days after the effective date of the
change of address and of any name change within 30 days and shall submit
proof of any name change to the Department.
d) An individual may satisfy the supervised clinical
experience requirement for placement on the Health Care Worker Registry through
supervised clinical experience at an assisted living establishment licensed
under the Assisted Living and Shared Housing Act. (Section 3-206(a)(5) of
the Act)
(Source: Amended at 49 Ill. Reg. 6539, effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1377 HEALTH CARE WORKER BACKGROUND CHECK
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1378 RESIDENT ATTENDANTS
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1379 CERTIFIED NURSING ASSISTANT INTERNS
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1380 CONTACTING LOCAL LAW ENFORCEMENT
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1385 EMPLOYEE ASSISTANCE PROGRAM
Section 340.1385 Employee
Assistance Program
a) For
the purposes of this Section, an "employee assistance program" is a
program that supports individual physical and mental well-being and that is
provided by the facility or through an insurance or employee benefits program
offered by the facility. Employee assistance programs may include, but are not
limited to, programs that offer professional counseling, stress management,
mental wellness support, smoking cessation, and other support services.
b) A
facility shall ensure that nurses employed by the facility are aware of
employee assistance programs or other like programs available for the physical
and mental well-being of the employee.
c) The
facility shall provide information on these programs, no less than at the time
of employment and during any benefit open enrollment period, by an information
form about the respective programs that a nurse shall sign during
onboarding at the facility, and upon request of the employee.
d) The
signed information form shall be added to the nurse's personnel file. The
facility may provide this information to nurses electronically. (Section
3-613 of the Act from PA 102-1007)
(Source: Added
at 49 Ill. Reg. 6539, effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1390 ELECTRONIC MONITORING
Section 340.1390 Electronic
Monitoring
A facility shall comply with
Section 2-115 and subsections 3-318(a)(8) and (9) of the Act, with the
Authorized Electronic Monitoring in Long-Term Care Facilities Act, and with the
Authorized Electronic Monitoring in Long-Term Care Facilities Code.
(Source: Added at 49 Ill. Reg. 6539,
effective April 22, 2025)
SUBPART C: RESIDENT RIGHTS
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1400 IMPLEMENTATION OF RESIDENT RIGHTS AND FACILITY RESPONSIBILITIES
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1410 GENERAL
Section 340.1410 General
a) No resident shall be deprived of any rights, benefits, or
privileges guaranteed by State or federal law, the Constitution of the State of
Illinois, or the Constitution of the United States solely on account of
their status as a resident of a facility.
1) Residents shall have the right to be treated with courtesy
and respect by employees or persons providing medical services or care and
shall have their human and civil rights maintained in all aspects of medical
care as defined in the State Operations Manual for Long-Term Care Facilities.
2) In accordance with 42 CFR 483.10, residents shall have
their basic human needs, including, but not limited to, water, food,
medication, toileting, and personal hygiene, accommodated in a timely manner,
as defined by the person and agreed upon by the interdisciplinary team.
3) Residents have the right to maintain their autonomy as much as
possible. (Section 2-101 of the Act)
b) A resident shall be permitted 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)
h) A resident may refuse to perform labor for a facility.
Residents shall not perform labor or services for the facility unless
consistent with F566 of the State Operations Manual for Long-Term Care
Facilities. The activities shall be included for therapeutic purposes
and be appropriately goal related to the individual's care plan. If a resident
chooses to perform labor or services, the resident shall be compensated
at or above the prevailing wage rate. (Section 2-113 of the Act)
i) Posting Requirements for Facilities
1) Every facility shall conspicuously post for display in an
area of its offices accessible to residents, employees, and visitors the
following:
A) Phone numbers and websites for rights protection services
must be posted in common areas and at the main entrance and provided upon entry
and at the request of residents or the resident's representative in accordance
with 42 CFR 483.10(j)(4); and
B) The statement "The Illinois Long-Term Care Ombudsman
Program is a free resident advocacy service available to the public."
2) The administrator shall post for all residents and at the
main entrance the name, address, and telephone number of the appropriate State
governmental office where complaints may be lodged in language the resident can
understand, which must include notice of the grievance procedure of the
facility or program as well as addresses and phone numbers for the Office of
Health Care Regulation and the Long-Term Care Ombudsman Program and a website
showing the information of a facility's ownership. The facility shall include
a link to the Long-Term Care Ombudsman Program's website on the home page of
the facility's website. (Section 3-209 of the Act)
(Source: Amended at 49 Ill. Reg. 6539, effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1420 CONTRACT BETWEEN RESIDENT AND FACILITY
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1430 RESIDENTS' ADVISORY COUNCIL
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1440 ABUSE AND NEGLECT
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1450 COMMUNICATION AND VISITATION
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1460 RESIDENT'S FUNDS
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1470 TRANSFER OR DISCHARGE
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 10th 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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1480 COMPLAINT PROCEDURES
Section 340.1480 Complaint
Procedures
a) The facility shall develop procedures for investigating
complaints concerning theft of residents' 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 of the resident's choice, free from restraint, interference,
coercion, or discrimination and without threat of discharge or reprisal in any
form or manner whatsoever. Every facility licensed under the Act
shall have a written internal grievance procedure that, at a minimum:
1) Sets forth the process to be followed;
2) Specifies time limits, including time limits for facility
response;
3) Informs residents of their right to have the assistance of
an advocate;
4) Provides for a timely response within 25 days by an
impartial and nonaffiliated third party, including, but not limited to, the
Long-Term Care Ombudsman, if the grievance is not otherwise resolved by the
facility;
5) Requires the facility to follow applicable State and
federal requirements for responding to and reporting any grievance alleging
potential abuse, neglect, misappropriation of resident property, or
exploitation; and
6) Requires the facility to keep a copy of all grievances,
responses, and outcomes for 3 years and provide the information to the
Department upon request. (Section 2-112 of the Act)
c) The administrator shall provide all residents or their
representatives upon admission and at request with the name, address, and
telephone number of the appropriate State governmental office where complaints
may be lodged in language the resident can understand, which must include
notice of the grievance procedure of the facility or program and addresses and
phone numbers for the Office of Health Care Regulation and the Long-Term Care
Ombudsman Program. (Section 2-112 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, by electronic means, or by personal visit. An oral complaint will
be reduced to writing by the Department. (Section 3-702(a) of the Act)
e) The substance of the complaint will be provided in
writing to the licensee, owner or administrator no earlier than at the
commencement of the on-site inspection of the facility that takes place
pursuant to the complaint. (Section 3-702(b) of the Act)
f) The Department will not disclose the name of the
complainant unless the complainant consents in writing to the disclosure or the
investigation results in a judicial proceeding, or unless disclosure is
essential to the investigation. The complainant will be given the
opportunity to withdraw the complaint before disclosure. Upon the request of
the complainant, the Department will permit the complainant or a
representative of the complainant to accompany the person making the on-site
inspection of the facility. (Section 3-702(c) of the Act)
g) Upon receipt of a complaint, the Department will
determine whether the Act or this Part has been or is being violated.
The Department will investigate all complaints alleging abuse or neglect
within seven days after the receipt of the complaint except that complaints of
abuse or neglect which indicate that a resident's life or safety is in imminent
danger shall be investigated with 24 hours after receipt of the complaint. All
other complaints shall be investigated within 30 days after the receipt of the
complaint, except that, during a statewide public health emergency, as defined
in the Illinois Emergency Management Agency Act, all other complaints will
be investigated within appropriate time frames to the extent feasible.
(Section 3-702(d) of the Act)
h) The Department employees investigating a complaint will
conduct a brief, informal exit conference with the facility to alert its administration
of any suspected serious deficiency that poses a direct threat to the health,
safety, or welfare of a resident to enable an immediate correction for the
alleviation or elimination of the threat. Information and findings discussed
in the brief exit conference will become a part of the investigating
record but will not in any way constitute an official or final notice of
violation as provided under Section 3-301 of the Act and Section 300.276 of
this Part. All complaints will be classified as "an
invalid report," "a valid report," or "an undetermined
report". For any complaint classified as "a valid
report," the Department will determine within 30 working
days after any Department employee enters a facility to begin an on-site
inspection if this Part or provision of the Act has been
or is being violated. (Section 3-702(d) of the Act)
i) In all cases, the Department will inform the
complainant of its findings within ten days after its determination
unless otherwise indicated by the complainant, and the complainant may direct
the Department to send a copy of the findings to another person. The
Department's findings may include comments or documentation provided by either
the complainant or the licensee pertaining to the complaint. The Department will
also notify the facility of these findings within ten days after
the determination, but the name of the complainant or residents will not
be disclosed in this notice to the facility. The notice of findings will
include a copy of the written determination; the correction order, if any; the
warning notice, if any; the inspection report; or the State licensure
form on which the violation is listed. (Section 3-702(e) of the
Act)
j) A written determination, correction order, or warning
notice concerning a complaint, together with the facility's response, will
be available for public inspection, but the name of the complainant or resident
will not be disclosed without their consent. (Section
3-702(f) of the Act)
k) A complainant who is dissatisfied with the determination or
investigation by the Department may request a hearing under subsection (k)
of this Section. The facility will be given notice of the
hearing and may participate in the hearing as a party. If a facility requests
a hearing under subsection (k) of this Section that concerns a matter
covered by a complaint, the complainant will be given written notice and
may participate in the hearing as a party. A request for a hearing by either a
complainant or a facility shall be submitted in writing to the Department
within 30 days after the mailing of the Department's findings as described
in subsection (h) of this Section. Upon receipt of the request the
Department will conduct a hearing as provided under subsection (k)
of this Section. (Section 3-702(g) of the Act)
l) Any person aggrieved by a decision of the Department rendered
in a particular case that affects the legal rights, duties or privileges
created under the Act may have the decision reviewed in accordance with
Sections 3-703 through 3-712 of the Act.
m) When the Department finds that a provision of Article II of the
Act regarding residents' rights has been violated with regard to a particular
resident, the Department will issue an order requiring the facility to
reimburse the resident for injuries incurred, or $100, whichever is greater.
(Source: Amended at 49 Ill. Reg. 6539, effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1490 PRIVATE RIGHT OF ACTION
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1491 SOCIAL ISOLATION
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
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1500 MEDICAL CARE POLICIES
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 the resident's informed, written
consent. The conduct of any experimental research or treatment shall be
authorized and monitored by an institutional review board appointed by the
Director. 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)
j) An identification wristlet may be employed for any resident
upon a physician's order, which shall document the need for the identification
wristlet in the resident's clinical record. A facility may require a resident
residing in an Alzheimer's disease unit with a history of wandering to wear an
identification wristlet, unless the resident's guardian or power of attorney
directs that the wristlet be removed. All identification wristlets shall
include, at a minimum, the resident's name and the name, telephone number, and
address of the facility issuing the identification wristlet. (Section
2-106a of the Act)
k) A facility shall not refer a patient or the family
of a patient to a home health agency, home nursing agency, or home services
agency unless the agency is licensed under the Act. A facility
shall request a copy of an agency's license prior to making a referral to that
agency. (Sec 3.8 of the Home Health, Home Services, and Home Nursing Agency
Licensing Act)
(Source: Amended at 49 Ill. Reg. 6539, effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1505 MEDICAL, NURSING AND RESTORATIVE SERVICES
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1510 COMMUNICABLE DISEASE POLICIES
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1520 TUBERCULIN SKIN TEST PROCEDURES
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1530 PHYSICIAN SERVICES
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.
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1535 DENTAL PROGRAMS
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.
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1540 LIFE-SUSTAINING TREATMENTS
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.
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1550 OBSTETRICAL AND GYNECOLOGICAL CARE
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1560 NURSING PERSONNEL
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.
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1570 PERSONAL CARE
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1575 CARE AND TREATMENT OF SEXUAL ASSAULT SURVIVORS
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1580 RESTRAINTS
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1590 NONEMERGENCY USE OF PHYSICAL RESTRAINTS
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.
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1600 EMERGENCY USE OF PHYSICAL RESTRAINTS
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).
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1610 UNNECESSARY, PSYCHOTROPIC, AND ANTIPSYCHOTIC DRUGS
Section 340.1610
Unnecessary, Psychotropic, and Antipsychotic Drugs
a) For the purposes of this Section, the following definitions
shall apply:
1) "Adverse consequence" – unwanted, uncomfortable, or
dangerous effects that a medication may have, such as impairment or decline in
an individual's mental or physical condition or functional or psychosocial
status. It may include, but is not limited to, various types of adverse
medication reactions and interactions (e.g., medication-medication,
medication-food, and medication-disease).
2) "Antipsychotic medication" – a medication that is
used to treat symptoms of psychosis such as delusions, hearing voices,
hallucinations, paranoia, or confused thoughts. Antipsychotic medications are
used in the treatment of schizophrenia, severe depression, and severe anxiety.
Older antipsychotic medications tend to be called typical antipsychotics. Those
developed more recently are called atypical antipsychotics.
3) "Dose" – the total amount/strength/concentration of
a medication given at one time or over a period of time. The individual dose is
the amount/strength/concentration received at each administration. The amount
received over a 24-hour period may be referred to as the daily dose.
4) "Duplicative
therapy" – multiple medications of the same pharmacological class or
category or any medication therapy that substantially duplicates a particular
effect of another medication that the individual is taking.
5) "Emergency" – has the same meaning as in
Section 1-112 of the Act and Section 340.1000 of this Part. (Section
2-106.1(b-3) of the Act)
6) "Excessive dose" – the total amount of any
medication (including duplicative therapy) given at one time or over a period
of time that is greater than the amount recommended by the manufacturer's
label, package or insert, and the accepted standards of practice for a resident's
age and condition.
7) "Gradual dose reduction" – the stepwise tapering of
a dose to determine if symptoms, conditions or risks can be managed by a lower
dose or if the dose or medication can be discontinued.
8) "Informed consent" – documented, written permission
for specific medications, given freely, without coercion or deceit, by a
capable resident, or by a resident's surrogate decision maker, after the
resident, or the resident's surrogate decision maker, has been fully informed
of, and had an opportunity to consider, the nature of the medications, the
likely benefits and most common risks to the resident of receiving the
medications, any other likely and most common consequences of receiving or not
receiving the medications, and possible alternatives to the proposed
medications.
9) "Licensed nurse" – in this Section only,
an advanced practice registered nurse, a registered nurse, or a licensed
practical nurse. (Section 2-106.1(d) of the Act)
10) "Psychotropic medication" – medication that
is used for or listed as used for psychotropic, antidepressant, antimanic or
antianxiety behavior modification or behavior management purposes in the
Prescribers Digital Reference database, the UpToDate Lexidrug online database,
or the American Society of Health-System Pharmacists database.
11) "Surrogate decision maker" – an individual
representing the resident's interests in regard to consent to receive
psychotropic medications, as permitted by Section 2-106.1 of the Act and
this Section. (Section 2-106.1(b-3) of the Act)
b) A resident shall not be given unnecessary drugs. An
unnecessary drug is any drug used:
1) In an excessive dose, including in duplicative therapy;
2) For excessive duration;
3) Without adequate monitoring;
4) Without adequate indications for its use;
5) In the presence of adverse consequences that indicate the
drugs should be reduced or discontinued (Section 2-106.1(a) of the Act);
or
6) Any combination of the circumstances stated in subsections
(b)(1) through (5).
c) Psychotropic medications shall be used only when the
medication is appropriate to treat a resident's specific, diagnosed, and
documented condition and the medication is beneficial to the resident, as
demonstrated by monitoring and documentation of the resident's response to the
medication. (Section 2-106.1(b) of the Act)
d) Residents shall not be given antipsychotic medications unless
antipsychotic medication therapy is ordered by a physician or an authorized
prescribing professional, as documented in the resident's comprehensive
assessment, to treat a specific symptom or suspected condition as diagnosed and
documented in the clinical record or to rule out the possibility of one of the
conditions in accordance with Section 340.TABLE B.
e) Residents who use antipsychotic medications shall receive gradual
dose reductions and behavior interventions, unless clinically contraindicated,
in an effort to discontinue these medications in accordance with Section
340.TABLE B. In compliance with subsection 2-106.1(b-3) of the Act and
subsection (h)(12), the facility shall obtain informed consent for each dose
reduction that was not included in the original informed consent.
f) Except in the case of an emergency, psychotropic medication
shall not be administered without the informed consent of the resident or the
resident's surrogate decision maker. Psychotropic medication shall be
given in both emergency and nonemergency situations only if the diagnosis of
the resident supports the benefit of the medication and clinical documentation
in the resident's medical record supports the benefit of the medication over
the contraindications related to other prescribed medications. (Section
2-106.1(b-3) of the Act) In an emergency, a facility shall:
1) Document the alleged emergency in detail, including the
facts surrounding the medication's need, pursuant to the requirements of
Section 340.1810; and
2) Present this documentation to the resident and the
resident's representative or other surrogate decision maker no later than
24 hours after the administration of emergency psychotropic medication.
(Section 2-106.1(b-3) of the Act)
g) Informed consent includes information about potential negative
outcomes of psychotropic medication use and the information in subsection
(h)(4). Additional informed consent is not required for changes in the
prescription so long as those changes are described in the original written
informed consent form, as required by subsection (h)(12)(A). The informed
consent may provide for a medication administration program of sequentially
increased doses or a combination of medications to establish the lowest
effective dose that will achieve the desired therapeutic outcome, pursuant to
subsection (h)(12)(A). The most common side effects of the medications shall
be described.
h) Protocol for Securing Informed Consent for Psychotropic Medication
1) Except in the case of an emergency as described in subsection
(f), a facility shall obtain voluntary informed consent, in writing,
from a resident or the resident's surrogate decision maker before administering
or dispensing a psychotropic medication to that resident. When informed
consent is not required for a change in dosage as described in subsection (h)(12)(A),
the facility shall note in the resident's file that the resident was informed
of the dosage change prior to the administration of the medication or that
verbal, written, or electronic notice has been communicated to the resident's
surrogate decision maker that a change in dosage has occurred. (Section
2-106.1(b-5) of the Act)
2) No resident shall be administered psychotropic medication
prior to a discussion between the resident or the resident's surrogate
decision maker, or both, and the resident's physician or a physician
the resident was referred to, a registered pharmacist, or a licensed nurse
about the most common possible risks and benefits of a recommended
medication and the use of standardized consent forms designated by the
Department. (Section 2-106.1(b-3) of the Act)
3) Prior to initiating any detailed discussion designed to secure
informed consent, a licensed health care professional shall inform the resident
or the resident's surrogate decision maker that the resident's physician has
prescribed a psychotropic medication for the resident, and that informed
consent is required from the resident or the resident's surrogate decision
maker before the resident may be given the medication.
4) The discussion shall include information about:
A) The name of the medication;
B) The condition or symptoms that the medication is intended to
treat, and how the medication is expected to treat those symptoms;
C) How the medication is intended to affect those symptoms;
D) Other common effects or side effects of the medication, and any
reasons (e.g., age, health status, other medications) that the resident is more
or less likely to experience side effects;
E) Dosage information, including how much medication would be
administered, how often, and the method of administration (e.g., orally or by
injection; with, before, or after food);
F) Any tests and related procedures that are required for the
safe and effective administration of the medication;
G) Any food or activities the resident should avoid while taking
the medication;
H) Any possible alternatives to taking the medication that could
accomplish the same purpose; and
I) Any possible consequences to the resident of not taking the
medication.
5) Pursuant to Section 2-105 of the Act, the discussion designed
to secure informed consent shall be private, between the resident or the
resident's surrogate decision maker and the resident's physician, or a
physician the resident was referred to, or a registered pharmacist, or a
licensed nurse.
6) In addition to the oral discussion, the resident or their
surrogate decision maker shall be given the information in subsection (h)(4) in
writing, in a form designated or developed by the Department. Each form shall
be written in plain language understandable to the resident or the
resident's surrogate decision maker, be able to be downloaded from the
Department's official website or another website designated by the Department,
shall include information specific to the psychotropic medication for
which consent is being sought, and will be used for every resident for
whom psychotropic drugs are prescribed. (Section 2-106.1(b-3) of the Act)
7) If the written information is in a language not understood by
the resident or the resident's surrogate decision maker, the facility, in
compliance with the Language Assistance Services Act and the Language
Assistance Services Code, shall provide, at no cost to the resident or the
resident's surrogate decision maker, an interpreter capable of communicating
with the resident or their surrogate decision maker and the authorized
prescribing professional conducting the discussion.
8) The authorized prescribing professional shall guide the
resident through the written information. The written information shall
include a place for the resident or their surrogate decision maker to give, or
to refuse to give, informed consent. The written information shall be placed
in the resident's record. Informed consent is not secured until the resident or
surrogate decision maker has given written informed consent. If the resident
has dementia and the facility is unable to contact the resident's surrogate
decision maker, the facility shall not administer psychotropic medication to
the resident except in an emergency as provided by subsection (f).
9) Informed consent shall be sought first from a resident,
then from a surrogate decision maker, in the following order or
priority:
A) The resident's guardian of the person if one has been named
by a court of competent jurisdiction.
B) In the absence of a court-ordered guardian, informed consent
shall be sought from a health care agent under the Illinois Power of Attorney
Act who has authority to give consent.
C) If neither a court-ordered guardian of the person, nor a
health care agent under the Power of Attorney Act, is available, and the
attending physician determines that the resident lacks capacity to make
decisions, informed consent shall be sought from the resident's
attorney-in-fact designated under the Mental Health Treatment Preference
Declaration Act, if applicable, or the resident's representative. (Section
2-106.1(b-3) of the Act)
10) Regardless of the availability of a surrogate decision maker,
the resident may be notified and present at any discussion required by this
Section. Upon request, the resident or the resident's surrogate decision maker
shall be given, at a minimum, written information about the medication and an
oral explanation of common side effects of the medication to facilitate the
resident in identifying the medication and in communicating the existence of
side effects to the direct care staff.
11) The facility shall inform the resident, surrogate decision
maker, or both of the existence of a copy of:
A) The resident's care plan;
B) The facility policies and procedures adopted in compliance
with Section 2-106.1(b-15) of the Act, and this Section; and
C) A notification that the most recent of the resident's care
plans and the facility's policies are available to the resident or surrogate
decision maker upon request. (Section 2-106.1(b-3) of the Act)
12) The maximum possible period for informed consent shall be
until:
A) A change in the prescription occurs, either as to type of
psychotropic medication or an increase or decrease in dosage, dosage range, or
titration schedule of the prescribed medication that was not included in the
original informed consent; or
B) A resident's care plan changes in a way that affects the
prescription or dosage of the psychotropic medication. (Section 2-106.1(b-3)
of the Act).
13) A resident or their surrogate decision maker shall not be asked
to consent to the administration of a new psychotropic medication in a dosage
or frequency that exceeds the maximum recommended daily dosage as found in the
Prescribers Digital Reference database, the Lexicomp-online database, or the
American Society of Health-System Pharmacists database unless the reason for
exceeding the recommended daily dosage is explained to the resident or their
surrogate decision maker by a licensed medical professional, and the reason for
exceeding the recommended daily dosage is justified by the prescribing professional
in the clinical record. The dosage and frequency shall be reviewed and
re-justified by the licensed prescriber on a weekly basis and reviewed by a
consulting pharmacist. The justification for exceeding the recommended daily
dosage shall be recorded in the resident's record and shall be approved within
seven calendar days after obtaining informed consent, in writing, by the
medical director of the facility.
14) Pursuant to Section 2-104(c) of the Act, the resident or the
resident's surrogate decision maker shall be informed, at the time of the
discussion required by subsection (h)(2), that their informed consent may be
withdrawn at any time, and that, even with informed consent, the resident may
refuse to take the medication.
15) The facility shall obtain informed consent using forms provided
by the Department on its official website, or on forms approved by the
Department, pursuant to Section 2-106.1(b-3) of the Act. The facility shall
document on the consent form whether the resident is capable of giving informed
consent for medication therapy, including for receiving psychotropic
medications. If the resident is not capable of giving informed consent, the
identity of the resident's surrogate decision maker shall be placed in the
resident's record.
16) No facility shall deny continued residency to a person on
the basis of the person's or resident's, or the person's or resident's
surrogate decision maker's, refusal of the administration of psychotropic
medication, unless the facility can demonstrate that the resident's refusal
would place the health and safety of the resident, the facility staff, other
residents, or visitors at risk. A facility that alleges that the
resident's refusal to consent to the administration of psychotropic medication
will place the health and safety of the resident, the facility staff, other
residents, or visitors at risk shall:
A) Document the alleged risk in detail, along with a description
of all nonpharmacological or alternative care options attempted and why they
were unsuccessful;
B) Present this documentation to the resident or the resident's
surrogate decision maker, to the Department, and to the Office of the State
Long Term Care Ombudsman; and
C) Inform the resident or their surrogate decision maker
of their right to appeal an involuntary transfer or discharge to
the Department as provided in the Act and this Part. (Section
2-106.1(b-10) of the Act)
i) All facilities shall implement written policies and
procedures for compliance with Section 2-106.1 of the Act and this Section.
A facility's failure to make available to the Department the
documentation required under this subsection is sufficient to demonstrate its
intent to not comply with Section 2-106.1 of the Act and this
Section and shall be grounds for review by the Department. (Section
2-106.1(b-15) of the Act)
j) Upon the receipt of a report of any violation of Section
2-106.1 of the Act and this Section, the Department will investigate
and, upon finding sufficient evidence of a violation of Section 2-106.1 of the
Act and this Section, may proceed with disciplinary action against the
licensee of the facility. In any administrative disciplinary action under this
subsection, the Department will have the discretion to determine the
gravity of the violation and, taking into account mitigating and aggravating
circumstances and facts, may adjust the disciplinary action accordingly.
(Section 2-106.1(b-20) of the Act)
k) A violation of informed consent that, for an individual
resident, lasts for seven days or more under this Section is, at a minimum, a
Type "B" violation. A second violation of informed consent within a year
from a previous violation in the same facility regardless of the duration of
the second violation is, at a minimum, a Type "B" violation.
(Section 2-106.1(b-25) of the Act)
l) Any violation of Section 2-106.1 of the Act and this
Section by a facility may be enforced by an action brought by the Department
in the name of the People of Illinois for injunctive relief, civil penalties,
or both injunctive relief and civil penalties. The Department may initiate the
action upon its own complaint or the complaint of any other interested party.
(Section 2-106.1(b-30) of the Act)
m) Any resident who has been administered a psychotropic
medication in violation of Section 2-106.1 of the Act and this
Section may bring an action for injunctive relief, civil damages, and costs
and attorney's fees against any facility responsible for the violation.
(Section 2-106.1(b-35) of the Act)
n) An action under this Section shall be filed within two years
after either the date of discovery of the violation that gave rise to the claim
or the last date of an instance of a noncompliant administration of
psychotropic medication to the resident, whichever is later. (Section
2-106.1(b-40) of the Act)
o) A facility subject to action under Section 2-106.1 of the
Act and this Section shall be liable for damages of up to $500 for each
day, after discovery of a violation, that the facility violates the
requirements of Section 2-106.1 of the Act and this Section. (Section
2-106.1(b-45) of the Act)
p) The rights provided for in Section 2-106.1 of the Act
and this Section are cumulative to existing resident rights. No part of this
Section shall be interpreted as abridging, abrogating, or otherwise diminishing
existing resident rights or causes of action at law or equity. (Section
2-106.1(b-55) of the Act)
q) In addition to the penalties described in this Section
and any other penalty prescribed by law, a facility that is found to have
violated Section 2-106.1 of the Act and this Section, or the federal
certification requirement that informed consent be obtained before
administering a psychotropic medication, shall thereafter be required to obtain
the signatures of two licensed health care professionals on every form purporting
to give informed consent for the administration of a psychotropic medication,
certifying the personal knowledge of each health care professional that the
consent was obtained in compliance with the requirements of Section 2-106.1
of the Act and this Section. (Section 2-106.1(b-3) of the Act)
(Source:
Amended at 49 Ill. Reg. 6539, effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1620 MEDICATION ADMINISTRATION (REPEALED)
Section 340.1620 Medication
Administration (Repealed)
(Source: Repealed at 27 Ill.
Reg. 5903, effective April 01, 2003)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1630 SELF-ADMINISTRATION OF MEDICATION (RENUMBERED)
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1640 VACCINATIONS
Section 340.1640 Vaccinations
a) A
facility shall annually administer or arrange for administration of a
vaccination against influenza to each resident, in accordance with the
recommendations of the Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention that are most recent to the time of
vaccination, unless the vaccination is medically contraindicated or the
resident has refused the vaccine. Influenza vaccinations for all residents age
65 and over shall be completed by November 30 of each year or as soon as
practicable if vaccine supplies are not available before November 1. Residents
admitted after November 30, during the flu season, and until February 1 shall,
as medically appropriate, receive an influenza vaccination prior to or upon
admission or as soon as practicable if vaccine supplies are not available at
the time of the admission, unless the vaccine is medically contraindicated or
the resident has refused the vaccine. (Section 2-213(a) of the Act)
b) A
facility shall document in the resident's medical record that an annual
vaccination against influenza was administered, arranged, refused, or medically
contraindicated. (Section 2-213(a) of the Act)
c) A
facility shall 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(b) of the Act)
d) A
facility shall document in each resident's medical record that a vaccination
against pneumococcal pneumonia was offered and administered, arranged, refused,
or medically contraindicated. (Section 2-213(b) of the Act)
e) A
facility shall distribute educational information provided by the
Department on all vaccines recommended by the Centers for Disease Control
and Prevention's Advisory Committee on Immunization Practices (available
at:
https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf),
including, but not limited to, the risks associated with shingles and how to protect
oneself against the varicella-zoster virus. The facility shall provide the
information to each resident who requests the information and each newly
admitted resident. The facility may distribute the information to residents
electronically. (Section 2-213(e) of the Act)
f) A
facility shall document in the resident's medical record that the resident
was verbally screened for risk factors associated with hepatitis B, hepatitis
C, and HIV, and whether or not the resident was immunized against hepatitis B.
(Section 2-213(c) of the Act)
g) All
persons determined to be susceptible to the hepatitis B virus shall be offered
immunization within 10 days of admission to any nursing facility. (Section
2-213(c) of the Act)
(Source: Amended at 49 Ill. Reg. 6539,
effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1645 LANGUAGE ASSISTANCE SERVICES
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
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1650 MEDICATION POLICIES AND PROCEDURES
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1655 COMPLIANCE WITH LICENSED PRESCRIBER'S ORDERS
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 order 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 telephone orders shall be
immediately written on the resident's clinical record, or a telephone order
form and signed by the nurse or pharmacist taking the order. These orders shall
be countersigned by the licensed prescriber within 10 calendar days.
c) 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 judgment,
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 documented in the clinical record.
Portions of this review may be done outside the facility. Any irregularities
noted shall be reported to the attending physician, the advisory physician, the
director of nursing and the administrator and shall be acted upon.
d) A medication order not specifically limiting the time or
number of doses shall be automatically stopped in accordance with written
policies approved by the pharmaceutical advisory committee.
e) The resident's licensed prescriber shall be notified of medications
about to be stopped so that the licensed prescriber may promptly renew such
orders to avoid interruption of the resident's therapeutic regimen.
f) The licensed prescriber shall approve the release of any medications
to the resident, or person responsible for the resident's care, at the time of
discharge or when the resident is going to be temporarily out of the facility
at medication time. Disposition of the medications shall be noted in the
resident's clinical record.
(Source: Amended at 49 Ill.
Reg. 6539, effective April 22, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1660 ADMINISTRATION OF MEDICATION
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)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 340
ILLINOIS VETERANS' HOMES CODE
SECTION 340.1665 CONTROL OF MEDICATIONS
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)
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