TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.110 GENERAL REQUIREMENTS
Section 390.110 General
Requirements
a) This Part applies to the operator/licensee of facilities, or
distinct parts of facilities that are licensed and classified to provide
nursing care to persons pursuant to the terms and conditions of the MC/DD Act.
b) The license issued to each operator/licensee shall designate
the licensee's name, the facility name and address, the classification by level
of service authorized for that facility, the number of beds authorized for each
level, the date the license was issued, and the expiration date. Licenses shall
be issued for a period of not less than 6 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. The Department will set the
period of the license based on the license expiration dates of the facilities
in the geographical area surrounding the facility in order to distribute the
expiration dates as evenly as possible throughout the calendar year.
(Section 3-110 of the Act)
c) An applicant may request that the license issued by the
Department have distinct parts classified according to levels of services. The
distinct part shall meet the applicable physical plant standards of this Part based
on a level of service classification sought for that distinct part. The
facility shall comply with additional physical plant standards pursuant to local
or regional codes that are necessary, in any distinct part, to protect the
health, welfare, and safety of residents as required by the highest level of
care offered by the facility. Administrative, supervisory, and other personnel
may be shared by the entire facility to meet the health, welfare, and safety
needs of the residents of the facility.
d) A facility shall admit only that number of residents for
which it is licensed. (See Section 2-209 of the Act)
e) No person shall:
1) Willfully file any false, incomplete or intentionally
misleading information required to be filed under the Act, or willfully
fail or refuse to file any required information;
2) Open
or operate a facility without a license (Section 3-318(a) of the Act)
f) A violation of subsection (e) is a business offense,
punishable by a fine not to exceed $10,000, except as otherwise provided in
subsection (2) of Section 3-103 of the Act and Section 390.120(c) as to
submission of false or misleading information in a license application. (Section
3-318(b) of the Act)
g) A facility shall not use in its title or description
"Hospital," "Sanitarium," "Sanatorium," or any
other word or description in its title or advertisements that indicates that a
type of service is provided by the facility for which the facility is not
licensed to provide or does not provide. A facility may use in its title or
advertisement the words or description: "Nursing Home,"
"Intermediate Care," or "Skilled Nursing Facility".
h) Any person establishing, constructing, or modifying a health
care facility or portion thereof without obtaining a required permit from
the Health Facilities and Services Review Board, or in violation of the
terms of the required permit, shall not be eligible to apply for any necessary
operating licenses or be eligible for payment by any State agency for services
rendered in that facility until the required permit is obtained. (Section
13.1 of the Illinois Health Facilities Planning Act)
i) Any owner of a facility licensed under this Act
and this Part shall give 90 days' notice prior to voluntarily closing a
facility or closing any part of a facility, or prior to closing any part of a
facility if closing such part will require the transfer or discharge of more
than 10% of the residents. Such notice shall be given to the Department, to any
resident who must be transferred or discharged, to the resident's
representative, and to a member of the resident's family, where practicable.
Notice shall state the proposed date of closing and the reason for closing.
The facility shall offer to assist the resident in securing an alternative
placement and shall advise the resident on available alternatives. Where the
resident is unable to choose an alternate placement and is not under
guardianship, the Department shall be notified of the need for relocation assistance.
The facility shall comply with all applicable laws and regulations until the
date of closing, including those related to transfer or discharge of
residents. The Department may place a relocation team in the facility as
provided under Section 3-419 of the Act and Section 390.3300.
(Section 3-423 of the Act)
j) The facility may not refer a resident or the family
of a resident to a home health agency, home services agency,
or home nursing agency unless the agency is licensed under the Home
Health, Home Services, and Home Nursing Agency Licensing Act. If the status of
an agency's license is unknown, the facility shall request a copy of the agency's
license prior to making a referral to that agency. (Section 3.8 of the Home
Health, Home Services, and Home Nursing Agency Licensing Act)
k) Each facility shall notify the Department electronically at DPH.StrikePlan@illinois.gov
within 24 hours after receiving a notice of impending strike of staff providing
direct care. The facility shall submit a strike contingency plan to the
Department no later than three calendar days prior to the impending strike.
l) Each facility shall have a facility-specific email address
and shall provide that email address to the Department. The facility shall not
change the email address without prior notice to the Department.
(Source: Amended at 46 Ill. Reg. 8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.120 APPLICATION FOR LICENSE
Section 390.120 Application
for License
a) Application for a license to establish or operate a Medically
Complex for the Developmentally Disabled (MC/DD) facility shall be made in
writing and submitted to the Department on forms furnished by the Department.
(Section 3-103(1) of the Act) The facility shall provide a written description
of the proposed program and other information that the Department may require
to determine the appropriate level of licensure. The application form and
other required information shall be submitted and approved prior to surveys of
the physical plant or review of building plans and specifications.
b) An application for a new facility shall be accompanied by a
permit as required by the Illinois Health Facilities Planning Act.
c) The application shall be under oath and the submission of
false or misleading information shall be a Class A misdemeanor. The
application shall contain the following information:
1) The name and address of the applicant if an individual, and
if a firm, partnership, or association, the name and address of every
member thereof, and in the case of a corporation, the name and address thereof
and of its officers and its registered agent, and in the case of a unit of
local government, the name and address of its chief executive officer;
2) The name and location of the facility for which a license
is sought;
3) The name of the person or persons under whose management or
supervision the facility will be conducted;
4) The number and type of residents for which maintenance,
personal care, or nursing is to be provided; and
5) The information relating to the number, experience, and
training of the employees of the facility, any management agreements for the
operation of the facility, and of the moral character of the applicant and
employees as the Department may deem necessary. (Section 3-103(2) of the
Act)
d) Ownership
Change or Discontinuation
1) The license is not transferable. It is issued to a specific
licensee and for a specific location. The license and the valid current
renewal certificate immediately become void and shall be returned to the
Department when the facility is sold or leased; when operation is discontinued;
when operation is moved to a new location; when the licensee (if an individual)
dies; when the licensee (if a corporation or partnership) dissolves or
terminates; or when the licensee (whatever the entity) ceases to be.
2) A license issued to a corporation shall become null, void and
of no further effect upon the dissolution of the corporation. The license
shall not be revived if the corporation is subsequently reinstated. A new license
shall be obtained.
e) Each initial application shall be accompanied by a
financial statement setting forth the financial condition of the applicant and
by a statement from the unit of local government having zoning jurisdiction
over the facility's location stating that the location of the facility is not
in violation of a zoning ordinance. An initial application for a new facility
shall be accompanied by a permit as required by the Illinois Health Facilities
Planning Act. After the application is approved, the applicant shall advise
the Department every 6 months of any changes in the information originally
provided in the application. (Section 3-103(3) of the Act)
f) The Director may issue licenses or renewals for
periods of not less than 6 months nor more than 18 months for facilities
with annual licenses and not less than 18 months for facilities with 2-year
licenses in order for the Department to distribute the expiration dates
of such licenses throughout the calendar year, and fees for such
licenses shall be pro-rated on the basis of the portion of the
year for which they are issued. (Section 3-110 of the Act)
(Source: Amended at 43 Ill.
Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.130 LICENSEE
Section 390.130 Licensee
a) The licensee is the corporate body, political subdivision,
individual, or individuals responsible for the operation of the facility and
upon whom rests the responsibility for meeting the licensing requirements. The
licensee is not required to own the building being used.
b) If the licensee does not own the building, a lease or
management agreement between the licensee and the owner of the building is
required. A copy of the lease or management agreement shall be furnished to
the Department. The licensee also shall provide the Department with a copy of
all new lease agreements or any changes to existing agreements within 30 days after
the effective date of the changes.
c) If the licensee is not a corporation or a political
subdivision of the State of Illinois, each person responsible for the operation
of the facility, and upon whom rests the responsibility for meeting the requirements
of the Act and this Part, shall be at least 18 years of age.
(Source: Amended at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.140 ISSUANCE OF AN INITIAL LICENSE FOR A NEW FACILITY
Section 390.140 Issuance of
an Initial License for a New Facility
a) Upon receipt and review of an application for a license and
inspection of the applicant facility, the Director will issue a
probationary license if the Director finds:
1) That the individual applicant, or the corporation,
partnership or other entity if the applicant is not an individual, is a person
responsible and suitable to operate or to direct or participate in the
operation of a facility by virtue of financial capacity, appropriate business
or professional experience, a record of compliance with lawful orders of the
Department and lack of revocation of a license during the previous five years
and is not the owner of a facility designated pursuant to Section 3-304.2 of
the Act and Section 390.185 as a distressed facility;
2) That the facility is under the supervision of an
administrator who is licensed, if required, under the Nursing Home
Administrators Licensing and Disciplinary Act; and
3) That the facility is in substantial compliance with the
Act and this Part. (Section 3-109 of the Act)
b) The Department will issue a probationary license for 120 days
from the date of issuance.
c) Within 30 days prior to the termination of a probationary
license, the Department will fully and completely inspect the facility
and, if the facility meets the applicable requirements for licensure, will
issue a license under Section 3-109 of the Act, except that, during a
statewide public health emergency, as defined in the Illinois Emergency
Management Agency Act, the Department will inspect facilities within an
appropriate time frame to the extent feasible. (Section 3-116 of the Act)
If the facility is not in compliance and satisfactory progress toward
compliance is not being made, the Department will allow the probationary
license to expire.
d) If the Department finds that the facility does not meet the
requirements for licensure but has made substantial progress toward meeting
those requirements, the license may be renewed once for a period not to exceed
120 days from the expiration date of the initial probationary license. (Section
3-116 of the Act) The Department will not issue more than two consecutive
probationary licenses.
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.
(Source: Amended at 49 Ill. Reg. 7071, effective April 30, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.150 ISSUANCE OF AN INITIAL LICENSE DUE TO A CHANGE OF OWNERSHIP
Section 390.150 Issuance of
an Initial License Due to a Change of Ownership
a) Upon receipt and review of an application for a license and
inspection of the applicant facility, the Director will issue a
probationary license if the Director finds:
1) That the individual applicant, or the corporation,
partnership, or other entity if the applicant is not an individual, is a person
responsible and suitable to operate or to direct or to participate in the
operation of a facility by virtue of financial capacity, appropriate business
or professional experience, a record of compliance with lawful orders of the
Department and lack of revocation of a license during the previous five years,
and is not the owner if a facility designated pursuant to Section 3-304.2 of
the Act and Section 390.185 as a distressed facility;
2) That the facility is under the supervision of an
administrator who is licensed, if required, under the Nursing Home
Administrators Licensing and Disciplinary Act; and
3) That the facility is in substantial compliance with the
Act and this Part. (Section 3-109 of the Act)
b) Whenever ownership of a facility is transferred from the
person named in the license to any other person, the transferee shall
obtain a new probationary license. The transferee shall notify the Department
of the transfer and apply for a new license at least 30 days prior to final
transfer. The Department will not approve the transfer of
ownership to an owner of a facility designated pursuant to Section 3-304.2 of the
Act and Section 390.185 as a distressed facility. (Section 3-112
of the Act)
c) The transferor shall notify the Department at least 30 days
prior to final transfer. The transferor shall remain responsible for the
operation of the facility until the license is issued to the new
transferee. (Section 3-112 of the Act)
d) The license granted to the transferee shall be subject to the
plan of correction submitted by the previous owner and approved by the
Department and any conditions contained in a conditional license issued to the
previous owner. If there are outstanding violations and no approved plan of
correction has been implemented, the Department may issue a conditional license
and plan of correction as provided in Sections 3-311 through 3-317 of the
Act in place of a probationary license. (Section 3-113 of the Act)
e) The transferor shall remain liable for all penalties
assessed against the facility that are imposed for violations occurring
prior to transfer of ownership. (Section 3-114 of the Act)
f) The Department will issue a probationary license. A
probationary license will be valid for 120 days unless sooner suspended
or revoked under Section 3-119 of the Act. (Section 3-116 of the Act)
g) Within 30 days prior to the termination of a probationary
license, the Department will fully and completely inspect the facility
and, if the facility meets the applicable requirements for licensure, will
issue a license under Section 3-109 of the Act, except that, during a
statewide public health emergency, as defined in the Illinois Emergency
Management Agency Act, the Department will inspect facilities within an
appropriate time frame to the extent feasible. (Section 3-116 of the Act)
If the facility is not in compliance and satisfactory progress toward
compliance is not being made, the Department will allow the probationary
license to expire.
h) If the Department finds that the facility does not meet the
requirements for licensure but has made substantial progress toward meeting
those requirements, the license may be renewed once for a period not to exceed
120 days from the expiration date of the initial probationary license.
(Section 3-116 of the Act) The Department will not issue more than two
consecutive probationary licenses.
i) The issuance date of the probationary license to the new
owner will be the date the last licensure requirement is met as determined by
the Department.
j) 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.
(Source: Amended at 49 Ill. Reg. 7071, effective April 30, 2025)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.160 ISSUANCE OF A RENEWAL LICENSE
Section 390.160 Issuance of
a Renewal License
At least 120 days, but not
more than 150 days, prior to license expiration, the licensee shall submit an
application for renewal of the license in such form and containing such
information as the Department requires. If the application is approved,
and the facility is in compliance with all licensure requirements in the Act
and this Part, the license shall be renewed in accordance with
Section 3-110 of the Act. (Section 3-115 of the Act)
(Source: Amended at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.165 CRITERIA FOR ADVERSE LICENSURE ACTIONS
Section 390.165 Criteria for
Adverse Licensure Actions
a) Adverse licensure actions are determinations to deny the
issuance of an initial license, to deny the issuance of a renewal of a license,
to impose a ban on admissions to a facility, or to revoke the current license
of a facility.
b) A determination by the Director or the Director's designee to
take adverse licensure action against a facility will be based on a finding
that one or more of the following criteria are met:
1) A substantial failure to comply with the Act or this Part.
For purposes of this provision, substantial failure is a failure to meet the
requirements of this Part that is other than a variance from strict and literal
performance and that results only in unimportant omissions or defects given the
particular circumstances involved. A substantial failure by the facility
shall include, but not be limited to, 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 this
Act after the Department has sent to the facility and licensee 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 2 or more misdemeanors
involving moral turpitude, during the previous 5 years as shown by a
certified copy of the record of the court of conviction. (Section
3-119(a)(2) of the Act)
3) The moral character of the licensee, administrator, manager,
or supervisor of the facility is not reputable. Evidence to be considered will
include verifiable statements by residents of a facility, law enforcement
officials, or other persons with knowledge of the individual's character. In
addition, the definition afforded to the terms "reputable,"
"unreputable," and "irreputable" by the circuit courts of
the State of Illinois shall apply when appropriate to the given situation. For
purposes of this Section, a manager or supervisor of the facility is an
individual with responsibility for the overall management, direction,
coordination, or supervision of the facility or the facility staff.
4) Personnel is insufficient in number or unqualified
by training or experience to properly care for the number and type of residents
served by the facility. Requirements in this Part concerning personnel,
including Sections 390.810, 390.820, 390.830, 390.1030, 390.1040 and 390.1050,
will be considered in making this determination. (Section 3-119(a)(3) of the
Act)
5) Financial or other resources are insufficient to conduct
and operate the facility in accordance with the Act and this Part.
Financial information and changes in financial information provided by the
facility under Section 390.120(e) and under Section 3-208 of the Act will be
considered in making this determination. (Section 3-119(a)(4) of the Act)
6) The facility is not under the direct supervision of a
full-time administrator as required by Section 390.500. (Section
3-119(a)(5) of the Act)
7) The facility has violated the rights of residents of the
facility by any of the following actions:
A) A pervasive pattern of cruelty or indifference to residents has
occurred in the facility.
B) The facility has appropriated the property of a resident or has
converted a resident's property for the facility's use without the written
consent of the resident or the resident's legal guardian.
C) The facility has secured property, or a bequest of property,
from a resident by undue influence.
8) The facility knowingly submitted false information either on
the licensure or renewal application forms or during the course of an
inspection or survey of the facility.
9) The facility has refused to allow an inspection or survey of
the facility by agents of the Department.
10) The facility has committed 2 Type "AA"
violations within a 2-year period. (Section 3-119(a)(6) of the Act)
11) The facility has committed a Type "AA" violation
while the facility is listed as a "distressed facility". (Section
3-119(a)(7) of the Act)
c) The Director or the Director's designee will 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 46 Ill. Reg. 8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.170 DENIAL OF INITIAL LICENSE
Section 390.170 Denial of
Initial License
a) A determination by the Director or his designee to deny the
issuance of an initial license shall be based on a finding that one or more of
the criteria outlined in Section 390.165 or the following criteria are met.
1) The applicant, any member of the firm, partnership, or
association which is the applicant, any officer or stockholder of the
corporation which is the applicant, or the person designated to manage or
supervise the facility has been convicted of any of the following crimes during
the previous five years. Such convictions shall be verified by a
certified copy of the record of the court of conviction.
A) A felony.
B) Two or more misdemeanors involving moral turpitude.
(Section 3-117(2) of the Act)
2) Prior license revocation. Both of the following conditions
must be met:
A) The license of a facility under this Act has been revoked
during the past five years, which was owned or operated by the
applicant, by a controlling owner of the applicant, by a controlling
combination of owners of the applicant, or by an affiliate who is a controlling
owner of the applicant. Operation for the purposes of this provision shall
include individuals with responsibility for the overall management, direction,
or supervision of the facility.
B) Such prior revocation renders the applicant unqualified or
incapable of maintaining a facility in accordance with the minimum standards
set forth in the Act or in this Part. This determination will be based on
the applicant's qualifications and ability to meet the criteria outlined in
Section 390.165(b) as evidenced by the application and the applicant's prior
history. (Section 3-117(5) of the Act)
b) The Department shall notify an applicant immediately upon
denial of any application. Such notice shall be in writing and
shall include:
1) A clear and concise statement of the basis of the
denial. The statement shall include a citation to the provisions of Section
3-117 of the Act and the provisions of this Part under which the application is
being denied.
2) A description of the right of the applicant to appeal the
denial of the application and the right to a hearing. (Section 3-118 of
the Act)
(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.175 DENIAL OF RENEWAL OF LICENSE
Section 390.175 Denial of
Renewal of License
a) Application for renewal of a license of a facility shall be
denied and the license of the facility shall be allowed to expire when the
Director or his or her designee finds that a condition, occurrence, or
situation in the facility meets any of the criteria specified in Section
390.165(b) and in Section 3-1219(a) of the Act. Pursuant to Section 10-65 of
the Illinois Administrative Procedure Act, licensees who are individuals are
subject to denial of renewal of licensure if the individual is more than 30 days
delinquent in complying with a child support order.
b) When the Director or his or her designee determines that an
application for renewal of a license of a facility is to be denied, the
Department will notify the facility. The notice to the facility will be in
writing and will include:
1) A clear and concise statement of the violations on
which the nonrenewal or revocation is based, and the statute or rule
violated.
2) A statement of the date on which the current license of the
facility will expire as provided in subsection (c) and Section 3-119(d) of the
Act.
3) Notice of the opportunity for a hearing under
Section 3-703 of the Act. (Section 3-119(b) of the Act)
c) The effective date of the nonrenewal of a license shall be as
provided in Section 3-119(d) of the Act.
d) The Department may extend the effective date of license
revocation 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 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.180 REVOCATION OF LICENSE
Section 390.180 Revocation
of License
a) The license of a facility shall be revoked when the Director
or his or her designee finds that a condition, occurrence or situation in the
facility meets any of the criteria specified in Section 390.165(b) and in
Section 3-119(a) of the Act. In addition, the license of a facility will be
revoked when the facility fails to abate or eliminate a Type A violation as
provided in Section 390.282(b) or when the facility has committed 2 Type AA
violations within a 2-year period. (Section 3-119(a)(6) of the Act)
Pursuant to Section 10-65 of the Illinois Administrative Procedure Act,
licensees who are individuals are subject to revocation of licensure if the
individual is more than 30 days delinquent in complying with a child support
order.
b) When the Director or his or her designee determines that the
license of a facility is to be revoked, the Department will notify the
facility. The notice to the facility will be in writing and will include:
1) A clear and concise statement of the violations on
which the revocation is based, and the statute or rule violated.
2) A statement of the date on which the revocation will take
effect as provided in subsection (c) and Section 3-119(d) of the Act.
3) Notice of opportunity for a hearing under Section 3-703 of
the Act. (Section 3-119(b) of the Act)
c) The effective date of the revocation of a license shall be as
provided in Section 3-119(d) of the Act.
d) The Department may extend the effective date of license
revocation 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 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.185 DESIGNATION OF DISTRESSED FACILITIES
Section 390.185 Designation of Distressed Facilities
a) No
facility shall be identified as a distressed facility unless it has committed
violations or deficiencies that have actually harmed residents. (Section
3-304.2(a) of the Act) Facilities that have received a written notice of
violations, pursuant to Section 390.276, for a failure to comply with the Act
or this Part that resulted in harm to a resident will be added to the quarterly
list of distressed facilities using the following methodology:
1) Facility
histories will be reviewed for the preceding 24 months. Violations will be
assigned a point value as follows:
A) Type
"B" violation: 10 points;
B) Repeat
Type "B" violation: 20 points;
C) Type
"A" violation: 35 points;
D) Repeat
Type "A" violation: 50 points;
E) Type
"AA" violation: 50 points; and
F) Repeat
Type "AA" violation: 75 points.
2) The
points assigned to a facility by the Department will be calculated on the last
day of every quarter in a calendar year. Violations from the 24 months prior
to the current quarter will be scored based on the criteria in subsection
(a)(1).
3) Any
facility with a total score of 100 points or above and that has committed
violations that resulted in harm to a resident will be included in the
quarterly list of distressed facilities. The Department will, by
registered mail, notify each facility and licensee of its distressed
designation and of the calculation on which it is based. (Section 3-304.2(b)
of the Act)
4) For
the purposes of this Section, facilities will not accrue points for harm to a
resident while the resident is at a day training program or other entity or
activity outside the facility that is not under the control
or supervision of the facility. Facilities shall immediately notify the
Department and the Department of Human Services – Division of
Developmental Disabilities when a resident is injured, or is subject to alleged
abuse or neglect, at a day training program.
b) A
distressed facility may contract with an independent consultant. If the
distressed facility does not seek the assistance of an independent consultant,
the Department will place a monitor or a temporary manager in the
facility, depending on the Department's assessment of the condition of the
facility. (Section 3-304.2(c) of the Act)
c) The
purpose of a contract between a facility and an independent consultant shall be
to develop and assist in the implementation of a plan of improvement to
bring and keep the facility in compliance with the Act and, if applicable, with
federal certification requirements. (Section 3-304.2(d) of the Act)
d) An
independent consultant contracted by the facility shall:
1) Possess
a baccalaureate degree, a nursing license or a nursing home administrator's
license, and a minimum of two years of full-time work experience in the
long-term care industry, including one year of experience working directly with
individuals with a developmental disability diagnosis, or shall have a
professional background that best meets the needs of the facility;
2) Have no
professional or financial relationship with the facility, or have any
reportable ownership interest in the facility, or any related parties. In
this Section, "related parties" has the meaning attributed to it
in the instructions for completing Medicaid cost reports. (Section
3-304.2(d) of the Act); and
3) Have
no ownership interest in, or be employed by, another facility on the most
recent quarterly list of distressed facilities. This provision is not intended
to prevent an independent consultant from providing consultation to more than
one distressed facility.
e) A
facility that contracts with an independent consultant shall have 90 days to
develop a plan of improvement and demonstrate a good faith effort at
implementation, and another 90 days to achieve compliance and take whatever
additional actions are called for in the improvement plan to maintain
compliance with the Act and this Part. (Section 3-304.2(d) of the Act)
f) A
distressed facility that does not contract with a consultant shall be assigned
a monitor or a temporary manager at the Department's discretion. The cost of
the temporary manager will be paid by the Department. (Section
3-304.2(e) of the Act) The Department’s decision whether to place a monitor or
temporary manager in a facility will be based on the following factors:
1) The
severity of violations cited against the facility;
2) Whether
the violations show a pattern of non-compliance or demonstrate an impact on a
number of facility systems; and
3) Whether
the facility was issued a notice of any high-risk violations in the prior 12
months.
g) A
monitor or temporary manager placed in a facility by the Department shall have
the same authority as an independent consultant would have, if contracted with
a facility.
h) If
a distressed facility that contracts with an independent consultant does not,
in a timely manner, develop an adequate plan of improvement or comply with the
plan of improvement, then the Department may place a monitor in the facility.
(Section 3-304.2(e) of the Act)
i) In
addition to any other sanctions in the Act and this Part, distressed facilities
not in compliance with the Act and this Part shall be subject to a ban on new
admissions until the distressed facility implements the plan of correction, as
certified by a follow-up visit from the Department.
j) To
be removed from the distressed facilities list, a facility shall not, for a
period that includes at least two consecutive annual surveys and any
intervening complaint investigations or other surveys, receive any:
1) Type "AA"
violations;
2) Type "A"
violations with harm; and
3) Combination
of violations that harmed residents or that equals or exceeds 100 points as
determined by the point values in this Section.
(Source: Added at 46 Ill. Reg. 8192,
effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.190 EXPERIMENTAL PROGRAM CONFLICTING WITH REQUIREMENTS
Section 390.190 Experimental
Program Conflicting With Requirements
a) 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. The Department will not approve
experimental programs that would violate residents' rights under the Act, this
Section, and Section 390.3220(e). Additionally, experimental programs in
facilities shall comply with the following:
1) No
facility shall permit experimental research or treatment to be conducted on a
resident or give access to any person or person's records for a retrospective
study about the safety or efficacy of any care or treatment without the prior
written approval of the institutional review board;
2) No
administrator, or person licensed by the State to provide medical care or
treatment to any person, may assist or participate in any experimental research
on or treatment of a resident, including a retrospective study, that does not
have the prior written approval of the institutional review board. Such conduct
shall be grounds for professional discipline by the Department of Financial and
Professional Regulation; and
3) The
institutional review board may exempt from ongoing review research or treatment
initiated on a resident before the individual's admission to a facility and for
which the board determines there is adequate ongoing oversight by another
institutional review board.
b) Nothing
in the Act or this Section shall prevent a facility, any facility
employee, or any other person from assisting or participating in any
experimental research on or treatment of a resident if the research or
treatment began before the person's admission to a facility, until the board
has reviewed the research or treatment and decided to grant or deny approval or
to exempt the research or treatment from ongoing review. (Section 2-104(a)
of the Act)
(Source: Amended at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.200 INSPECTIONS, SURVEYS, EVALUATIONS AND CONSULTATION
Section 390.200 Inspections,
Surveys, Evaluations and Consultation
a) The terms survey, inspection, and evaluation are synonymous.
These terms refer to the overall examination of compliance with the Act and
this Part.
1) All facilities to which this Part applies shall be subject to
and shall be deemed to have given consent to annual inspections, surveys, or
evaluations by properly identified personnel of the Department, or by other
properly identified persons, including local health department staff, as the
Department may designate.
2) 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. Submission of a facility's current Consumer Choice
Information Report required by Section 2-214 of the Act shall be
verified at the time of inspection. (Section 3-212(a) of the Act)
3) The licensee, or person representing the licensee in the
facility, shall provide access and entry to the premises or facility for
obtaining information required to carry out the Act and this Part. In addition,
the Department shall have access to and may reproduce or photocopy at
its cost any books, records, and other documents maintained by the
facility, the licensee or their representatives to the extent necessary
to carry out the Act and this Part. (Section 3-213 of the Act)
4) A facility may charge the Department for photocopying at a
rate determined by the facility not to exceed the rate in Access to Records of
the Department of Public Health (2 Ill. Adm. Code 1127).
5) A facility shall complete a Consumer Choice Information
Report and shall file it with the Office of State Long Term Care Ombudsman
electronically as prescribed by the Office. The Report shall be filed annually
and upon request by the Office of State Long Term Care Ombudsman. This
report shall be completed by the facility in full. (Section 2-214(a) of
the 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 this Act or the rules promulgated under
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 390.120(c) as to
submission of false or misleading information in a license application.
(Section 3-318(b) of the Act)
d) In determining whether to make more than the
required number of unannounced inspections, surveys and
evaluations of a facility, the Department shall consider one or more of
the following:
1) Previous inspection reports;
2) The facility's history of compliance with the Act and
this Part, and correction of violations, penalties or other enforcement
actions;
3) The number and severity of complaints received
about the facility;
4) Any allegations of resident abuse or neglect;
5) Weather conditions;
6) Health emergencies;
7) Other reasonable belief that deficiencies exist;
(Section 3-212(b) of the Act) and
8) Requirements pursuant to the "1864 Agreement" (42 U.S.C.
1395aa) between the Department and the U.S. Department of Health and Human
Services (HHS) (e.g., annual and follow-up certification inspections, life
safety code inspections and any inspections requested by the Secretary of HHS).
e) The Department shall not be required to determine whether a
facility certified to participate in the Medicare program under Title XVIII of
the Social Security Act, or the Medicaid Program under Title XIX of the Social
Security Act, and which the Department determines by inspection to be in
compliance with the certification requirements of Title XVIII or XIX, is in
compliance with any requirement of the Act and this Part that is
less stringent than or duplicates a federal certification requirement.
(Section 3-212(b-1) of the Act)
f) The Department shall, in accordance with Section
3-212(a) of the Act, determine whether a certified facility is in compliance
with requirements of the Act that exceed federal certification requirements.
(Section 3-212(b-1) of the Act)
g) If a certified facility is found to be out of compliance
with federal certification requirements, the results of the inspection
conducted pursuant to Title XVIII or XIX of the Social Security Act
(Section 3-212 (b-1) of the Act) shall be reviewed to determine which, if any,
of the results shall be considered licensure findings, as follows:
1) The result identifies potential violations of the MC/DD Act
and this Part; and
2) The result, based on available information, would likely
represent a Type "AA", a Type "A", or a Type "B"
violation if tested against the factors described in Sections 390.272 and
390.274.
h) All results of an inspection conducted pursuant to Title XVIII
or XIX of the Social Security Act that the Department considers licensure
findings shall be provided to the facility at the time of exit or by mail in
accordance with subsection (i).
i) Upon the completion of each inspection, survey, and
evaluation, the appropriate Department personnel who
conducted the inspection, survey, or evaluation shall submit a copy of their
report to the licensee or the licensee's representative upon exiting the
facility or upon considering results of an inspection conducted pursuant to
Title XVIII or XIX of the Social Security Act as licensure findings. A copy of
the information gathered during a complaint investigation will not be provided
upon exiting the facility. Comments or documentation provided by the
licensee, which may refute findings in the report, which explain extenuating
circumstances that the facility could not reasonably have prevented, or which
indicate methods and timetables for correction of deficiencies described in the
report shall be provided to the Department within 10 days of receipt of the
copy of the report. (Section 3-212(c) of the Act)
j) Consultation consists of providing advice or suggestions to
the staff of a facility at their request relative to specific matters of the
scope of regulation, methods of compliance with the Act or this Part, or
general matters of patient care. A request for consultation by a facility or
facility staff does not obligate Department personnel to provide consultation.
A facility that requests and obtains consultation from the Department retains
legal responsibility for compliance with the Act and this Part.
(Source: Amended at 46 Ill. Reg. 8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.210 FILING AN ANNUAL ATTESTED FINANCIAL STATEMENT
Section 390.210 Filing an
Annual Attested Financial Statement
a) Each licensee shall file annually an attested
financial statement. The Director may order an audited financial statement of a
particular facility by an auditor of the Director's choice. The Department
will pay the cost of extra audits ordered by the Director. The time period
covered in the financial statement shall be a period determined by the
Department for the initial filing, and after the initial filing shall coincide
with the facility's fiscal year or the calendar year. (Section 3-208(a) of the
Act)
b) The financial statement shall be filed with the Department
within 90 days following the end of the designated reporting period. The
financial statement will not be considered as having been filed unless all
sections of the prescribed forms have been properly completed. Those sections that
do not apply to a particular facility shall be noted "not applicable"
on the forms.
c) The information required to be submitted in the financial
statement shall include, but is not limited to, the following:
1) Facility information, including: facility name and address,
licensure information, type of ownership, licensed bed capacity, date and cost
of building construction and additions, date and cost of acquisition of
buildings, building sizes, equipment costs and dates of acquisition.
2) Resident information, including: number and level of care of
residents by source of payment, income from residents by level of care.
3) Cost information by level of care, including:
A) General service costs such as dietary, food, housekeeping,
laundry, utilities, and plant operation and maintenance.
B) Health care costs such as medical director, nursing,
medications, oxygen, activities, medical records, other medical services,
social services, and utilization reviews.
C) General administration costs such as administrative salaries,
professional services, fees, subscriptions, promotional, insurance, travel,
clerical, employee benefits, license fees, and in-service training and
education.
D) Ownership costs such as depreciation, interest, taxes, rent,
and leasing.
E) Special Service cost centers such as habilitative and
rehabilitative services, therapies, transportation, education, barber and
beauty care, and gift and coffee shops.
4) Income information, including operating and non-operating
income.
5) Ownership information, including balance sheet and payment to
owners.
6) Personnel information, including the number and type of people
employed and salaries paid.
7) Related organization information, including related organizations
from which services are purchased.
d) The new owner or a new lessee of a previously licensed
facility may file a projection of capital costs at the time of closing or
signing of the lease.
e) The new owner or new lessee of a facility that is licensed for
the first time (a newly constructed facility) shall file a projection of
capital costs.
f) The owner or lessee in subsections (d) and (e) shall file a
full cost report within nine months after acquisition (covering the first six
months of operation). Each shall also file a cost report within 90 days after
the close of its first complete fiscal year.
g) No public funds shall be expended for the maintenance of
any resident in a facility that has failed to file the financial
statement, and no public funds shall be paid to, or on behalf of, a facility that
has failed to file a statement. (Section 3-208(b) of the Act)
(Source: Amended at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.220 INFORMATION TO BE MADE AVAILABLE TO THE PUBLIC BY THE DEPARTMENT
Section 390.220 Information
to be Made Available to the Public by the Department
a) The Department shall respect the confidentiality of a
resident's record and shall not divulge or disclose the contents of a record in
a manner which identifies a resident, except upon a resident's death to a
relative or guardian, or under judicial proceedings. This Section shall not be
construed to limit the right of a resident or a resident's representative to
inspect or copy the resident's records. (Section 2-206(a) of the Act)
b) Confidential medical, social, personal or financial
information identifying a resident shall not be available for public inspection
in a manner that identifies a resident. (Section 2-206(b) of the
Act)
c) The following information is subject to disclosure to the
public from the Department or the Department of Healthcare and Family Services:
1) Information submitted under Sections 3-103 and 3-207 of
the Act, except information concerning the remuneration of personnel licensed,
registered, or certified by the Department of Financial and Professional
Regulation and monthly charges for an individual private resident;
2) Records of license and certification inspections, surveys,
and evaluations of facilities, other reports of inspections, surveys, and
evaluations of resident care, whether a facility is designated a distressed
facility and the basis for the designation, and reports concerning a facility
prepared pursuant to Titles XVIII and XIX of the Social Security Act, subject
to the provisions of the Social Security Act subject to the provisions of the
Social Security Act;
3) Cost and reimbursement reports submitted by a facility
under Section 3-208 of the Act reports of audits of facilities, and
other public records concerning the cost incurred by, revenues received by, and
reimbursement of facilities; and
4) Complaints filed against a facility and complaint
investigation reports, except that a complaint or complaint investigation
report shall not be disclosed to a person other than the complainant or
complainant's representative before it is disclosed to a facility under Section
3-702 of the Act, and, further, except that a complainant or resident's
name shall not be disclosed except under Section 3-702 of the Act. (Section
2-205 of the Act)
d) The Department shall disclose information under this
Section in accordance with provisions for inspection and copying of public
records required by the Freedom of Information Act.
e) However, the disclosure of information described in subsection
(c)(1) shall not be restricted by any provision of the Freedom of
Information Act. (Section 2-205 of the Act)
f) Copies of reports available to the public may be obtained by
making a written request to the Department in accordance with the Department's
rules, Access to Records of the Department of Public Health.
(Source: Amended at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.230 INFORMATION TO BE MADE AVAILABLE TO THE PUBLIC BY THE LICENSEE
Section 390.230 Information
to be Made Available to the Public by the Licensee
a) Every facility shall conspicuously post or display in an
area of its offices accessible to residents, employees, and visitors the
following:
1) Its current license;
2) A description, provided by the Department of complaint
procedures established under the Act and the name, address, and
telephone numbers of a person authorized by the Department to receive
complaints;
3) A copy of any order pertaining to the facility issued by
the Department or a court; and
4) A list of the material available for public inspection
under subsection (b). (Section 3-209 of the Act)
b) A facility shall retain the following for public
inspection:
1) A complete copy of every inspection report of the facility
received from the Department during the past five years;
2) A copy of every order pertaining to the facility issued by
the Department or a court during the past five years;
3) A description of the services provided by the facility and
the rates charged for those services and items for which a resident may be
separately charged;
4) A copy of the Statement of Ownership required by Section
3-207 of the Act;
5) A record of personnel employed or retained by the facility
who are licensed, certified or registered by the Department of Financial and Professional
Regulation;
6) A complete copy of the most recent inspection report of the
facility received from the Department; and
7) A copy of the current Consumer Choice Information Report
required by Section 2-214 of the Act. (Section 3-210 of the Act)
(Source: Amended at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.240 MUNICIPAL LICENSING
Section 390.240 Municipal
Licensing
a) Municipalities that have adopted a licensing ordinance as
provided under Section 3-104 of the Act and this Part shall adopt this Part by
complying with Article I, Division 3, of the Illinois Municipal Code [65 ILCS
5/1-3].
b) Expiration dates on licenses issued by municipalities shall be
distributed throughout the calendar year. The month the license expires shall
coincide with the date of original licensure of the licensee.
c) The municipality shall notify the Department within 10 days following
the date of issuance or denial of a license that the municipal license has been
issued or denied. If the license is issued, the notice shall include the
facility name, address, the date of issuance, and the number of beds by level
of care for which the license was issued. If the license is denied, the notice shall
indicate reason for denial and the current status of licensee's (applicant's) application
for municipal license.
d) The municipality shall use the same licensing classifications
as the Department, and a municipality shall not issue a license to a facility
for a different classification from the license issued by the Department.
e) The Department and the municipality shall have the right at
any time to visit and inspect the premises and personnel of any facility for
the purpose of determining whether the applicant or licensee is in compliance
with the Act, this Part, or with the local ordinances that govern the
regulation of the facility. The Department may survey any former facility that
once held a license to ensure that the facility is not operating without a
license. Municipalities may charge a reasonable license or renewal fee for the
regulation of facilities, which shall be in addition to the fees paid to the
Department.
f) The licensing and enforcement provisions of the
municipality shall fully comply with the Act and this Part and
the municipality shall make available information as required by the Act.
(Section 3-104 of the Act)
g) Municipalities which may have ordinances requiring the
licensing and regulation of facilities with at least the minimum standards
established by the Department under the Act, shall make periodic reports
to the Department as required by the Department. This report shall
include a list of those facilities licensed by the municipality, the
number of beds of each facility and the date the license of each facility is
effective. (Section 3-105 of the Act)
h) The Department will not issue a license to any
person who has failed to qualify for a municipal license. If the issuance of a
license by the Department antedates regulatory action by a municipality, the
municipality shall issue a local license unless the standards and requirements
under its ordinance or resolution are greater than those prescribed under the
Act and this Part. (Section 3-106(a) of the Act)
i) In the event that the standards and requirements under the
ordinance or resolution of the municipality are greater than those prescribed
under the Act and this Part, the license issued by the Department
shall remain in effect pending reasonable opportunity provided by the
municipality, which shall not be less than 60 days, for the licensee to comply
with the local requirements. (Section 3-106(b) of the Act)
(Source: Amended at 46 Ill. Reg. 8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.250 OWNERSHIP DISCLOSURE
Section 390.250 Ownership
Disclosure
a) As a condition of the issuance or renewal of the license of
any facility, the applicant shall file a statement of ownership. The applicant
shall update the information required in the statement of
ownership within 10 days after any change. (Section 3-207(a) of the Act)
b) The statement of ownership shall include the following:
1) The name, address, telephone number, occupation or business
activity, business address and business telephone number of the person who is
the owner of the facility and every person who owns the building in which the
facility is located, if other than the owner of the facility, which is the
subject of the application or license;
2) If the owner is a partnership or corporation, the name of
every partner and stockholder of the owner (3-207(b) of the Act);
3) The percent of direct or indirect financial interest of those
persons who have a direct or indirect financial interest of five percent or more
in the legal entity designated as the operator/licensee of the facility that is
the subject of the application or license;
4) The name, address, telephone number, occupation or business activity,
business address, business telephone number and the percent of direct or
indirect financial interest of those persons who have a direct or indirect
financial interest of five percent or more in the legal entity that owns the
building in which the operator/licensee is operating the facility that is the
subject of the application or license; and
5) The name and address of any facility, wherever located, any
financial interest in which 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. 6716, effective March 29, 2018)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.260 ISSUANCE OF CONDITIONAL LICENSES
Section 390.260 Issuance of
Conditional Licenses
a) The Director may issue a conditional license under
Section 3-305 of the Act to any facility if the Director finds that
either a Type "A" or Type "B" violation exists in such
facility. The issuance of a conditional license shall revoke any license held
by the facility. (Section 3-311 of the Act)
b) Prior to the issuance of a conditional license, the
Department shall review and approve a written plan of correction. The
Department shall specify the violations that prevent full licensure and
shall establish a time schedule for correction of the deficiencies. Retention
of the license shall be conditional on the timely correction
of the deficiencies in accordance with the plan of correction. (Section
3-312 of the Act)
c) Written notice of the decision to issue a conditional
license shall be sent to the applicant or licensee, together with the
specification of all violations of the Act and this Part that prevent
full licensure and that form the basis for the Department's decision to
issue a conditional license and the required plan of correction. The notice
shall inform the applicant or licensee of its right to a full hearing under
Section 3-315 of the Act to contest the issuance of the conditional
license. (Section 3-313 of the Act)
d) If the applicant or licensee desires to contest the
basis for issuance of a conditional license, or the terms of the plan
of correction, the applicant or licensee shall send a written request for
hearing to the Department within 10 days after receipt by the
applicant or licensee of the Department's notice and decision to issue a
conditional license. The Department shall hold the hearing as provided under
Section 3-703 of the Act. The terms of the conditional license shall be
stayed pending the issuance of the Final Order at the conclusion of the
hearing, and the facility may operate in the same manner as with an unrestricted
license. Section 3-315 of the Act)
e) A conditional license shall be issued for a period
specified by the Department, but in no event for more than one year. The
effective date of the conditional license shall not begin until the applicant or
licensee has had the opportunity to request a hearing pursuant to subsection
(d), and if a hearing is requested in a timely manner, then the terms of the
conditional license shall be stayed as provided for in subsection (d). The
Department shall periodically inspect any facility operating under a
conditional license. If the Department finds substantial failure by the
facility to timely correct the violations which prevented full
licensure and formed the basis for the Department's decision to issue a conditional
license in accordance with the required plan of correction, the conditional
license may be revoked as provided under Section 3-119 of the Act.
(Section 3-316 of the Act)
(Source: Amended at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.270 MONITOR AND RECEIVERSHIP
Section 390.270 Monitor and
Receivership
a) The Department may place an employee or agent to serve as a
monitor in a facility or may petition the circuit court for appointment of a
receiver for a facility, or both, when any of the following conditions exist:
1) The facility is operating without a license;
2) The Department has suspended, revoked or refused to renew
the existing license of the facility;
3) The facility is closing or has informed the Department that
it intends to close and adequate arrangements for relocation of residents have
not been made at least 30 days prior to closure;
4) The Department determines that an emergency exists, whether
or not it has initiated revocation or nonrenewal procedures, if because of the
unwillingness or inability of the licensee to remedy the emergency the
Department believes a monitor or receiver is necessary; as used in this
subsection, "emergency" means a threat to the health, safety or
welfare of a resident that the facility is unwilling or unable to correct;
5) The Department receives notification that the facility is
terminated or will not be renewed for participation in the federal
reimbursement program under either Title XVIII (Medicare) or Title XIX
(Medicaid) of the Social Security Act; or
6) At
the discretion of the Department when a review of facility compliance history,
incident reports, or reports of financial problems raises a concern that a
threat to resident health, safety, or welfare exists. (Section 3-501 of
the Act)
b) The monitor shall meet the following minimum requirements:
1) Be in good physical health as evidenced by a physical
examination by a physician within the last year;
2) Have an understanding of the needs of long-term care facility
residents as evidenced by one year of experience in working, as appropriate,
with elderly or developmentally disabled individuals in programs such as
patient care, social work or advocacy;
3) Have an understanding of the Act and this Part, which are the
subject of the monitors' duties as evidenced in a personal interview of the
candidate;
4) Not be related to the owners of the involved facility through
blood, marriage or common ownership of real or personal property, except
ownership of stock that is traded on a stock exchange;
5) Have successfully completed a baccalaureate degree or possess
a nursing license or a nursing home administrator's license; and
6) Have two years of full-time work experience, relevant to the
reason the monitor has been placed in the facility, in the long-term care
industry of the State of Illinois.
c) The monitor shall be under the supervision of the Department,
perform the duties of a monitor delineated in Section 3-502 of the Act, and
accomplish the following actions:
1) Visit the facility as directed by the Department;
2) Review all records pertinent to the condition for the monitor's
placement under subsection (a);
3) Provide to the Department written and oral reports detailing
the observed conditions of the facility; and
4) Be available as a witness for hearings involving the condition
for placement as monitor.
d) All communications, including but not limited to data,
memoranda, correspondence, records and reports, shall be transmitted to and
become the property of the Department. In addition, findings and results of
the monitor's work done under this Part shall be confidential and not subject
to disclosure without written authorization from the Department or by court
order subject to disclosure only in accordance with the Freedom of Information
Act, subject to the confidentiality requirements of the Act.
e) The Department may terminate the assignment as monitor at any
time.
f) Through consultation with the long-term care industry
associations, professional organizations, consumer groups and health care
management corporations, the Department will maintain a list of receivers.
Preference on the list shall be given to individuals possessing a valid
Illinois nursing home administrator's license and experience in financial and
operations management of a long-term care facility and to individuals with
access to consultative experts with this experience. To be placed on the list,
individuals shall meet the following minimum requirements:
1) Be in good physical health, as evidenced by a physical
examination by a physician within the last year;
2) Have an understanding of the needs of long-term care facility
residents and the delivery of the highest possible quality of care, as
evidenced by one year of experience in working with elderly or developmentally
disabled individuals in programs such as patient care, social work, or
advocacy;
3) Have an understanding and working knowledge of the Act and
this Part, as evidenced in a personal interview of the candidate;
4) Have successfully completed a baccalaureate degree or possess
a nursing license or a nursing home administrator's license; and
5) Have two years full-time working experience, relevant to the
reason the monitor has been placed in the facility, in the Illinois long-term
care industry.
g) Upon a court appointment of a receiver for a facility, the
Department will inform the individual of all legal proceedings to date that concern
the facility.
h) The receiver may request that the Director authorize
expenditures from monies appropriated, pursuant to Section 3-511 of the Act, if
incoming payments from the operation of the facility are less than the costs
incurred by the receiver.
i) In the case of Department-ordered patient transfers, the
receiver may:
1) Assist in providing for the orderly transfer of all residents
in the facility to other suitable facilities or make other provisions for their
continued health;
2) Assist in providing for transportation of the resident and his
or her medical records and belongings if he or she is transferred or
discharged; assist in locating alternative placement; assist in preparing the
resident for transfer; and permit the resident's legal guardian to participate
in the selection of the resident's new location;
3) Unless emergency transfer is necessary, explain alternative
placements to the resident and provide orientation to the place chosen by the
resident or resident's guardian.
j) In any action or special proceeding, brought against a
receiver in the receiver's official capacity, for acts committed while carrying
out powers and duties under the Act and this Section, the
receiver shall be considered a public employee under the Local Governmental and
Governmental Employees Tort Immunity Act. A receiver may be held liable
in a personal capacity only for the receiver's own gross negligence,
intentional acts, or breach of fiduciary duty. (Section 3-513 of the Act)
(Source: Amended at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.271 PRESENTATION OF FINDINGS
Section 390.271 Presentation
of Findings
a) If it is probable findings will be presented that could be
issued as violations of regulations that represent a direct threat to the
health, safety, or welfare of residents, Department surveyors shall notify the
administrator or designee during the course of the survey of possible findings.
b) The Department will 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 will be presented
during the exit conference. If the investigation has not been completed at the
time of the facility exit, the Department will inform the facility
administrator or designee that the investigation is not complete and that
findings will 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 will
schedule a time and place for the exit conference to be held at the conclusion
of the survey.
d) At the exit conference, surveyors will 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, at
their discretion, modify or eliminate all preliminary findings in accordance
with any facts presented by the facility to the Department during the exit
conference.
e) Additional comments or documentation may be submitted by the
facility to the Department during a 10-day comment period as allowed by the
Act.
f) If the Department determines, after review of the comments
submitted pursuant to subsection (d), that the facility may have committed
violations of the Act or this Part different than or in addition to those
presented at the exit conference and the violations may be cited as either Type
AA, Type A, or repeat Type B violations, the Department shall inform the
facility in writing. The facility shall then have an opportunity to submit
additional comments addressing the different or additional Sections of the Act
or this Part. The surveyors will be advised of any code changes made after
their recommendations are submitted.
g) The facility shall have five working days from receipt of the
notice required by this subsection to submit its additional comments to the
Department. The Department will consider the additional comments in
determining the existence and level of violation of the Act and 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 the recording is provided,
at facility expense, to the surveyors at the conclusion of the exit conference.
Video-taped recordings shall not be allowed.
i) Surveyors shall not conduct an exit conference for the
following reasons:
1) The facility administrator or designee requests that an exit
conference not be held;
2) During a scheduled exit conference, facility staff or their
guests create an environment that is not conducive to a meaningful exchange of
information.
(Source: Amended at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.272 DETERMINATION TO ISSUE A NOTICE OF VIOLATION OR ADMINISTRATIVE WARNING
Section 390.272
Determination to Issue a Notice of Violation or Administrative Warning
a) Upon receipt of a report of an inspection, survey or
evaluation of a facility, the Director or his or her designee will review the
findings contained in the report to determine whether the report's findings
constitute a violation or violations of which the facility must be given notice.
All information, evidence, and observations made during an inspection, survey
or evaluation shall be considered findings or deficiencies. (Section 3-212(c)
of the Act)
b) In making this determination, the Director or his or her
designee will consider any comments and documentation provided by the
licensee within 10 days after receipt of the copy of the report in
accordance with Section 390.200(e). (Section 3-212(c) of the Act)
c) In determining whether the findings warrant the issuance of a
notice of violation, the Director or his or her designee will base his or her
determination on the following factors:
1) The severity of the finding. The Director or his or
her designee will consider whether the finding constitutes a merely technical
non-substantial error or whether the finding is serious enough to constitute an
actual violation of the intent and purpose of the Act or this Part.
2) The danger posed to resident health and safety. The
Director or his or her designee will consider whether the finding could pose
any direct harm to the residents.
3) The diligence and efforts to correct deficiencies and
correction of reported deficiencies by the facility. The Director or his
or her designee will consider comments and documentation provided by the
facility evidencing that steps have been taken to correct reported findings
and to insure a reduction of deficiencies.
4) The frequency and duration of similar findings in previous
reports and the facility's general inspection history. The Director or his
or her designee will consider whether the same finding or a similar finding
relating to the same condition or occurrence has been included in previous
reports and the facility has allowed the condition or occurrence to continue or
to recur. (Section 3-212(c) of the Act)
d) If the Director or his or her designee determines that the
report's findings constitute a violation or violations that do not directly
threaten the health, safety, or welfare of a resident or residents, the Department
shall issue an administrative warning as provided in Section 390.277.
(Section 3-303.2(a) of the Act)
e) Violations shall be determined under this Section no
later than 90 days after completion of each inspection, survey, and evaluation.
(Section 3-212(c) of the Act)
(Source: Amended at 46 Ill. Reg. 8192,
effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.274 DETERMINATION OF THE TYPE OF A VIOLATION
Section 390.274
Determination of the Type of a Violation
a) After determining that issuance of a notice of violation is
warranted and prior to issuance of the notice, the Director will review the
findings that are the basis of the violation and any comments and documentation
provided by the facility to determine the level of the violation. Each
violation will be determined to be either a Type AA, a Type A, a Type B, or a
Type C violation based on the criteria outlined in this Section.
b) The following definitions of levels of violations shall be
used in determining the level of each violation:
1) A
"Type AA violation" is a violation of the Act or
this Part that creates a condition or occurrence relating to the operation
and maintenance of a facility that proximately caused a resident's death.
(Section 1-128.5 of the Act)
2) A "Type A violation" is a violation
of the Act or this Part that creates a condition or
occurrence relating to the operation and maintenance of a facility that creates
a substantial probability that the risk of death or serious mental or physical
harm to a resident will result from the violation or the violation
has resulted in actual physical or mental harm to a resident. (Section
1-129 of the Act)
3) A "Type B violation" is a violation
of the Act or this Part that creates a condition or
occurrence relating to the operation and maintenance of a facility that is more
likely than not to cause more than minimum physical or mental harm to a
resident or is specifically designated as a Type "B" violation in the
Act. (Section 1-130 of the Act)
4) A "Type C violation" is a violation of
the Act or this Part that creates a condition or occurrence
relating to the operation and maintenance of a facility that creates a
substantial probability that less than minimal physical or mental harm to a
resident will result from the violation. (Section 1-132 of the Act)
c) In determining the level of a violation, the Director or his or
her designee will consider the following criteria:
1) The degree of danger to the resident or residents that is
posed by the condition or occurrence in the facility. The following factors
will be considered in assessing the degree of danger:
A) Whether the resident or residents of the facility are able to
recognize conditions or occurrences that may be harmful and are able to take
measures for self-preservation and self-protection. The extent of nursing care
required by the residents as indicated by review of patient needs will be
considered in relation to this determination.
B) Whether the resident or residents have access to the area of
the facility in which the condition or occurrence exists and the extent of the
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 the notice. Failure of
the facility to notify residents of potentially harmful conditions or
occurrences will be considered. The adequacy of the method of the notification
and the extent to which the 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 harm.
B) Whether available statistics and records from similar
facilities indicate that direct and imminent danger to the resident has
resulted from similar conditions or occurrences and the frequency of 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 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.276 NOTICE OF VIOLATION
Section 390.276 Notice of
Violation
a) Each notice of violation shall be prepared in writing
and contain the following information:
1) A description of the nature of the violation.
2) A citation of the specific statutory provision or rule alleged
by the Department to have been violated. (Section 3-301 of the Act)
3) A statement of the level of the violation as determined
pursuant to Section 390.274.
4) One of the following requirements for corrective action:
A) The situation, condition, or practice constituting a Type "AA"
violation or a Type "A" violation shall be abated or eliminated
immediately unless a fixed period of time, not exceeding 15 days, as determined
by the Department and specified in the notice of violation, is required for
correction. In setting this period, the Department will consider whether
harm to residents of the facility is imminent, whether necessary precautions
can be taken to protect residents before the corrective action is completed,
and whether delay would pose additional risks to the residents.
B) At the time of issuance of a notice of a Type "B"
violation, the Department will request a plan of correction that is
subject to the Department's approval. The facility shall have 10 days after
receipt of notice of violation in which to prepare and submit a plan of
correction. (Section 3-303(b) of the Act)
5) A statement that the Department may take additional action
under the Act, including assessment of penalties or licensure action.
6) A description of the licensee's right to appeal the notice and
its right to a hearing.
b) For each notice of violation, the Director or his or her
designee shall serve a notice of violation upon the licensee within 10 days
after the Director determines that issuance of a notice of violation is
warranted under Section 390.272. (Section 3-301 of the Act)
1) Each day the violation exists after the date upon which a
notice of violation is served under Section 3-301 of the Act shall
constitute a separate violation for purposes of assessing penalties or fines
under Section 3-305 of the Act.
2) The submission of a plan of correction pursuant to Section
3-303(b) of the Act does not prohibit or preclude the Department from assessing
penalties or fines pursuant to Section 3-305 of the Act for those
violations found to be valid except as provided under Section 3-308 of the
Act in relation to Type "B" violations. (Section 3-302 of the
Act)
c) Residents
and their guardians or other resident representatives, if any, shall be
notified of any violation of the Act or this Part pursuant to
Section 2-217 of the Act, or of violations of the requirements of Title XVIII
or XIX of the Social Security Act or federal regulations, with respect
to the health, safety, or welfare of the resident. (Section 2-115 of the
Act)
d) The
issuance or renewal of a license after notice of a violation has been sent
shall not constitute a waiver by the Department of its power to rely on the
violation as the basis for subsequent license revocation or other enforcement
action under the Act or this Part arising out of the notice of
violation. (Section 3-111 of the Act)
(Source: Amended at 46 Ill. Reg. 8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.277 ADMINISTRATIVE WARNING
Section 390.277
Administrative Warning
a) If
the Department finds a situation, condition, or practice that violates the Act
or this Part that does not constitute a Type AA, Type A, Type B, or Type
C violation, the Department 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 determines that issuance of an administrative warning is warranted
under this Section.
d) The facility is not required to submit a plan of correction in
response to an administrative warning, except for violations in Sections
3-401 through 3-413 of the Act. (Section 3-303.2(a) of the Act)
e) If the Department finds, during the next on-site inspection
by the Department that occurs no earlier than 90 days from the issuance
of the administrative warning, a written plan of correction must be
submitted in the same manner as provided in Section 3-303(b) of the Act.
The Department will consider the plan of correction and take any necessary
action in accordance with Section 390.278. (Section 3-303.2(b) of the Act)
(Source: Amended at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.278 PLANS OF CORRECTION
Section 390.278 Plans of
Correction
a) The situation, condition or practice constituting a Type "AA"
violation or a Type "A" violation shall be abated or eliminated
immediately unless a fixed period of time, not exceeding 15 days, as determined
by the Department and specified in the notice of violation, is required for
correction. (Section 3-303(a) of the Act)
b) The facility shall have 10 days after receipt of notice
of violation for a Type "B" violation, or after receipt of a
notice under Section 390.277(e) of failure to correct a situation, condition,
or practice that resulted in the issuance of an administrative warning, to
prepare and submit a plan of correction to the Department. (Section
3-303(b) of the Act)
c) Within the 10-day period, a facility may request additional
time for submission of the plan of correction. The Department will extend the
period for submission of the plan of correction for an additional 30 days, when
it finds that corrective action by a facility to abate or eliminate the
violation will require substantial capital improvement. The Department
will consider the extension 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 (d) 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 390.120(c) as to submission of false or misleading
information in a license application. (Section 3-318(a)(1) and (b) of the
Act)
e) Each plan or 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. The facility shall maintain
evidence of the assessment and evaluation. Each plan of correction shall
include:
1) A description of the specific corrective action the facility
is taking, or plans to take, to abate, eliminate, or correct the violation
cited in the notice;
2) A description of the steps that will be taken to avoid future occurrences
of the same and similar violations; and
3) A specific date by which the corrective action will be
completed.
f) Submission of a plan of correction shall not be considered an
admission by the facility that the violation has occurred.
g) The Department will review each plan of correction to ensure
that it provides for the abatement, elimination, or correction of the
violation. The Department will reject a submitted plan only if it finds any of
the following deficiencies:
1) The plan does not appear to address the conditions or
occurrences that are the basis of the violation and an evaluation of the
practices, policies, and procedures that have caused or contributed to the
conditions or occurrences;
2) The plan is not specific enough to indicate the actual actions
the facility will be taking to abate, eliminate, or correct the violation;
3) The plan does not provide for measures that will abate,
eliminate, or correct the violation;
4) The plan does not provide steps that will avoid future
occurrences of the same and similar violations; or
5) The plan does not provide for timely completion of the
corrective action, considering the seriousness of the violation, any possible
harm to the residents, and the extent and complexity of the corrective action.
h) When the Department rejects a submitted plan of correction, it
will notify the facility. The notice of rejection shall be in writing and
shall specify the reason for the rejection. The facility shall have 10 days
after receipt of the notice of rejection in which to submit a
modified plan. (Section 3-303(b) of the Act)
i) If a facility fails to submit a plan or modified plan meeting
the criteria in subsection (e) within the prescribed time periods in subsection
(b) or (c), or anytime the Department issues a Type "AA", a Type "A",
or repeat Type "B" violation, the Department will impose an approved
plan of correction.
j) The Department will verify the completion of the corrective
action required by the plan of correction within the specified time period
during subsequent investigations, surveys and evaluations of the facility.
(Source: Amended at 46 Ill. Reg. 8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.280 REPORTS OF CORRECTION
Section 390.280 Reports of
Correction
a) In lieu of submitting a plan of correction, a facility may
submit a report of correction if the corrective action has been completed. The
report of correction shall be submitted within the time periods required in
Section 390.278 for submission of a plan of correction.
b) Each report of correction shall be based on an assessment by
the facility of the conditions or occurrences 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 report of
correction shall include:
1) A description of the specific corrective action the facility
has taken to abate, eliminate, or correct the violation cited in the notice.
2) A description of the steps taken to avoid future occurrences
of the same and similar violations.
3) The specific date on which the corrective action was
completed.
4) A signed statement by the administrator of the facility that
the report of correction is true and accurate, which shall be considered an
oath for the purposes of any legal proceedings.
c) Submission of a report of correction shall not be considered
an admission by the facility that the violation has occurred.
d) The Department shall review and approve or disapprove the
report of correction based on the criteria outlined in this Section for review
of plans of correction. If a report of correction is disapproved, the facility
shall be subject to a plan of correction imposed by the Department as provided
in Section 390.278.
e) The Department will verify the completion of the corrective
action outlined in the report of correction during subsequent investigations,
surveys, and evaluations of the facility.
(Source: Amended at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.282 CONDITIONS FOR ASSESSMENT OF PENALTIES
Section 390.282 Conditions
for Assessment of Penalties
The Department shall 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 of up to $25,000 per violation. For a facility licensed to
provide care to fewer than 100 residents, but no fewer than 17
residents, the fine shall be up to $18,500 per violation. For a facility
licensed to provide care to fewer than 17 residents, the fine shall be up to
$12,500 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. For a facility licensed to
provide care to fewer than 100 residents, but no fewer than 17
residents, the fine shall be up to $10,000 per violation. For a facility
licensed to provide care to fewer than 17 residents, the fine shall be up to
$6,250 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, that continues
beyond the time specified in Section 3-303(a), that is cited as a repeat
violation shall have its license revoked and shall be assessed a fine of 3
times the fine computed under subsection (a). (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. For a facility licensed to provide care to fewer than 100 residents,
but no fewer than 17 residents, the fine shall be up to $750 per violation. For
a facility licensed to provide care to fewer than 17 residents, the fine shall
be up to $550 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 this Part shall be
automatically issued a conditional license for a period of not less than 6
months. A second or subsequent acceptable plan of correction shall be filed. A
fine shall be assessed in accordance with subsection (d) when cited for
the repeat violation. This fine shall be computed for all days of the
violation, including the duration of the first plan of correction compliance
time. (Section 3-305(4) of the Act)
f) A
licensee who commits 8 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 facility licensed to provide care to fewer than 100
residents, but no fewer than 17 residents, that commits 8 or more Type "C"
violations in a single survey, shall be assessed a fine of up to $200 per
violation. A facility licensed to provide care to fewer than 17 residents, that
commits 8 or more Type "C" violations in a single survey, shall be
assessed a fine of up to $175 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), then 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(8) of the Act)
h) If
any facility willfully makes a misstatement of fact to the Department or
willfully fails to make a required notification to the Department and that
misstatement or failure delays the start of a survey or impedes a survey, then
it will constitute a Type "B" violation. The minimum and maximum
fines that may be assessed pursuant to this subsection (h) shall be 3
times those otherwise specified for any facility. (Section 3-305(9) of the
Act)
i) 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, then the
Department may assess a fine of up to 2 times the maximum fine otherwise
allowed. (Section 3-305(10) 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
390.681
2) Section
390.700
3) Section
390.750(b)
4) Section
390.760
5) Section
390.1010
6) Section
390.1040
7) Section
390.1310
8) Section
390.1316
9) Section
390.2740(f)
10) Section
390.3040(f)
11) Section
390.3240
k) When
the Department finds that a provision of Article II of the Act 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 of the Act 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)
l) In the case of a Type "AA" or Type "A"
violation, a penalty may be assessed from the date on which the violation is
discovered.
m) In the case of a Type "B" violation or an
administrative warning issued pursuant to Sections 3-401 through 3-413 of
the Act or this Part, a penalty shall be assessed on the date of notice of
the violation.
n) In the case of a Type "B" or Type "C"
violation or an administrative warning issued pursuant to Sections 3-401
through 3-413 of the Act or this Part, the facility shall submit
a plan of correction as provided in Section 390.278.
o) If a plan of correction is approved and carried out for a
Type "C" violation, the fine provided under Section 3-305 of the
Act shall be suspended for the time period specified in the approved plan of
correction.
p) If a plan of correction is approved and carried out for a
Type "B" violation or an administrative warning issued pursuant to
Sections 3-401 through 3-413 of the Act or this Part, with respect to a
violation that continues after the date of notice of violation, the fine
provided under Section 3-305 shall be suspended for the time period specified
in the approved plan of correction.
q) If a good faith plan of correction is not received within
the time provided by Section 3-303 of the Act, a penalty may be assessed
from the date of the notice of the Type "B" or "C"
violation or an administrative warning issued pursuant to Sections 3-401
through 3-413 of the Act or this Part, until the date of the receipt
of a good faith plan of correction, or until the date the violation is
corrected, whichever is earlier.
r) If a violation is not corrected within the time specified
by an approved plan of correction or any lawful extension thereof, a penalty
may be assessed from the date of notice of the violation, until the date the
violation is corrected. (Section 3-308 of the Act)
(Source: Amended at 46 Ill. Reg. 8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.284 CALCULATION OF PENALTIES (REPEALED)
Section 390.284 Calculation
of Penalties (Repealed)
(Source: Repealed at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.286 NOTICE OF PENALTY ASSESSMENT: RESPONSE BY FACILITY
Section 390.286 Notice of
Penalty Assessment: Response by Facility
a) If the Director or his or her designee determines that a
penalty is to be assessed, a written notice of penalty assessment shall be sent
to the facility. Each notice of penalty assessment shall include:
1) The amount of the penalty assessed as provided
in Section 390.282.
2) The amount of any reduction or whether the penalty has been
waived pursuant to Section 390.288.
3) A description of the violation, including a reference to the
notices of violation and plans of correction that are the basis of the
assessment.
4) A citation to the provision of the statute or rule alleged
to have been violated.
5) A description of the right of the facility to appeal the
assessment and of the right to a hearing under Section 3-703 of the Act.
(Section 3-307 of the Act)
6) For violations that are continuing at the time of
the notice of assessment, the amount of additional penalties per day
that will be assessed. (Section 3-307 of the Act)
b) A
facility may contest an assessment of a penalty by sending a written request
for hearing to the Department under Section 3-703 of the Act. Upon
receipt of the request, the Department will hold a hearing as provided under
Section 3-703 of the Act. Instead of requesting a hearing pursuant to
Section 3-703 of the Act, a facility may, within 10 business days after
receipt of the notice of violation and fine assessment, transmit to the
Department 65% of the amount assessed for each violation specified in
the penalty assessment. (Section 3-309 of the Act)
c) The facility shall pay the penalties to the Department within
the time periods provided in Section 3-310 of the Act.
d) The
submission of 65% of the amount assessed for each violation specified in the
penalty assessment shall constitute a waiver by the facility of a right to
hearing (see Section 3-703 of the Act).
(Source: Amended at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.287 CONSIDERATION OF FACTORS FOR ASSESSING PENALTIES
Section 390.287 Consideration of Factors for Assessing
Penalties
At any hearing requested by a facility that challenges the
appropriateness of any penalty imposed by the Department, the facility may
present evidence as to any or all of the following factors. The Director will
then consider any evidence presented by the facility, or any evidence otherwise
available to the Department, regarding the following factors in determining
whether a penalty is to be imposed and in determining the amount of the penalty
to be imposed, if any, for a violation.
a) The
gravity of the violation, including the probability that death or serious
physical or mental harm to a resident will result or has resulted, the severity
of the actual or potential harm, and the extent to which the provisions of the
Act or this Part were violated. A penalty will be assessed when the
Director finds that death or serious physical or mental harm to a resident
has occurred or that the facility has knowingly subjected residents to potential
serious harm.
b) The
reasonable diligence exercised by the licensee and efforts to correct
violations. The Director will assess a monetary penalty if he or she finds
that the violation recurred or continued, is widespread throughout the facility,
or evidences flagrant violation of the Act or this Part.
c) Any
previous violations committed by the licensee. The Director will assess a
penalty when he or she finds that the facility has been cited for similar
violations and has failed to correct those violations as promptly as
practicable or has failed to exercise diligence in taking necessary corrective
action. The Director will also consider any evidence that the violations
constitute a pattern of deliberate action by the facility. Any change in the
ownership and management of the facility will be considered in relation to the
seriousness of previous violations.
d) The
financial benefit to the facility of committing or continuing the violation.
These benefits include, but are not limited to, diversion of costs associated
with physical plant repairs, staff salaries, consultant fees, or direct patient
care services. (Section 3-306 of the Act)
(Source: Added at 43 Ill. Reg. 3564,
effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.288 REDUCTION OR WAIVER OF PENALTIES
Section 390.288 Reduction or
Waiver of Penalties
a) The Director may reduce or waive payment for penalties
assessed pursuant to Section 390.287 and Section 3-308 of the Act and will
consider the following factors in determinations to reduce or waive
penalties resulting from any violations subject to penalties pursuant to
the Act or this Part:
1) The violation has not caused actual harm to a resident;
2) The facility has made a diligent effort to correct the
violation and to prevent its recurrence;
3) The facility has no record of a pervasive pattern of the
same or similar violations; and
4) The facility has a record of substantial compliance with the
Act and this Part. (Section 3-308(d) of the Act)
b) When the Director or the Director's designee finds that
correction of a violation required capital improvements or repairs in the
physical plant of the facility and the facility has a history of compliance
with physical plant requirements, the penalty will be reduced by the amount of
the cost of the improvements or repairs. This reduction, however, shall not
reduce the penalty for a Type "A" violation to an amount less than
$1000.
c) Penalties resulting from Type "B" violations, or
administrative warnings issued pursuant to Sections 3-401 through 3-413 of the
Act, may be reduced or waived only under one of the following conditions:
1) The facility submits a true report of correction within 10
days after the notice of violation is received, and the report is
subsequently verified by the Department.
2) The facility submits a plan of correction within 10 days
after the notice of violation is received, the plan is approved by the
Department, and the facility subsequently submits a true report of
correction within 15 days after submission of the plan of correction, and
the report is subsequently verified by the Department.
3) The facility submits a plan of correction within 10 days
after the notice of violation is received, which provides for a period
of correction 30 or fewer days after submission of the plan of
correction, and the Department approves the plan.
4) When the 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 that provides for correction within the initial 90-day
limit, and the Department approves the plan. (Section 3-308 of the Act)
(Source: Amended at 46 Ill. Reg. 8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.290 QUARTERLY LIST OF VIOLATORS (REPEALED)
Section 390.290 Quarterly
List of Violators (Repealed)
(Source: Repealed at 24 Ill. Reg. 17283, effective November 1, 2000)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.300 ALCOHOLISM TREATMENT PROGRAMS IN LONG-TERM CARE FACILITIES
Section 390.300 Alcoholism
Treatment Programs in Long-Term Care Facilities
a) A facility that desires to provide an alcoholism treatment
program shall first receive written approval from the Department. The approval
will be granted only if the facility can demonstrate that the program will not
interfere in any way with the residents in the other distinct parts of the
facility.
b) Any alcoholism treatment program in a facility shall meet the program
standards of 77 Ill. Adm. Code 2060 ( Alcoholism and Substance Abuse Treatment
and Intervention Licenses).
c) The alcoholism treatment program shall be in a separate
distinct part of the facility and shall include all beds in that distinct part.
It shall be separated from the rest of the facility and have separate
entrances.
d) Beds designated for alcoholism treatment shall not be used for
long-term care residents, nor shall beds designated for long-term care
residents be used for residents undergoing treatment for alcoholism.
e) The alcoholism treatment program staff shall not perform
services in the long-term care distinct part of the facility, nor shall
long-term care program staff provide any services in the alcoholism treatment
designated area.
f) Joint use of laundry, food service, housekeeping and
administrative services is permitted, provided written approval is obtained
from the Department. The approval will be granted only if the facility can
demonstrate that joint usage will not interfere in any way with the residents in
other distinct parts of the facility.
(Source: Amended at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.310 DEPARTMENT MAY SURVEY FACILITIES FORMERLY LICENSED
Section 390.310 Department
May Survey Facilities Formerly Licensed
The Department may survey any
former facility that once held a license to ensure that the facility is
not again operating without a license. (Section 3-107 of the Act)
(Source: Amended at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.315 SUPPORTED CONGREGATE LIVING ARRANGEMENT DEMONSTRATION (REPEALED)
Section 390.315 Supported
Congregate Living Arrangement Demonstration (Repealed)
(Source: Repealed at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.320 WAIVERS
Section 390.320 Waivers
a) Upon application by a facility, the Director may grant or
renew the waiver of the facility's compliance with a rule or standard for a
period not to exceed the duration of the current license or, in the case of an application
for license renewal, the duration of the renewal period. (Section 3-303.1
of the Act)
b) The waiver may be conditioned upon the facility taking
action prescribed by the Director as a measure equivalent to compliance.
(Section 3-303.1 of the Act)
c) In determining whether to grant or renew a waiver, the
Director shall consider:
1) The duration and basis for any current waiver with respect
to the same rule or standard and the validity and effect upon patient health
and safety of extending it on the same basis;
2) The effect upon the health and safety of residents;
3) 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);
4) 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
5) 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 the Act and this Section at the time
of the indicated reviews, unless it can show why the waivers should not be
extended for the following reasons:
1) The condition of the physical plant has deteriorated or its
use substantially changed so that the basis upon which the waiver was issued is
materially different; or
2) The facility is renovated or substantially remodeled in
such a way as to permit compliance with the applicable rules and standards
without substantial increase in cost. (Section 3-303.1 of the Act)
(Source: Amended at 43 Ill. Reg. 3564, effective February 26, 2019)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.330 DEFINITIONS
Section 390.330 Definitions
The terms defined in this
Section are terms that are used in licensing standards established by the
Department to license medically complex for the developmentally disabled
facilities. They are defined as follows:
Abuse – any
physical or mental injury or sexual assault inflicted on a resident other than
by accidental means in a facility. (Section 1-103 of the Act)
Abuse means:
Physical abuse
refers to the infliction of injury on a resident that occurs other than by
accidental means and that requires (whether or not actually given) medical
attention.
Mental injury
arises from the following types of conduct:
Verbal abuse
refers to the use by a licensee, employee or agent of oral, written or gestured
language that includes disparaging and derogatory terms to residents or within
their hearing or seeing distance, regardless of their age, ability to
comprehend or disability.
Mental abuse
includes, but is not limited to, humiliation, harassment, threats of punishment
or deprivation, or offensive physical contact by a licensee, employee or agent.
Sexual
harassment or sexual coercion perpetrated by a licensee, employee or agent.
Sexual
assault.
Access –
the right to:
Enter any facility;
Communicate
privately and without restriction with any resident who consents to the
communication;
Seek
consent to communicate privately and without restriction with any resident;
Inspect the
clinical and other records of a resident with the express written consent of the
resident; or
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 MC/DD Act.
Activity
Program – a specific planned program of varied group and individual activities
geared to the individual resident's needs and available for a reasonable number
of hours each day.
Adaptive
Behavior – the effectiveness or degree with which the individual meets the
standards of personal independence and social responsibility expected of the
individual's age and cultural group.
Adaptive
Equipment – a physical or mechanical device, material or equipment attached or
adjacent to the resident's body that may restrict freedom of movement or normal
access to one's body, the purpose of which is to permit or encourage movement,
or to provide opportunities for increased functioning, or to prevent
contractures or deformities. Adaptive equipment is not a physical restraint. No
matter the purpose, adaptive equipment does not include any device, material or
method described in Section 390.1310 as a physical restraint.
Addition – any
construction attached to the original building, that increases the area or
cubic content of the building.
Adequate or
Satisfactory or Sufficient – enough in either quantity or quality, as
determined by a reasonable person familiar with the professional standards of
the subject under review, to meet the needs of the residents of a facility
under the particular set of circumstances in existence at the time of review.
Administrative
Warning – a notice to a facility issued by the Department under Section 390.277
and section 3-303.2 of the Act that indicates that a situation, condition or
practice that violates the Act or the Department's administrative rules,
but does not constitute 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 which that person or
any affiliate of that person is a partner; and each corporation in which that
person or any affiliate of that person is an officer, director or stockholder.
(Section 1-106 of the Act)
Aide or
Orderly – any person providing direct personal care, training or habilitation
services to residents.
Alteration –
any construction change or modification of an existing building which does not
increase the area or cubic content of the building.
Ambulatory
Resident – a person who is physically and mentally capable of walking without
assistance, or is physically able with guidance to do so, including the ascent and
descent of stairs.
Applicant –
any person making application for a license. (Section 1-107 of the Act)
Appropriate –
term used to indicate that a requirement is to be applied according to the
needs of a particular individual or situation.
Approved –
acceptable to the authority having jurisdiction.
Assessment – the
use of an objective system with which to evaluate the physical, social, developmental,
behavioral, and psychosocial aspects of an individual.
Audiologist – a
person who is licensed as an audiologist under the Illinois Speech-Language
Pathology and Audiology Practice Act.
Autism
Spectrum Disorder – a disorder that is characterized by persistent deficits in
social communication and social interaction across multiple contexts, including
deficits in social reciprocity, nonverbal communicative behaviors used for
social interactions, and skills in developing, maintaining, and understanding
relationships. In addition to the social communication deficits, the diagnosis
of autism spectrum disorder requires the presence of restricted, repetitive
patterns of behavior, interests, or activities.
Autoclave – an
apparatus for sterilizing by superheated steam under pressure.
Basement – when
used in this Part, any story or floor level below the main or street floor. Where,
due to grade difference, two levels each qualify as a street floor, a basement
is any floor below the level of the two street floors. Basements shall not be
counted in determining the height of a building in stories.
Behavior
Modification – treatment to be used to establish or change behavior patterns.
Cerebral Palsy
– a disorder dating from birth or early infancy, nonprogressive, characterized
by examples of aberrations of motor function (paralysis, weakness, incoordination)
and often other manifestations of organic brain damage such as sensory
disorders, seizures, developmental disability, learning difficulty and behavior
disorders.
Certification
for Title XVIII and XIX – the issuance of a document by the Department to the U.S.
Department of Health and Human Services or the Department of Healthcare and
Family Services verifying compliance with applicable statutory or regulatory
requirements for the purposes of participation as a provider of care and
service in a specific federal or State health program.
Certified
Nursing Assistant – any person who meets the requirements of 77 Ill. Adm. Code 395
and who provides nursing care or personal care to residents of facilities,
regardless of title, and who is not otherwise licensed, certified or registered
by the Department of Financial and Professional Regulation to render medical
care. Nursing assistants shall function under the supervision of a licensed
nurse.
Charge Nurse –
a registered professional nurse or a licensed practical nurse in charge of the
nursing activities for a specific unit or floor during a shift.
Chemical
Restraint – any drug that is used for discipline or convenience and
is not required to treat medical symptoms or behavior manifestations of
mental illness. (Section 2-106 of the Act) For the purposes of this term and
its use in Section 390.1310, "convenience" means the use of any
restraint by the facility to control resident behavior or maintain a resident
that is not in the resident's best interest, and with less use of the
facility's effort and resources than would otherwise be required by the
facility.
Community
Alternatives – service programs in the community provided as an alternative to
institutionalization.
Continuing
Care Contract – a contract through which a facility agrees to supplement all
forms of financial support for a resident throughout the remainder of the
resident's life.
Contract – a
binding agreement between a resident or the resident's guardian (or, if the
resident is a minor, the resident's parent) and the facility or its agent.
Dentist – any
person licensed by the State of Illinois to practice dentistry, includes persons
holding a Temporary Certificate of Registration, as provided in the Illinois
Dental Practice Act.
Department
– the Department of Public Health. (Section 1-109 of the Act)
Developmental
Disabilities (DD) Aide – any person who provides nursing, personal or
habilitative care to residents of Medically Complex for the Developmentally
Disabled Facilities, regardless of title, and who is not otherwise licensed,
certified or registered to render medical care. Other titles often used to
refer to DD Aides include, but are not limited to, Direct Support Persons, Program
Aides, and Program Technicians. DD Aides shall function under the supervision
of a licensed nurse or a Qualified Intellectual Disabilities Professional (QIDP).
Developmental
Disability – means a severe, chronic disability of a person which:
is
attributable to a mental or physical impairment or combination of mental and
physical impairments, such as intellectual disability, cerebral palsy,
epilepsy, autism spectrum disorder;
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 that are of lifelong or extended
duration and are individually planned and coordinated. (Section 3-801.1 of
the Act)
Dietetic Service
Supervisor − a person who:
is a
dietitian;
is a graduate
of a dietetic and nutrition school or program authorized by the Accreditation
Council for Education in Nutrition and Dietetics, the Academy of Nutrition and
Dietetics, or the American Clinical Board of Nutrition;
is a graduate,
prior to July 1, 1990, of a Department-approved course that provided 90 or more
hours of classroom instruction in food service supervision and has had
experience as a supervisor in a health care institution that included
consultation from a dietitian;
has
successfully completed an Association of Nutrition & Foodservice
Professionals approved Certified Dietary Manager or Certified Food Protection
Professionals 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 licensed as a dietitian or a licensed dietitian nutritionist
under the Dietitian Nutritionist Practice Act.
Direct
Supervision – under the guidance and direction of a supervisor who is
responsible for the work, who plans work and methods, who is available on short
notice to answer questions and deal with problems that are not strictly
routine, who regularly reviews the work performed, and who is accountable for
the results.
Direct Support
Person (DSP) (or Direct Support Professional or Direct Service Provider) – any
person who provides habilitative care, services or support to individuals with
developmental disabilities and is listed on the Department's Health Care Worker
Registry. DSPs shall function under the supervision of a Qualified
Intellectual Disabilities Professional (QIDP) or a Licensed or Registered Professional
Nurse. Other titles often used to refer to Direct Support Persons include, but
are not limited to, Developmental Disabilities (DD) Aide, Mental Health
Technician, Program Aide or Program Technician.
Director – the
Director of Public Health or his or her designee. (Section 1-110 of
the Act)
Director of
Nursing Service – the full-time Registered Professional Nurse who is directly
responsible for the immediate supervision of the nursing services.
Discharge –
the full release of any resident from a facility. (Section 1-111 of the
Act)
Discipline – any
action taken by the facility for the purpose of punishing or penalizing
residents.
Distinct Part –
an entire, physically identifiable unit consisting of all of the beds within
that unit and having facilities meeting the standards applicable to the levels
of service to be provided. Staff and services for a distinct part are
established as set forth in the respective regulations governing the levels of
services approved for the distinct part.
Distressed
facility – a facility determined by the Department to be a distressed facility
pursuant to Section 3-304.2 of the Act. (Section 1-111.05 of the
Act) A facility that has committed violations or that the Department has cited
for deficiencies that resulted in harm to a resident will be designated as a
distressed facility by the Department according to the methodology described in
Section 390.185.
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. (Section 1-112 of the Act)
Epilepsy – a
chronic symptom of cerebral dysfunction, characterized by recurrent attacks,
involving changes in the state of consciousness, sudden in onset, and of brief duration.
Many attacks are accompanied by a seizure in which the person falls involuntarily.
Existing
Facility – any facility initially licensed as a health care facility or
approved for construction by the Department, or any facility initially licensed
or operated by any other agency of the State of Illinois, prior to March 1,
1980. Existing facilities shall meet the design and construction standards for
existing facilities for the level of long-term care for which the license (new
or renewal) is to be granted.
Facility or
MC/DD Facility – a medically complex for the developmentally disabled facility,
whether operated for profit or not, that provides, through its ownership or
management, personal care or nursing for 3 or more persons not related to the
applicant or owner by blood or marriage. 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, the 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
facility licensed under the Nursing Home Care Act;
Any ID/DD
facility under the ID/DD Community Care 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; or
A home,
institution, or other place operated by or under the authority of the Illinois
Department of Veterans' Affairs. (Section 1-113 of the Act)
Financial
Responsibility – having sufficient assets to provide adequate services such as:
staff, heat, laundry, foods, supplies, and utilities for at least a two-month
period of time.
Full-time – on
duty a minimum of 36 hours, four days per week.
Goal – an
expected result or condition that involves a relatively long period of time to achieve,
that is specified in behavioral terms in a statement of relatively broad scope,
and that provides guidance in establishing specific, short-term objectives
directed toward its attainment.
Governing Body
− the policy-making authority, whether an individual or a group, that
exercises general direction over the affairs of a facility and establishes
policies concerning its operation and the welfare of the individuals it serves.
Guardian – a
person appointed as a guardian of the person or guardian of the estate, or
both, of a resident under the Probate Act of 1975. (Section 1-114 of the
Act)
Habilitation
– an effort directed toward increasing a person’s level of physical, mental,
social, or economic functioning. Habilitation may include, but is not limited
to, diagnosis, evaluation, medical services, residential care, day care,
special living arrangements, training, education, employment services,
protective services, and counseling. (Section 1-114.001 of the Act)
Health Information
Management Consultant – a person who is certified as a Registered Health
Information Administrator (RHIA) or a Registered Health Information Technician
(RHIT) by the American Health Information Management Association; or is a
graduate of a school of health information management that is accredited
jointly by the American Medical Association and the American Health Information
Management Association.
Health
Services Supervisor (Director of Nursing Service) – the full-time Registered Professional
Nurse who is directly responsible for the immediate supervision of the health
services in a facility.
High-Risk
Designation – a designation, as described in Section 390.282(j), that
has been identified by the Department to be inherently necessary to
protect the health, safety, and welfare of a resident. (Section 1-114.005
of the Act)
Hospitalization
– the care and treatment of a person in a hospital as an inpatient.
Identified
offender – a person who meets any of the following criteria:
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.
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.
Is any
other resident as determined by the Department of State Police. (Section
1-114.01 of the Act)
Immediate Family
– the spouse, an adult child, a parent, an adult brother or sister, or
an adult grandchild of a person. (Section 1-114.1 of the Act)
Individual
Habilitation Plan or IHP – a total plan of care that is developed by the interdisciplinary
team for each resident, and that is developed on the basis of all assessment
results.
Intellectual
Disability or Intellectually Disabled – a disorder with onset during the
developmental period that includes both intellectual and adaptive functioning
deficits in conceptual, social, and practical domains. The essential features
of intellectual disability are deficits in general intellectual abilities and
impairment in everyday adaptive functioning.
Interdisciplinary
Team – a group of persons that represents those professions, disciplines, or
service areas that are relevant to identifying an individual's strengths and
needs, and designs a program to meet those needs. This team shall include at
least a physician, a nurse with responsibility for the resident, the resident,
the resident's guardian, the resident's primary service providers, including
staff most familiar with the resident, and other appropriate professionals and
caregivers as determined by the resident's needs. The resident or the
resident's guardian may also invite other individuals to meet with the
Interdisciplinary Team and participate in the process of identifying the
resident's strengths and needs.
Licensed
Nursing Home Administrator – see "Administrator".
Licensed
Practical Nurse – a person with a valid Illinois license to practice as a
practical nurse under the Nurse Practice Act.
Licensee – the
individual or entity licensed by the Department to operate the facility. (Section
1-115 of the Act)
Life Care
Contract – a contract through which a facility agrees to provide maintenance
and care for a resident throughout the remainder of the resident's life.
Maintenance
– food, shelter, and laundry services. (Section 1-116 of the Act)
Maladaptive
Behavior – impairment in adaptive behavior as determined by a clinical
psychologist or by a physician. Impaired adaptive behavior may be reflected in
delayed maturation, reduced learning ability or inadequate social adjustment.
Medically
complex – a term used when a child has a medical condition, or multiple medical
conditions, that require ongoing specialized care. The medical condition may
vary from rare illnesses, to premature birth, or incidents involving physical
trauma.
Misappropriation
of a Resident's Property – the deliberate misplacement, exploitation, or
wrongful temporary or permanent use of a resident's belongings or money without
the resident's consent or the consent of a resident's guardian or
representative. Misappropriation of a Resident's Property includes failure to
return valuables after a resident's discharge or failure to refund money after
death or discharge when there is an unused balance in the resident's personal
account. (Section 1-116.5 of the Act)
Monitor – a
qualified person placed in a facility by the Department to observe operations
of the facility, assist the facility by advising it on how to comply with the
State regulations, and report periodically to the Department on the operations
of the facility.
Neglect – a
failure in a facility to provide adequate medical or personal care or maintenance,
which failure results in physical or mental injury to a resident or in the
deterioration of a resident's physical or mental condition. (Section 1-117
of the Act) This shall include any allegation in which:
the alleged
failure causing injury or deterioration is ongoing or repetitious;
a resident
required medical treatment as a result of the alleged failure; or
the failure is
alleged to have caused a noticeable negative impact on a resident's health,
behavior or activities for more than 24 hours.
New Facility –
any facility initially licensed as a health care facility by the Department, or
any facility initially licensed or operated by any other agency of the State of
Illinois, on or after March 1, 1980. New facilities shall meet the design and
construction standards for new facilities for the level of long-term care for
which the license (new or renewal) is to be granted.
Nurse – an
advanced practice registered nurse, a registered professional nurse,
or a licensed practical nurse as defined in the Nurse Practice
Act. (Section 1-118 of the Act)
Nursing Care –
a complex of activities that carries out the diagnostic, therapeutic, and
rehabilitative plan as prescribed by the physician; care for the resident's
environment; observing symptoms and reactions and taking necessary measures to
carry out nursing procedures involving understanding of cause and effect to
safeguard life and health.
Nursing Unit –
a physically identifiable designated area of a facility consisting of all the
beds within the designated area, but having no more than 75 beds, none of which
are more than 120 feet from the nurse's station.
Objective – an
expected result or condition that involves a relatively short period of time to
achieve, that is specified in behavioral terms, and that is related to the achievement
of a goal.
Occupational
Therapist, Registered or OTR – a person who is registered as an occupational
therapist under the Illinois Occupational Therapy Practice Act.
Occupational
Therapy Assistant – a person who is registered as a certified occupational
therapy assistant under the Illinois Occupational Therapy Practice Act.
Operator – the
person responsible for the control, maintenance and governance of the facility,
its personnel and physical plant.
Oversight – general
watchfulness and appropriate reaction to meet the total needs of the residents,
exclusive of nursing or personal care. Oversight shall include, but is not
limited to, social, recreational and employment opportunities for residents
who, by reason of mental disability, or in the opinion of a licensed physician,
are in need of residential care.
Owner – the
individual, partnership, corporation, association or other person who owns a facility.
In the event a facility is operated by a person who leases the physical plant,
which is owned by another person, "owner" means the person who
operates the facility, except that, if the person who owns the physical plant
is an affiliate of the person who operates the facility and has significant
control over the day-to-day operations of the facility, the person who owns the
physical plant shall incur jointly and severally with the owner all liabilities
imposed on an owner under the Act and this Part. (Section
1-119 of the Act)
Person – with
regard to the term "owner", "person" means any individual,
partnership, corporation, association, municipality, political subdivision,
trust, estate or other legal entity.
Personal
Care – assistance with meals, dressing, movement, bathing or other personal
needs or maintenance, or general supervision and oversight of the
physical and mental well-being of an individual who is incapable
of maintaining a private, independent residence or who is incapable of
managing his or her person, whether or not a guardian has been appointed for
that individual. (Section 1-120 of the Act)
Pharmacist, Licensed
– a person who holds a license as a pharmacist under the Pharmacy Practice Act.
Physical
Restraint – any manual method or physical or mechanical device, material, or
equipment attached or adjacent to a resident's body that the resident cannot
remove easily and that restricts freedom of movement or normal access to
one's body. (Section 2-106 of the Act)
Physical
Therapist – a person who is licensed as a physical therapist under the Illinois
Physical Therapy Act.
Physical
Therapist Assistant – a person who has graduated from a two-year college level
program approved by the American Physical Therapy Association.
Physician – any
person licensed by the State of Illinois to practice medicine in all its branches
as provided in the Medical Practice Act of 1987.
Probationary
License – an initial license issued for a period of 120 days during which time
the Department will determine the qualifications of the applicant.
Provisional
admission period – the time between the admission of an identified offender as
defined in Section 1-114.01 of the Act and 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)
Psychiatrist –
a physician who has successfully completed a residency program in psychiatry
accredited by either the Accreditation Council for Graduate Medical Education
or the American Osteopathic Association.
Psychologist –
a person who is licensed to practice clinical psychology under the Clinical
Psychologist Licensing Act.
Qualified Intellectual
Disabilities Professional (QIDP) – a person who has at least one year of
experience working directly with individuals with developmental disabilities
and meets at least one of the following additional qualifications:
Be a physician
as defined in this Section.
Be a
registered professional nurse as defined in this Section.
Hold at least
a bachelor's degree in one of the following fields: occupational therapy,
physical therapy, psychology, social work, speech or language pathology,
recreation (or a recreational specialty area such as art, dance, music, or
physical education), dietary services or dietetics, or a human services field
(such as sociology, special education, or rehabilitation counseling).
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
Visiting Hour – any time between the hours of 10 a.m. and 8 p.m.
daily. (Section 1-121 of the Act)
Registered Professional
Nurse – a person with a valid Illinois license to practice as a registered
professional nurse under the Nurse Practice Act.
Repeat
Violation – for purposes of assessing fines under Section 3-305 of the Act
and this Part, a violation that has been cited during one inspection
of the facility for which a subsequent inspection indicates that an
accepted plan of correction was not complied with, within a period of not
more than 12 months from the issuance of the initial violation, or a new
citation of the same rule if the licensee is not substantially addressing the
issue routinely throughout the facility. (Section 3-305(7) of the Act)
Reputable
Moral Character –
having no history of a conviction:
of the applicant; or
if the applicant
is :
a firm,
partnership, or association, of any of its members; or
a corporation,
of any of its officers or directors, or of the person designated to manage or
supervise the facility;
of a felony, or of two or more misdemeanors involving moral turpitude, as
shown by a certified copy of the record of the court of conviction or, in the
case of the conviction of a misdemeanor by a court not of record, as shown by
other evidence; or
no other satisfactory
evidence indicates that the moral character of the applicant, manager, or supervisor
of the facility is not reputable.
Resident – a
person receiving personal or medical care, including, but not limited to,
habilitation, psychiatric services, therapeutic services, 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 MC/DD facility.
Resident's
Representative – a person, other than the owner or an agent or employee of a facility,
not related to the resident, designated in writing by a resident to be his or
her representative; or the resident's guardian, or the parent of a minor
resident for whom no guardian has been appointed. (Section 1-123 of the
Act)
Restorative – services
or measures designed to assist residents to attain and maintain the highest
degree of function of which they are capable (physical, mental, and social).
Room – a part
of the inside of a facility that is partitioned continuously from floor to
ceiling with openings closed with glass or hinged doors.
Sanitization –
the reduction of pathogenic organisms on a utensil surface to a safe level,
which is accomplished through the use of steam, hot water, or chemicals.
Seclusion or
confinement – the retention of a resident alone in a room with a door that the
resident cannot open.
Self-Preservation
– the ability to follow directions and recognize impending danger or emergency
situations and react by avoiding or leaving the unsafe area.
Social Worker –
a person who is a licensed social worker or a licensed clinical social worker
under the Clinical Social Work and Social Work Practice Act.
State Fire
Marshal –the Illinois State Fire Marshal, who serves as the executive
director of the Office of the State Fire Marshal. (Section 1 of the State
Fire Marshal Act).
Sterilization –
the act or process of destroying completely all forms of microbial life,
including viruses.
Stockholder
of a Corporation – any person who, directly or indirectly,
beneficially owns, holds or has the power to vote, at least 5% of any class of
securities issued by the corporation. (Section 1-125 of the Act)
Story – when
used in this Part, means that portion of a building between the upper surface
of any floor and the upper surface of the floor above, except that the topmost story
shall be the portion of a building between the upper surface of the topmost floor
and the upper surface of the roof above.
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; or
immediately
succeeds a full quarter, semester or trimester of academic enrollment in either
a high school or undergraduate institution, provided that such person is
registered for another full quarter, semester or trimester of academic
enrollment in either a high school or undergraduate institution, which quarter,
semester or trimester will commence immediately following the term of
employment. (Section 1-125.1 of the Act)
Substantial
Compliance – meeting requirements, except for variance from the strict and
literal performance that results in unimportant omissions or defects given the
particular circumstances involved. This definition is limited to the term as
used in Sections 390.140(a)(3) and 390.150(a)(3).
Substantial
Failure – the failure to meet requirements other than a variance from the
strict and literal performance that results in unimportant omissions or defects
given the particular circumstances involved. This definition is limited to the
term as used in Section 390.165(b)(1).
Supervision –
authoritative guidance by a qualified person for the accomplishment of a
function or activity within the qualified person's sphere of competence.
Therapeutic
Recreation Specialist – a person who is certified by the National Council for
Therapeutic Recreation Certification and who meets the minimum standards it has
established for classification as a Therapeutic Recreation Specialist.
Time Out – removing
an individual from a situation that results in undesirable behavior. It is a
behavior modification procedure that is developed and implemented under the
supervision of a qualified professional.
Title XVIII
– Title XVIII of the federal Social Security Act. (Section 1-126 of the
Act)
Title XIX –
Title XIX of the federal Social Security Act. (Section 1-127 of the Act)
Transfer – a
change in status of a resident's living arrangements from one facility to another
facility. (Section 1-128 of the Act)
Type "AA"
violation – a violation of the Act or this Part 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 or is specifically designated as a Type "B" violation
in the Act or this Part. (Section 1-130 of the Act)
Type "C"
violation – a violation of the Act or this Part that creates a
condition or occurrence relating to the operation and maintenance of a facility
that creates a substantial probability that less than minimal physical or mental
harm to a resident will result therefrom. (Section 1-132 of the Act)
Unit – an
entire physically identifiable residence area having facilities meeting the
standards applicable to the levels of service to be provided. Staff and
services for each distinct resident area are established as set forth in the
respective rules governing the approved levels of service.
Universal
Progress Notes – a common record with periodic narrative documentation by all persons
involved in resident care.
Valid License –
a license that is unsuspended, unrevoked and unexpired.
(Source: Amended at 46 Ill.
Reg. 8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.340 INCORPORATED AND REFERENCED MATERIALS
Section 390.340 Incorporated
and Referenced Materials
a) The following regulations, guidelines, and standards are
incorporated in this Part:
1) ANSI/ASME Standard No. A17.1-2007, Safety Code for Elevators
and Escalators, which may be obtained from the American Society of Mechanical
Engineers (ASME) International, 22 Law Drive, Box 2900, Fairfield, NJ 07007-2900.
2) ANSI/ASHRAE/ASHE Standard 170-2008, Ventilation of Health Care
Facilities, which may be accessed at:
http://sspc170.ashraepcs.org/pdf/170_2008_FINAL.pdf
3) American Society of Heating, Refrigerating, and Air
Conditioning Engineers (ASHRAE), Handbook of Fundamentals (2009), and Handbook
of Applications (2007), which may be obtained from the American Society of
Heating, Refrigerating, and Air Conditioning Engineers, Inc., 1791 Tullie
Circle, N.E., Atlanta, GA 30329.
4) American Society for Testing and Materials (ASTM),
International Standard No. E90-02 (2009): Standard Test Method for Laboratory
Measurement of Airborne Sound Transmission Loss of Building Partitions and
Elements, and Standard No. E84-16, Standard Test Method for Surface Burning
Characteristics of Building Materials (2006), Standard E 413 (2010) Classification
for Rating Sound Insulation, which may be obtained from ASTM International, 100
Barr Harbor Drive, P.O. Box C700, West Conshohocken, PA 19428-2959.
5) International Building Code (IBC) (2012), which may be
obtained from Building Officials and Code Administrators (BOCA) International,
4051 W. Flossmoor Road, Country Club Hills, IL 60478-5795.
6) For existing facilities (see Subpart N), National Fire
Protection Association (NFPA) 101 (2012): Life Safety Code, Chapter 19
(Existing Health Care Occupancies), and all appropriate references under
Chapter 2.12 (New Assembly Occupancies), which may be obtained from the
National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169.
7) For new facilities (see Subpart M), NFPA 101 (2012): Life
Safety Code, Chapter 18 (New Health Care Occupancies), including all
appropriate references under Chapter 2 (Definitions) and Chapter 18, and
excluding Chapter 5 (Performance Based Options), and all other references to
performance based options. NFPA 101A: Alternative Approaches to Life Safety
shall not apply to new construction. In addition to the publications
referenced in Chapter 2, the following standards, which may be obtained from
the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169,
shall be applicable for all long-term facilities:
A) NFPA
20 (2010), Standard for the Installation of Stationary Pumps for Fire
Protection
B) NFPA
22 (2008), Standard for Water Tanks for Private Fire Protection
C) NFPA
24 (2010), Standard for the Installation of Private Fire Service Mains and
Their Appurtenances
D) NFPA
50 (2001), Standard for Bulk Oxygen Systems at Consumer Sites
8) The following standards, which may be obtained from
Underwriters Laboratories (UL), Inc., 333 Pfingsten Rd., Northbrook, IL 60062:
A) Fire Resistance Directory (2015 Edition)
B) Building Material Directory (2015 Edition)
9) The following guidelines and toolkits of Centers for Disease
Control and Prevention, United States Public Health Service, Department of
Health and Human Services, and Agency for Healthcare Research and Quality:
A) Guideline for Prevention of Catheter-Associated Urinary Tract Infections
(2009), available at: https://www.cdc.gov/infection-control/media/pdfs/Guideline-CAUTI-H.pdf
(June 6, 2019)
B) Guideline for Hand Hygiene in Health-Care Settings (October 25,
2002), available at: https://www.cdc.gov/infection-control/media/pdfs/Guideline-Hand-Hygiene-P.pdf
C) Guidelines for the Prevention of Intravascular Catheter-Related
Infections, 2011 (October 2017), available at: https://www.cdc.gov/infection-control/media/pdfs/Guideline-BSI-H.pdf
D) Guideline for Prevention of Surgical Site Infection, 2017 (August
2017), available at: https://jamanetwork.com/journals/jamasurgery/fullarticle/2623725
E) Guideline for Preventing Healthcare-Associated Pneumonia, 2003
(April 12, 2004), available at: https://www.cdc.gov/infection-control/media/pdfs/Guideline-Healthcare-Associated-Pneumonia-H.pdf
F) 2007 Guideline for Isolation Precautions: Preventing
Transmission of Infectious Agents in Healthcare Settings (September 2024),
available at: http://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf
G) Infection Control in Healthcare
Personnel: Infrastructure and Routine Practices for Occupational Infection
Prevention and Control Services (October 25, 2019), available at: https://www.cdc.gov/infection-control/media/pdfs/Guideline-Infection-Control-HCP-H.pdf
H) Infection Control in Healthcare
Personnel: Epidemiology and Control of Selected Infections Transmitted Among
Healthcare Personnel and Patients (October 22, 2024), available at: https://www.cdc.gov/infection-control/media/pdfs/Guideline-IC-HCP-H.pdf
I) The
Core Elements of Antibiotic Stewardship for Nursing Homes, (March 18, 2024) available
at: https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html
J) The
Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A: Policy
and Practice Actions to Improve Antibiotic Use (March 18, 2024), available at: https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdf
K) Nursing
Home Antimicrobial Stewardship Guide (March 2023), available at: https://www.ahrq.gov/nhguide/index.html
L) Toolkit 3. Minimum Criteria for Common Infections Toolkit
(September 2017), available at: https://www.ahrq.gov/nhguide/toolkits/determine-whether-to-treat/toolkit3-minimum-criteria.html
M) TB Infection Control in Health Care Settings (December 15, 2023)
available at: https://www.cdc.gov/tb-healthcare-settings/hcp/infection-control/?CDC_AAref_Val=https://www.cdc.gov/tb/topic/infectioncontrol/TBhealthCareSettings.htm
N) Interim Infection Prevention and Control Recommendations to
Prevent SARS-CoV-2 Spread in Nursing Homes (February 2, 2022) available at: https://stacks.cdc.gov/view/cdc/114001
O) Implementation of Personal Protective Equipment (PPE) in
Nursing Homes to Prevent Spread of Novel or Targeted Multidrug-resistant
Organisms (MDROs) (April 2, 2024) available at: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html
P) Hospital Respiratory Protection Program Toolkit: Resources for
Respirator Program Administrators (April 2022) available at: https://www.cdc.gov/niosh/docs/2015-117/default.html
Q) Respiratory Protection Guidance for the Employers of Those
Working in Nursing Homes, Assisted Living, and Other Long-Term Care Facilities
During the COVID-19 Pandemic (October 30, 2020) available at: https://www.osha.gov/sites/default/files/respiratory-protection-covid19-long-term-care.pdf
R) Guidelines for Environmental Infection Control in Health-Care
Facilities (July 2019) available at: https://www.cdc.gov/infection-control/media/pdfs/Guideline-Environmental-H.pdf
10) American College of Obstetricians and Gynecologists,
Guidelines for Women's Health Care, Fourth Edition (2014), which may be
obtained from the American College of Obstetricians and Gynecologists
Distribution Center, P.O. Box 933104, Atlanta, GA 31193-3104 (800-762-2264).
(See Section 390.3220.)
11) The
Prescribers Digital Reference (PDR) database, which may be accessed at: www.pdr.net
12) The
Lexicomp-online database, which may be accessed at: www.wolterskluwercdi.com/lexicomp-online/
13) The
American Society of Health-System Pharmacists (ASHP) database, which may be
accessed at: www.ashp.org/
b) All incorporations by reference of federal regulations and the
standards of nationally recognized organizations refer to the regulations and
standards on the date specified and do not include any amendments or editions
subsequent to the date specified.
c) The following federal and State statutes and regulations are
referenced in this Part:
1) Federal statutes and regulations:
A) Civil Rights Act of 1964 (42 U.S.C. 2000e)
B) Social Security Act (42 U.S.C. 301, 1935 et seq. and 1936 et
seq.)
C) Controlled Substances Act (21 U.S.C. 802)
D) 42 CFR 483, Requirements for States and Long-Term Care
Facilities (October 1, 2024)
E) 42 CFR 483.80, Infection Control (October 1, 2024)
2) State of Illinois statutes:
A) Substance Use Disorder Act [20 ILCS 301]
B) Boiler and Pressure Vessel Safety Act [430 ILCS 75]
C) Child Care Act of 1969 [225 ILCS 10]
D) Code of Civil Procedure [735 ILCS 5]
E) Court of Claims Act [705 ILCS 505]
F) Illinois Dental Practice Act [225 ILCS 25]
G) Election Code [10 ILCS 5]
H) Freedom of Information Act [5 ILCS 140]
I) General Not For Profit Corporation Act of 1986 [805 ILCS 105]
J) Hospital Licensing Act [210 ILCS 85]
K) Illinois Controlled Substances Act [720 ILCS 570]
L) Illinois Health Facilities Planning Act [20 ILCS 3960]
M) Illinois Municipal Code [65 ILCS 5]
N) Life Care Facilities Act [210 ILCS 40]
O) Local Governmental and Governmental Employees Tort Immunity Act
[745 ILCS 10]
P) Medical Practice Act of 1987 [225 ILCS 60]
Q) Mental Health and Developmental Disabilities Code [405 ILCS 5]
R) Nurse Practice Act [225 ILCS 65]
S) Nursing Home Administrators Licensing and Disciplinary Act
[225 ILCS 70]
T) Nursing Home Care Act [210 ILCS 45]
U) Illinois Occupational Therapy Practice Act [225 ILCS 75]
V) Pharmacy Practice Act [225 ILCS 85]
W) Illinois Physical Therapy Act [225 ILCS 90]
X) Private Sewage Disposal Licensing Act [225 ILCS 225]
Y) Probate Act of 1975 [755 ILCS 5]
Z) Illinois Public Aid Code [305 ILCS 5]
AA) Safety Glazing Materials Act [430 ILCS 60]
BB) School Code [105 ILCS 5]
CC) Illinois Administrative Procedure Act [5 ILCS 100]
DD) Clinical Psychologist Licensing Act [225 ILCS 15]
EE) Dietitian Nutritionist Practice Act [225 ILCS 30]
FF) Health Care Worker Background Check Act [225 ILCS 46]
GG) Clinical Social Work and Social Work Practice Act [225 ILCS 20]
HH) Illinois Living Will Act [755 ILCS 35]
II) Illinois Power of Attorney Act [755 ILCS 45/Art. IV]
JJ) Health Care Surrogate Act [755 ILCS 40]
KK) Health Care Right of Conscience Act [745 ILCS 70]
LL) Abused and Neglected Long-Term Care Facility Residents Reporting
Act [210 ILCS 30]
MM) Supportive Residences Licensing Act [210 ILCS 65]
NN) MC/DD Act [210 ILCS 46]
OO) Community Living Facilities Licensing Act [210 ILCS 35]
PP) Community-Integrated Living Arrangements Licensure and
Certification Act [210 ILCS 135]
QQ) Counties Code [55 ILCS 5]
RR) Podiatric
Medical Practice Act of 1987 [225 ILCS 100]
SS) Illinois
Optometric Practice Act of 1987 [225 ILCS 80]
TT) Physician
Assistant Practice Act of 1987 [225 ILCS 95]
UU) Alternative
Health Care Delivery Act [210 ILCS 3]
VV) Illinois Uniform Conviction Information Act [20 ILCS 2635]
WW) Wrongs to Children Act [720 ILCS 150]
XX) Assisted Living and Shared Housing Act [210 ILCS 9]
YY) Language Assistance Services Act [210 ILCS 87]
ZZ) State
Fire Marshal Act [20 ILCS 2905]
AAA) Illinois
Speech-Language Pathology and Audiology Practice Act [225 ILCS 110]
BBB) Home
Health, Home Services, and Home Nursing Agency Licensing Act [210 ILCS 55]
CCC) Sex
Offender Registration Act [730 ILCS 150]
DDD) ID/DD
Community Care Act [210 ILCS 47]
EEE) Cannabis
Control Act [720 ILCS 550]
FFF) Methamphetamine
Control and Community Protection Act [720 ILCS 646]
GGG) Authorized
Electronic Monitoring in Long-Term Care Facilities Act [210 ILCS 32]
HHH) Illinois
Emergency Management Agency Act [20 ILCS 3305]
III) Latex
Glove Ban Act [410 ILCS 180]
3) State of Illinois rules:
A) Office of the State Fire Marshal, Boiler and Pressure Vessel
Safety (41 Ill. Adm. Code 2120)
B) Capital Development Board, Illinois Accessibility Code (71 Ill.
Adm. Code 400)
C) Department of Public Health
i) Control of Notifiable Diseases and Conditions Code (77 Ill.
Adm. Code 690)
ii) Control of Sexually Transmissible Infections Code (77 Ill.
Adm. Code 693)
iii) Food Code (77 Ill. Adm. Code 750)
iv) Illinois Plumbing Code (77 Ill. Adm. Code 890)
v) Private Sewage Disposal Code (77 Ill. Adm. Code 905)
vi) Drinking Water Systems Code (77 Ill. Adm. Code 900)
vii) Water Well Construction Code (77 Ill. Adm. Code 920)
viii) Illinois Water Well Pump Installation Code (77 Ill. Adm. Code
925)
ix) Access to Records of the Department of Public Health (2 Ill.
Adm. Code 1127)
x) Practice and Procedure in Administrative Hearings (77 Ill.
Adm. Code 100)
xi) Skilled Nursing and Intermediate Care Facilities Code (77 Ill.
Adm. Code 300)
xii) Sheltered Care Facilities Code (77 Ill. Adm. Code 330)
xiii) Intermediate Care for the Developmentally Disabled Facilities
Code (77 Ill. Adm. Code 350)
xiv) Long-Term Care Assistants and Aides Training Programs Code (77
Ill. Adm. Code 395)
xv) Control of Tuberculosis Code (77 Ill. Adm. Code 696)
xvi) Health Care Worker Background Check Code (77 Ill. Adm. Code
955)
xvii) Language Assistance Services Code (77 Ill. Adm. Code 940)
xviii) Health Facilities and Services Review Operational Rules (77
Ill. Adm. Code 1130)
D) Department of Financial and Professional Regulation:
i) Illinois Controlled Substances Act (77 Ill. Adm. Code 3100)
ii) Pharmacy Practice Act (68 Ill. Adm. Code 1330)
E) Department of Human Services, Alcoholism and Substance Abuse
Treatment and Intervention Licenses (77 Ill. Adm. Code 2060)
F) Department of Natural Resources, Regulation of Construction
within Flood Plains (17 Ill. Adm. Code 3706)
G) Department of Healthcare and Family Services, Medical Payment
(89 Ill. Adm. Code 140)
(Source: Amended at 49 Ill. Reg. 7071,
effective April 30, 2025)
SUBPART B: ADMINISTRATION
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.500 ADMINISTRATOR
Section 390.500 Administrator
a) There shall be an full-time administrator licensed under the
Nursing Home Administrators Licensing and Disciplinary Act (Ill. Rev. Stat.
1987, ch. 111, par. 1651 et seq.) for each licensed facility. The administrator
shall be a high school graduate or equivalent and at least 18 years of age. The
licensee will report any change in administrator to the Department, within five
days. (B)
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 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
purposes of Section 3-212 of the Act, which requires Department staff to
provide the licensee with a copy of their report before leaving the facility. (B)
c) The licensee and administrator shall be familiar with this
Part. They shall be responsible for seeing that the applicable regulations are
met in the facility and that employees are familiar with those regulations
according to the level of their responsibilities. (A, B)
d) The administrator shall arrange for facility supervisory
personnel to annually attend appropriate educational programs on supervision,
nutrition, and other pertinent subjects.
e) The administrator shall appoint in writing a member of the
facility staff to coordinate the establishment of, and render assistance to,
the residents' advisory council.
f) If the facility has an assistant administrator, the Department
shall be informed of the name and dates of employment and termination of this
person. This will provide documentation of service to qualify for a license
under the Nursing Home Administrators Licensing and Disciplinary Act (Ill. Rev.
Stat. 1987, ch. 111, par. 3651 et seq.)
(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)
SUBPART C: POLICIES
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.610 MANAGEMENT POLICIES
Section 390.610 Management
Policies
a) The facility's governing body shall exercise general direction
of the facility and shall establish the broad policies for the facility related
to its purpose, objectives, operation, and the welfare of the residents
served.
b) There shall be established a table of organization showing
the major operating programs of the facility, with staff divisions, the
administrative personnel in charge of programs and divisions, and their lines
of authority, responsibilities and communication.
(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.620 RESIDENT CARE POLICIES
Section 390.620 Resident Care
Policies
a) The facility shall have written policies and procedures
governing all services provided by the facility which shall be formulated with
the involvement of the administrator. These written policies shall be formulated
with the involvement of the medical advisory committee and representatives of
nursing and other services in the facility. The policies shall be available to
the staff, residents and the public. These written policies shall be followed
in operating the facility and shall be reviewed at least annually. (B)
b) These policies shall include:
1) A written statement of the philosophy, objectives and goals
the facility is striving to achieve.
2) A written statement linking the facility's role to the
"State Plan for the Developmentally Disabled" as filed with the Secretary
of State by the Governor's Planning Council for Developmental Disabilities.
3) A written statement of the facility's goals for its residents.
4) A written statement of the facility's concept of its
relationship to the parents of its residents or to the surrogates.
5) A written statement concerning admission, transfer, and
discharge of residents including categories of residents accepted and not
accepted, residents that will be transferred or discharged, and transfers
within the facility from one room to another.
6) A written statement for resident care services including
administrative services, physician services, emergency services, personal care
and nursing services, dental services, (re)habilitative services, physical
therapy, occupational therapy, psychology, social services, speech pathology
and audiology, organized recreational activity services, work activity and
prevocational, dietary services, resident medical records, pharmaceutical
services, diagnostic services (including laboratory and x-ray) and educational
services. (B)
c) The facility shall have a written agreement with one or more
hospitals which indicates that the hospital or hospitals will provide the
following services:
1) Emergency admissions.
2) Admission to a hospital of residents from the facility who are
in need of hospital care.
3) Needed diagnostic services.
4) Any other hospital based services needed by the resident.
d) There shall be a policy prohibiting blood transfusions, unless
the facility is hospital connected and appropriate services are available in
case of an adverse reaction to the transfusions. (B)
(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.625 DETERMINATION OF NEED SCREENING AND REQUEST FOR CRIMINAL HISTORY RECORD INFORMATION
Section
390.625 Determination of Need Screening and Request for Criminal History
Record Information
a) All persons age 18 or older seeking
admission to a facility must be screened to determine the need for facility
services prior to being admitted, regardless of income, assets, or funding
source. (Section 2-201.5(a) of the Act) A screening assessment is not
required provided one of the conditions in 89 Ill. Adm. Code 140.642(c) is met.
b) Any person who seeks to become eligible
for medical assistance from the Medical Assistance Program under the Illinois
Public Aid Code to pay for services while residing in a facility shall
be screened prior to receiving those benefits in accordance with 89 Ill.
Adm. Code 140.642. (Section 2-201.5(a) of the Act)
c) Screening for facility services shall be
administered through procedures established pursuant to 89 Ill. Adm. Code
140.642 (Section 2-201.5(a) of the Act)
1) Any screening shall also include an
evaluation of whether there are residential supports and services or an array
of community services that would enable the person to live in the community.
2) The person shall be told about the
existence of any such services that would enable the person to live safely and
humanely in the least restrictive environment, that is appropriate, that the
individual or guardian chooses, and the person shall be given the assistance
necessary to avail himself or herself of any available services. (Section
2-201.5(a-1) of the Act)
d) In addition to the screening required by
Section 2-201.5(a) of the Act and this Section, a facility shall, within 24
hours after admission of a resident, request a criminal history
background check pursuant to the Uniform Conviction Information Act for all
persons age 18 or older seeking admission to the facility. Background checks
conducted pursuant to the Act and this Section 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)
e) The facility shall check for the
individual's name on the Illinois State Police Sex Offender Registry website at
https://isp.illinois.gov/Sor, the Illinois Department of Corrections Parolee
Sex Offender Registrant website at https://www2.illinois.gov/idoc/Offender/Pages/ParoleeSexRegistrantSearch.aspx,
and the National Sex Offender Public Website at www.nsopw.gov/en/Search/Results
to determine if the individual is listed as a registered sex offender.
f) If the results of the background check
are inconclusive, the facility shall initiate a fingerprint-based check, unless
the fingerprint-based 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)
g) The facility shall arrange for a
fingerprint-based background check or request a waiver from the Department
within five days after receiving inconclusive results of a name-based
background check. The fingerprint-based background check shall be conducted
within 25 days after receiving the inconclusive results of the name-based
check.
h) A waiver, issued pursuant to Section
2-201.5(b) of the Act and criteria included in subsection (f), shall
be valid only while the resident is immobile or while the criteria supporting
the waiver exist. (Section 2-201.5(b) of the Act)
i) The facility shall provide for or
arrange for any required fingerprint-based checks. 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 wavier issued pursuant to
Section 2-201.5(b) of the Act.
j) The facility shall be responsible for
taking all steps necessary to ensure the safety of residents while the results
of a name-based background check or a fingerprint-based background check are
pending; while the results of a request for waiver of a fingerprint-based check
are pending; and while the Identified Offender Report and Recommendation is pending.
(Source: Former Section repealed at 31
Ill. Reg. 6145, effective April 3, 2007 and new Section adopted at 46 Ill. Reg.
8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.626 CRIMINAL HISTORY BACKGROUND CHECKS FOR PERSONS WHO WERE RESIDENTS ON JANUARY 1, 2022
Section
390.626 Criminal History Background Checks for Persons Who Were Residents on January
1, 2022
a) The
facility shall, within 30 days after the adoption of these amendments, compare
its residents against the Illinois Department of Corrections and Illinois State
Police registered sex offender databases. (Section 3-202.3(3) of the Act)
b) The
facility shall notify the Department, via the Department’s Identified
Offenders Program web-based portal at:
https://idph.illinois.gov/IOPFacilitySubmission, within 48 hours after
determining that a resident or residents of the licensed facility are listed on
the Illinois Department of Corrections or Illinois State Police registered sex
offender databases. (Section 3-202.3(4) of the Act) For a resident or
residents who are found to be on the Illinois Department of Corrections or
Illinois State Police sex offender databases, the facility shall initiate a
criminal history background check in compliance with Section 2-201.5(b) of the
Act and Section 390.625(d).
c) The
facility also shall comply with Section 390.625, subsections (f) through (j).
(Source: Added at 46 Ill. Reg. 8192,
effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.630 ADMISSION, RETENTION AND DISCHARGE POLICIES
Section 390.630 Admission,
Retention and Discharge Policies
a) The facility shall comply with Section 390.625 subsections (d)
through (j) for all new residents. The facility shall review the results of
the criminal history background checks immediately upon receipt of these
checks.
b) All involuntary discharges and transfers shall be in
accordance with Sections 3-401 through 3-423 of the Act.
c) A facility shall admit only residents who have had a
comprehensive evaluation of their medical history and physical and
psycho/social factors conducted by an appropriately constituted
interdisciplinary team. No resident determined by professional evaluation to
be in need of services not readily available in a particular facility shall be
admitted to or kept in that facility. Additionally, emotional and cognitive
histories shall be evaluated when applicable and available.
d) A facility shall be used exclusively for medically complex and
developmentally disabled persons ("medically complex" and "developmental
disability" are defined in Section 390.330), except when the facility's
interdisciplinary team has determined that either initial or continued
placement in the facility is appropriate because of the resident's physical and
mental functioning status, and that the facility has the service resources to
meet the needs of the resident. The facility interdisciplinary team shall
further determine that placement shall not constitute a serious danger to the
other residents.
e) A resident may be discharged from a facility after he or
she gives the administrator, a physician, or a nurse of the facility written
notice of his or her 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 his or her guardian or if the resident is a minor, his
or her parent unless there is a court order to the contrary. (Section
2-111 of the Act)
f) 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.
g) No resident shall be discharged without the concurrence of the
attending physician. If this approval is given, the facility shall have the right
to discharge or transfer a resident to an appropriate resource in accordance
with Sections 3-401 through 3-423 of the Act.
h) A facility shall not admit more residents than the number
authorized by the license issued to it.
i) Upon a finding by the Department that there has been a
substantial failure to comply with the Act and Section 390.165, including,
without limitation, the circumstances set forth in subsection (a) of Section
3-119 of the Act, or if the Department otherwise finds it would be in
the public interest or the interest of the health, safety, and welfare of
facility residents, the Department may impose a ban on new admissions to
any facility licensed under the Act. The ban shall continue until the
Department determines that the circumstances giving rise to the ban no longer
exist. (Section 3-119.1(a) of the Act)
j) The Department will provide notice to the facility
and licensee of any ban imposed pursuant to subsection (h) and Section 390.165. The notice shall provide
clear and concise statements of the circumstances on which the ban on new
admissions is based and notice of the opportunity for a hearing. (Section
3-119.1(b) of the Act)
k) If the Department finds that the public interest or the
health, safety, or welfare of facility residents imperatively requires
immediate action and if the Department incorporates a finding to that effect in
its notice per subsection (h), then the ban on new admissions may be
ordered pending any hearing requested by the facility. (Section 3-119.1(b)
of the Act)
l) No identified offender shall be admitted to or kept in the
facility, unless the requirements of Section 390.625(d) through (j) for new
admissions and the requirements of Section 390.635 are met.
(Source: Amended at 46 Ill.
Reg. 8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.635 IDENTIFIED OFFENDERS
Section
390.635 Identified Offenders
a) 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 or
while the results of a request for a waiver of a fingerprint-based check are
pending, and while the Identified Offender Report and Recommendation is
pending.
b) 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, in collaboration with the Department of Public Health, 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 (b)(2), any
criminal history record information contained in its files.
c) The facility shall comply with all
applicable provisions contained in the Uniform Conviction Information Act.
d) 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. (Section
2-201.5(c) of the Act)
e) If identified offenders, as defined in
Section 1-114.01 of the Act and Section 390.330, 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 or to verify compliance with applicable terms of probation,
parole, aftercare release, 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
390.750.
3) If identified offenders are residents of
the licensed facility, the licensed facility shall notify every resident or
resident's guardian in writing that offenders are residents of the licensed
facility. The licensed facility shall also provide notice to its employees and
to visitors to the facility that identified offenders are residents.
(Section 2-216 of the Act)
A) The notice shall 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.illinois.gov/idoc.
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 also shall
include the resident's criminal history record.
f) Facilities shall maintain written
documentation of compliance with Section 390.625.
g) Facilities shall annually complete all of
the steps required in subsection (e) for identified offenders.
h) For current residents who are identified
offenders, the facility shall at least annually review the security measures
listed in the Identified Offender Report and Recommendation provided by the
Department of the State Police, adopting recommended security measures
identified in subsection (j).
i) 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.
1) The care planning of identified
offenders shall include, but not be limited to, a description of the security
measures necessary to protect facility residents from the identified offender,
including whether the identified offender should be segregated from other
facility residents. (Section 3-202.3(5) of the Act).
2) If the identified offender is a
convicted (see 730 ILCS 150/2) or registered (see 730 ILCS 150/3) sex
offender, or if the Identified Offender Report and Recommendation prepared
pursuant to Section 2-201.6 of the Act reveals that the identified offender
poses a significant risk of harm to others within the facility, then 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)
j) The facility shall incorporate the
Identified Offender Report and Recommendation into the identified offender's individual
program plan. (Section 2-201.6(g) of the Act)
k) The facility's reliance on the Identified
Offender Report and Recommendation prepared pursuant to Section 2-201.6 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.
l) 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.
m) 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 390.700. 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, facility staff, or facility visitors from misconduct by the
identified offender, then the facility shall transfer or discharge the
identified offender in accordance with Section 3-402 of the Act and Section
390.3300.
n) 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.
o) 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: Former Section repealed at 31
Ill. Reg. 6145, effective April 3, 2007 and new Section adopted at 46 Ill. Reg.
8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.636 DISCHARGE PLANNING FOR IDENTIFIED OFFENDERS
Section 390.636 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, then it shall commence involuntary transfer or discharge
proceedings pursuant to Section 3-402 of the Act and Section 390.3300.
(Section 2-201.6(h) of the Act)
b) All discharges shall be pursuant to Section
390.3300.
c) When a resident who is an identified
offender is discharged, the discharging facility shall notify the Department
within 48 hours.
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 390.635 and subsection (a);
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 390.635(i).
(Source: Former Section repealed at 31
Ill. Reg. 6145, effective April 3, 2007 and new Section adopted at 46 Ill. Reg.
8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.637 TRANSFER OF AN IDENTIFIED OFFENDER
Section
390.637
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, then it shall commence involuntary transfer or discharge
proceedings pursuant to Section 3-402 of the Act and Section 390.3300.
(Section 2-201.6(h) of the Act)
b) All transfers shall be pursuant to Section
390.3300.
c) When a resident who is an
identified offender is transferred to another facility regulated by the
Department, the Department of Healthcare and Family Services, or the Department
of Human Services, the transferring facility shall notify the Department and
the receiving facility that the individual is an identified offender before
making the transfer. This notification shall include all of the documentation
required under Sections 390.635 and 390.3300 and a copy of the Identified
Offender Report and Recommendation provided by the Illinois State Police. The
transferring facility shall provide this information to the receiving facility
to complete
the transfer planning.
d) If the information contained in
this subsection (d) 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 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(c-5) of the Unified Code of Corrections)
e) 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 or regulated in their home state and would be
authorized to receive this information if they were in Illinois.
(Source: Former Section repealed at 31
Ill. Reg. 6145, effective April 3, 2007 and new Section adopted at 46 Ill. Reg.
8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.640 CONTRACT BETWEEN RESIDENT AND FACILITY
Section 390.640 Contract
Between Resident and Facility
a) Contract Execution
1) Before a person is admitted to a facility, or at the
expiration of the period of previous contract, or when the source of payment
for the resident's care changes from private to public funds or from public to private
funds, a written contract shall be executed between a licensee and the
following in order of priority:
A) The person, or if the person is a minor, his parent or
guardian; or
B) The person's guardian, if any, or agent, if any, as defined
in Section 2-3 of the Illinois Power of Attorney Act; or
C) A member of the person's immediate family. (Section
2-202(a) of the Act)
2) An adult person shall be presumed to have the capacity to
contract for admission to a long-term care facility unless he has been
adjudicated a "disabled person" within the meaning of Section 11a-2
of the Probate Act of 1975, or unless a petition for such an adjudication is
pending in a circuit court of Illinois. (Section 2-202(a) of the Act)
3) If there is no guardian, agent or member of the person's
immediate family available, able or willing to execute the contract required by
Section 2-202 of the Act and a physician determines that a person is so disabled
as to be unable to consent to placement in a facility, or if a person has already
been found to be a "disabled person," but no order has been entered allowing
residential placement of the person, that person may be admitted to a facility
before the execution of a contract required by that Section; provided that a petition
for guardianship or for modification of guardianship is filed within 15 days of
the person's admission to a facility, and provided further that
such a contract is executed within ten days of the disposition of the petition.
(Section 2-202 (a) of the Act)
4) No adult shall be admitted to a facility if he objects,
orally or in writing, to such admission, except as otherwise provided in
Chapters III and IV of the Mental Health and Developmental Disabilities Code
or Section 11a-14.1 of the Probate Act of 1975. (Section 2-202(a) of the
Act)
5) If on the effective date of this Part, a person has not
executed a contract as required by Section 2-202 of the Act, then such a
contract shall be executed by, or on behalf of, the person, within ten days of
the effective date of this Part, unless a petition has been filed for
guardianship or modification of guardianship. If a petition for guardianship or
modification of guardianship has been filed, and there is no guardian, agent or
member of the person's immediate family available, able, or willing to execute
the contract at that time, then a contract shall be executed within ten days of
the disposition of such petition.
b) The contract shall be clearly and unambiguously entitled,
"Contract Between Resident and (name of facility)."
c) Before a licensee (any facility licensed under the Act)
enters a contract under Section 2-202 of the Act, it shall provide the
prospective resident and his guardian, if any, with written notice of the
licensee's policy regarding discharge of a resident whose private funds for
payment of care are exhausted. (Section 2-202(a) of the Act)
d) A resident shall not be discharged or transferred at the
expiration of the term of a contract, except as provided in Sections 3-401
through 3-423 of the Act. (Section 2-202(b) of the Act)
e) At the time of the resident's admission to the facility, a
copy of the contract shall be given to the resident, his guardian, if any, and
any other person who executed the contract. (Section 2-202(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) Services Provided and Charges
1) The contract shall specify the services to be provided
under the contract and the charges for the services. (Section 2-202(g)(2)
of the Act)
2) A paragraph shall itemize the services and products to be
provided by the facility and express the costs of the itemized services and
products to be provided either in terms of a daily, weekly, monthly or yearly
rate, or in terms of a single fee.
3) The contract may provide that the charges for services may be
changed with thirty (30) days advance written notice to the resident or the
person executing the contract on behalf of the resident. The resident or the
person executing the contract on behalf of the resident may either assent to
the change or choose to terminate the contract at any time within 30 days of
the receipt of the written notice of the change. The written notice shall
become an addendum to the contract.
n) The contract shall specify the services that may be
provided to supplement the contract and the charges for the services.
(Section 2-202(g)(3) of the Act)
1) A paragraph shall itemize all services and products offered by
the facility or related institutions which are not covered by the rate or fee
established in subsection (m) of this Section. If a separate rate or fee for any
such supplemental service or product can be calculated with definiteness at the
time the contract is executed, then such additional cost shall be specified in
the contract.
2) If the cost of any itemized service or product to be provided
to the resident by the facility or related institutions cannot be established
or predicted with definiteness at the time of the resident's admission to the
facility or at the time of the execution of the contract, then no cost for that
service or product need be stated in the contract. But the contract shall
include a statement explaining the resident's liability for such itemized
service or product and explaining that the resident will be receiving a bill
for such itemized service or product beyond and in addition to any rate or fee
set forth in the contract.
3) The contract may provide that the charges for services and
products not covered by the rate or fee established in subsection (m) may be
changed with thirty (30) days advance written notice to the resident or the
person executing the contract on behalf of the resident. The resident or the
person executing the contract on behalf of the resident may either assent to
the change or choose to terminate the contract at any time within 30 days of
the receipt of the written notice of the change. The written notice shall
become an addendum to the contract.
o) The contract shall specify the sources liable for payments
due under the contract. (Section 2-202(g)(4) of the Act)
p) Deposit Provisions
1) The contract shall specify the amount of deposit paid. (Section
2-202(g)(5) of the Act)
2) Such amount shall be expressed in terms of a precise number of
dollars and be clearly designated as a deposit. The contract shall specify when
such deposit shall be paid by the resident, and the contract shall specify when
such deposit shall be returned by the facility. The contract shall specify the conditions
(if any) which must be satisfied by the resident before the facility shall return
the deposit. Upon the satisfaction of all such conditions, the deposit shall be
returned to the resident. If the deposit is nonrefundable, the contract shall
provide express notice of such nonrefundability.
q) The contract shall specify the rights, duties and
obligations of the resident, except that the specification of a resident's
rights may be furnished on a separate document which complies with the requirements
of Section 2-211 of the Act. (Section 2-202(g)(6) of the Act)
r) The contract shall designate the name of the resident's representative,
if any. The resident shall provide the facility with a copy of the written
agreement between the resident and the resident's representative which
authorizes the resident's representative to inspect and copy the resident's
records and authorizes the resident's representative to execute the contract on
behalf of the resident required by Section 2-202 of the Act. (Section
2-202(h) of the Act)
s) The contract shall provide that if the resident is
compelled by a change in physical or mental health to leave the facility, the
contract and all obligations under it shall terminate on seven days notice.
No prior notice of termination of the contract shall be required, however,
in the case of a resident's death. The contract shall also provide that
in all other situations, a resident may terminate the contract and all
obligations under it with 30 days notice. All charges shall be prorated as of
the date on which the contract terminates, and, if any payments have been made
in advance, the excess shall be refunded to the resident. This provision shall
not apply to life-care contracts through which a facility agrees to provide
maintenance and care for a resident throughout the remainder of the resident's
life nor to continuing-care contracts through which a facility agrees to
supplement all available forms of financial support in providing maintenance
and care for a resident throughout the remainder of the resident's life. (Section
2-202(i) of the Act)
t) All facilities which offer to provide a resident with
nursing services, medical services or personal care services, in addition to
maintenance services, conditioned upon the transfer of an entrance fee to the
provider of such services in addition to or in lieu of the payment of regular
periodic charges for the care and services involved, for a term in excess
of one year or for life pursuant to a life care contract, shall meet all of the
provisions of the Life Care Facilities Act (Ill. Rev. Stat. 1991, ch. 111½,
par. 4160-1 et seq.) [210 ILCS 40], including the obtaining of a permit from
the Department, before they may enter into such contracts. (Section 2(c) of the
Life Care Facilities Act)
u) In addition to all other contract specifications contained
in this Section, admission contracts shall also specify:
1) whether the facility accepts Medicaid clients;
2) whether the facility requires a deposit of the resident or
his family prior to the establishment of Medicaid eligibility;
3) in the event that a deposit is required, a clear and
concise statement of the procedure to be followed for the return of such
deposit to the resident or the appropriate family member or guardian of the
person;
4) that all deposits made to a facility by a resident, or on
behalf of a resident, shall be returned by the facility within 30 days of the
establishment of Medicaid eligibility, unless such deposits must be drawn upon
or encumbered in accordance with Medicaid eligibility requirements established
by the Illinois Department of Public Aid. (Section 2-202(j) of the Act)
v) It shall be a business offense for a facility to knowingly
and intentionally both retain a resident's deposit and accept Medicaid payments
on behalf of the resident. (Section 2-202(k) of the Act)
(Source: Amended at 18 Ill. Reg. 15807, effective October 15, 1994)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.650 RESIDENTS' ADVISORY COUNCIL
Section 390.650 Residents'
Advisory Council
a) Each facility shall establish a residents' advisory council
consisting of at least five resident members. If there are not five residents
capable of functioning on the residents' advisory council, as determined by the
Interdisciplinary Team, residents' representatives shall take the place of the required
number of residents. The administrator shall designate another member of the
facility staff (other than the administrator) to coordinate the establishment
of, and render assistance to, the council. (Section 2-203 of the Act)
b) Each facility shall develop and implement a plan for assuring
a liaison with concerned individuals and groups in the local community. Ways in
which this requirement can be met include, but are not limited to, the
following:
1) the inclusion of community members such as volunteers, family
members, residents' friends, residents' advocates, or community representatives
on the council;
2) the establishment of a separate community advisory group with
persons of the residents' choosing; or
3) finding a church or civic group to "adopt" the
facility.
c) The resident members shall be elected to the council by vote
of their fellow residents, found capable of voting. If a resident is not
capable of voting, the resident's parent or guardian shall vote to elect
members of the council. If there are not five residents capable of or willing
to serve on the council, then nonresident representatives shall be recruited to
meet this requirement.
d) In facilities of 50 or fewer beds, the council may consist of
all of the residents (or their parents or guardians) of the facility, if the
residents (or their parents or guardians) choose to operate this way.
e) All residents' advisory councils shall elect at least a
Chairperson or President and a Vice Chairperson or Vice President from among
the members of the council. These persons shall preside at the meetings of the
council, assisted by the facility staff person designated by the administrator
to provide such assistance.
f) Some facilities may wish to establish mini-residents' advisory
councils for various smaller units within the facility. If this is done, each
such unit shall be represented on an overall facility residents' advisory council
with the composition described in subsection (a) of this Section.
g) All residents' advisory council meetings shall be open to
participation by all residents and their representatives.
h) No employee or affiliate of any facility shall be a member
of any council. Such persons may attend to discuss interests or functions
of the non-members when invited by a majority of the officers of the council. (Section
2-203(a) of the Act)
i) The council shall meet at least once each month with the
staff coordinator who shall provide assistance to the council in preparing and
disseminating a report of each meeting to all residents, the administrator, and
the staff. (Section 2-203(b) of the Act)
j) Records of the council meetings shall be maintained in the
office of the administrator. (Section 2-203(c) of the Act)
k) The residents' advisory council may communicate to the
administrator the opinions and concerns of the resident. The council shall
review procedures for implementing resident rights and facility
responsibilities and make recommendations for changes or additions which will
strengthen the facility's policies and procedures as they affect residents'
rights and facility responsibilities. (Section 2-203(d) of the Act)
l) The council shall be a forum for:
1) Obtaining and disseminating information;
2) Soliciting and adopting recommendations for facility programming
and improvements;
3) Early identification of problems;
4) Recommending orderly resolution of problems. (Section
2-203(e) of the Act)
m) The council may present complaints on behalf of a resident
to the Department, or to any other person it considers appropriate.
(Section 2-203(f) of the Act)
n) Families
and friends of residents who live in the community retain the right to form
family councils.
1) If
there is a family council in the facility, or if one is formed at the request
of family members or the ombudsman, a facility shall make information about the
family council available to all current and prospective residents, their
families and their representatives. The information shall be provided by the
family council, prospective members or the ombudsman.
2) If a
family council is formed, facilities shall provide a place for the family
council to meet.
(Source: Amended at 31 Ill. Reg. 8864,
effective June 6, 2007)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.660 GENERAL POLICIES
Section 390.660 General
Policies
a) Financial Policies
1) The facility shall have policies and procedures, established
in writing, that protect the financial interests of residents and, when large
sums of money accrue to a resident, provide for counseling the resident or his
correspondent concerning its use, and for appropriate protection of such money.
These policies and procedures shall permit normalized and normalizing
possession and use of money by residents for work payment and property administration
as, for example, in performing cash and check transactions, and in buying
clothes and other items.
2) The administrator, or the administrator's designee, shall not
pay a resident's bills or make purchases for the resident unless requested in writing
to do so by the resident, the resident's correspondent or by the private or
public agency financially responsible for the resident's care. (See also
Section 390.1640(c))
b) The facility shall allow daily visiting between 10 A.M. and 8
P.M.
c) Residents over the age of six years occupying any bedroom
shall be of the same sex unless otherwise individually approved by the
interdisciplinary team.
d) There shall be no resident traffic through a resident's room
by residents to reach any other area of the building.
e) The facility shall provide for the registration and
disposition of complaints without threat of discharge or other reprisal against
any employee or resident.
(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.670 PERSONNEL POLICIES
Section 390.670 Personnel
Policies
a) Each facility shall develop and maintain written personnel
policies, which are followed in the operation of the facility. These policies
shall include, at a minimum, each of the requirements of this Section.
b) Employee Records
1) Employment application forms shall be completed for each
employee and kept on file in the facility. Completed forms shall be available
to Department personnel for review.
2) Individual personnel files for each employee shall contain
date of birth; home address; educational background; experience, including
types and places of employment; date of employment and position employed to
fill in this facility; and (if no longer employed in this facility) last date
employed and reasons for leaving.
3) Facilities shall maintain a confidential medical file for each
employee that shall contain health records, including the employee's
vaccination and testing records, initial health evaluation, and the results of
the tuberculin skin test required under Section 390.675, and any other pertinent
health records.
4) Individual personnel records for each employee shall also
contain records of evaluation of performance.
c) Prior to employing any individual in a position that requires
a State license, the facility shall contact the Illinois Department of Financial
and Professional Regulation to verify that the individual's license is active.
A copy of the license shall be placed in the individual's personnel file.
d) The facility shall check the status of all applicants with the
Department's Health Care Worker Registry prior to hiring.
e) All persons in supervisory or other responsible positions
shall be at least 18 years of age.
f) All personnel shall have either training or experience, or both,
in the job assigned to them.
g) Orientation and In-Service Training
1) All new employees, including student interns, shall complete
an orientation program covering, at a minimum, the following: general facility
and resident orientation; job orientation, emphasizing allowable duties of the
new employee; resident safety, including fire and disaster, emergency care and
basis resident safety; infection prevention and control; and understanding and
communicating with the type of residents being cared for in the facility. In
addition, all new direct care staff, including student interns, shall complete
an orientation program covering the facility's policies and procedures
concerning topics listed in Section 390.620(b)(6) before being assigned to
provide direct care to residents. This orientation program shall include
information on the prevention and treatment of decubitus ulcers and the
importance of nutrition in general health care.
2) All employees, except student interns shall attend in-service
training programs pertaining to their assigned duties at least annually. These
in-service training programs shall include the facility's policies, including
infection prevention and control policies required in Section 390.760; skill
training and ongoing education to enable all personnel to perform their duties
effectively. The in-service training sessions regarding personal care, nursing
and restorative services shall include information on the prevention and
treatment of decubitus ulcers. In-service training concerning dietary services
shall include information on the effects of diet in treatment of various
diseases or medical conditions and the importance of laboratory test results in
determining therapeutic diets. Written records of program content for each
session and of personnel attending each session shall be kept.
h) 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.
i) Personnel policies shall include a plan to provide personnel
coverage for regular staff when they are absent.
j) Every facility shall have a current, dated weekly employee
time schedule posted where employees may refer to it. This schedule shall
contain 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.
(Source: Amended at 46 Ill. Reg. 8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.675 INITIAL HEALTH EVALUATION FOR EMPLOYEES
Section 390.675 Initial
Health Evaluation for Employees
a) Each employee shall have an initial health evaluation which
shall be used to insure that employees are not placed in positions which would
pose undue risk of infection to themselves, other employees, residents, or
visitors.
b) The initial health evaluation shall be conducted not more than
30 days prior to the employee beginning employment in the facility. The
evaluation shall be completed not more than 30 days after the employee begins
employment in the facility.
c) The initial health evaluation shall include a health
inventory. This inventory shall be obtained from the employee and shall
include the employee's immunization status and any available history of
conditions which would predispose the employee to acquiring or transmitting
infectious diseases. This inventory shall include any history of exposure to,
or treatment for, tuberculosis. The inventory shall also include any history
of hepatitis, dermatologic conditions, or chronic draining infections or open
wounds.
d) The initial health evaluation shall include a physical
examination. The examination shall include at a minimum any procedures needed
in order to:
1) Detect any unusual susceptibility to infection and any
conditions which would increase the likelihood of the transmission of disease
to residents, other employees, or visitors.
2) Determine that the employee appears to be physically able to
perform the job functions which the facility intends to assign to the employee.
e) The initial health evaluation shall include a tuberculin skin
test which is conducted in accordance with the requirements of Section
390.1035. The test must meet one of the following timeframes:
1) The test must be completed no more than 90 days prior to the
date of initial employment in the facility, or
2) The test must be commenced no more than ten days after the
date of initial employment in the facility.
(Source: Added at 13 Ill. Reg. 6301, effective April 17, 1989)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.680 DIRECT SUPPORT PERSONS
Section 390.680 Direct
Support Persons
a) A facility shall not employ an individual as a nursing
assistant, home health aide, Direct Support Person (DSP), 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
checked 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. The facility shall not employ an individual as a nursing assistant
or DSP if that individual is not on the Health Care Worker Registry unless
the individual is enrolled in a training program under Section 3-206(a)(5) of
the Act. (Section 3-206.01 of the Act)
b) A DSP that is not listed on the Health Care Worker Registry
shall provide documentation of completion of, or enrollment in, a DSP training
program or a Department-approved basic nursing assistant training program (see
77 Ill. Adm. Code 395). The program shall be successfully completed no later
than 120 days after the date of initial employment. Programs approved in
accordance with 77 Ill. Adm. Code 395 may last longer than 120 days. However,
a DSP may be employed no more than 120 days prior to the successful completion
of the program.
c) Each person employed by the facility as a DSP shall meet each
of the following requirements:
1) Be at least sixteen years of age, of temperate habits and
good moral character, honest, reliable and trustworthy. (Section
3-206(a)(1) of the Act)
2) Be able to speak and understand the English language or a
language understood by a substantial percentage of the facility's residents.
(Section 3-206(a)(2) of the Act)
3) Provide evidence of prior employment or occupation,
if any, and residence for 2 years prior to his or her present employment.
(Section 3-206(a)(3) of the Act)
4) Have completed at least 8 years of grade school or provide
proof of equivalent knowledge. (Section 3-206(a)(4) of the Act)
5) Begin a current course of training for nursing assistants or
DSPs, approved by the Department, within 45 days of initial employment
in the capacity of a nursing assistant or DSP at any facility. Courses
of training shall be successfully completed within 120 days of initial
employment in the capacity of nursing assistant or DSP at a facility.
Nursing assistants and DSPs 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.(Section
3-206(a)(5) of the Act)
6) Be familiar with and have general skills related to
resident care. (Section 3-206(a)(6) of the Act.
d) It is unlawful for any facility to employ any person in the
capacity of nursing assistant or DSP, or under any other title, not
licensed by the State of Illinois to assist in the personal, medical, or
nursing care of residents in the facility unless the person has
complied with this Section. (Section 3-206(c) of the Act) The facility
shall verify on the Health Care Worker Registry that each nursing assistant or
DSP employed by the facility meets the requirements of this Section. The
facility shall print the employee's Registry profile as documentation of this
verification and maintain a copy as part of the employee's personnel record.
e) During inspections of the facility, when potential problems
arise regarding the care provided by DSPs, or when other evidence of inadequate
training is observed, the Department may require DSPs to demonstrate competency
in the principles, techniques, and procedures covered by the DSP training
program curriculum described in the rules governing training programs for DSPs
(see 77 Ill. Adm. Code 395.320). The State-approved manual skills evaluation
testing format and forms will be used to determine competency of a DSP when
appropriate. Failure to demonstrate competency of the principles, techniques
and procedures shall result in the provision of in-service training to the
individual by the facility. The in-service training shall address the DSP
training principles and techniques relative to the procedures in which the DSPs
are found to be deficient during inspection (see 77 Ill. Adm. Code 395).
(Source: Amended at 46 Ill. Reg. 8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.681 HEALTH CARE WORKER BACKGROUND CHECK
Section 390.681 Health Care
Worker Background Check
A facility shall comply with the
Health Care Worker Background Check Act and the Health Care Worker Background
Check Code.
(Source: Amended at 46 Ill.
Reg. 8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.682 RESIDENT ATTENDANTS
Section 390.682 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 child care/habilitation aide; or
4) performs any nursing or nursing-related services for
residents of a facility. (Section 3-206.03(a) of the Act)
c) A facility may employ resident attendants to assist the
child care/habilitation 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 of 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; 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
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 hand washing 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 residents 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:
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 revisions, needed to remedy any minor
deficiencies in the application or proposed program, which would not prevent
the program from being implemented, such as deficiencies in the number of hours
assigned to cover different areas of content, which can be corrected by
submitting a revised schedule or outline; or
3) Deny approval of the proposed program based on major
deficiencies in the application or proposed program that would prevent the
program from being implemented, such as deficiencies in the qualifications of
instructors or missing areas of content.
q) Programs shall be resubmitted to the Department for review
within 60 days prior to expiration of program approval.
r) If the Department finds that an approved program does not
comply with the requirements of this Section, the Department will notify the
facility in writing of non-compliance of the program and the reasons 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 390.681 of this Part.
(Source: Added at 24 Ill. Reg. 17283, effective November 1, 2000)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.683 HEALTH CARE WORKER REGISTRY
Section 390.683 Health Care
Worker Registry
a) An individual will be placed on the Department's Health Care
Worker Registry when that individual has successfully completed a training
program approved in accordance with the Long-Term Care Assistants and Aides
Training Program Code and has met background check information required in
Section 390.681 of this Part.
b) An individual shall be placed on the Health Care Worker
Registry if that individual has met background check information required by
the Health Care Worker Background Check Code and submits documentation
supporting one of the following equivalencies:
1) Documentation of current registration from another state.
2) Documentation of successful completion of a DSP training
course approved by another state as evidenced by a diploma or certificate. The
documentation must demonstrate that the course is equivalent to, or exceeds,
the requirements for DSPs in the Department's rules governing long-term care
assistants and aides training programs (see 77 Ill. Adm. Code 395).
3) Documentation of successful completion of a nursing arts
course with at least 40 hours of supervised clinical experience in an
accredited nurse training program as evidenced by a diploma, certification or
other written verification from the school.
(Source: Amended at 46 Ill. Reg. 8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.684 CERTIFIED NURSING ASSISTANT INTERNS
Section 390.684
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, 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. 14734, effective September 25, 2024)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.685 STUDENT INTERNS
Section 390.685 Student
Interns
a) No person who meets the definition of student intern in
Section 390.330 shall be required to complete a current course of training for DSPs.
b) The facility may utilize student interns to perform basic DSP
skills for which they have been evaluated and deemed competent by an approved
evaluator using the State approved manual skills competency evaluation (see 77
Ill. Adm. Code 395.320), but shall not allow interns to provide rehabilitation
nursing (see 77 Ill. Adm. Code 300.1210(b)), in-bed bathing, assistance with
skin care, foot care, or to administer enemas, except under the direct,
immediate supervision of a licensed nurse.
c) No facility shall have more than fifteen percent of its DSP
staff positions held by student interns.
(Source: Amended at 46 Ill. Reg. 8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.690 DISASTER PREPAREDNESS
Section 390.690 Disaster
Preparedness
a) For the purpose of this Section only, "disaster"
means an occurrence, as a result of a natural force or mechanical failure such
as water, wind or fire, or a lack of essential resources such as electrical
power, that poses a threat to the safety and welfare of residents, personnel,
and others present in the facility.
b) Each facility shall have policies covering disaster
preparedness, including a written plan for staff, residents and others to
follow. The plan shall include, but not be limited to, the following:
1) Proper instruction in the use of fire extinguishers for all
personnel employed on the premises;
2) A diagram of the evacuation route, which shall be posted and
made familiar to all personnel employed on the premises;
3) A written plan for moving residents to safe locations within
the facility in the event of a tornado warning or severe thunderstorm warning;
and
4) An established means of facility notification when the
National Weather Service issues a tornado or severe thunderstorm warning that
covers the area within 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 action 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
390.Table F), 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 390.2410(b), 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 the 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 local
emergency management agency, the facility shall participate in emergency
planning activities.
(Source: Amended at 34 Ill.
Reg. 19239, effective November 23, 2010)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.700 INCIDENTS AND ACCIDENTS
Section 390.700 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 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 33 Ill.
Reg. 9406, effective June 17, 2009)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.750 CONTACTING LOCAL LAW ENFORCEMENT
Section 390.750 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 390.330.
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 procedures;
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. 4890, effective April 1, 2002)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.760 INFECTION CONTROL
Section 390.760 Infection
Control
a) A
facility shall have an infection prevention and control program for the
surveillance, investigation, prevention, and control of healthcare-associated
infections and other infectious diseases. The infection prevention and control
program shall also include an antibiotic stewardship program that includes
antibiotic use protocols and a system to monitor antibiotic use.
b) Written policies and procedures for surveillance,
investigation, prevention, and control of infectious agents and
healthcare-associated infections in the facility shall be established and
followed, including the appropriate use of personal protective equipment as
provided in the Centers for Disease Control and Prevention's Guideline of
Isolation Precautions, Hospital Respiratory Protection Program Toolkit, and the
Occupational Safety and Health Administration's Respiratory Protection Guidance.
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.
1) All staff shall be trained annually on the
facility’s infection control policies and procedures, and training records
shall be maintained for 3 years. For the purposes of this Section, "staff"
means any individual employed by the facility, any individual contracted by the
facility or employed by an entity that is contracted by the facility to provide
treatment and services, and any volunteer providing services on behalf of the
facility.
2) Students enrolled in accredited health care training
programs who are providing direct care during internships or clinical rotations
must have previously completed infection prevention and control training
as part of their curriculum prior to entering a facility for the first time. The
facility shall maintain a record of all interns and students who have completed
infection and prevention control training and provide a copy of this record
upon request by the Department.
3) Activities
shall be monitored on an ongoing basis by the infection preventionist to ensure
adherence to all infection prevention and control policies and procedures.
4) Infection
prevention and control policies and procedures shall be maintained in the
facility and made available upon request to facility staff, the resident and
the resident's family or resident's representative, the Department, the
certified local health department, and the public.
c) A group, e.g., an infection prevention and control
committee, quality assurance committee, or other facility entity, shall
periodically, but no less than annually, review the measures and outcomes of
investigations and activities to prevent and control infections, documented by
written, signed, and dated minutes of the meeting.
d) Each facility shall adhere to the following
guidelines and toolkits of the Centers for Disease Control and Prevention,
United States Public Health Services, Department of Health and Human Services,
Agency for Healthcare Research and Quality, and Occupational Safety and Health
Administration (see Section 390.340):
1) Guideline
for Prevention of Catheter-Associated Urinary Tract Infections
2) Guideline
for Hand Hygiene in Health Care Settings
3) Guidelines
for the Prevention of Intravascular Catheter-Related Infections
4) Guideline
for Prevention of Surgical Site Infection
5) Guideline for Preventing
Healthcare-Associated Pneumonia
6) 2007 Guideline for Isolation Precautions:
Preventing Transmission of Infectious Agents in Healthcare Settings
7) Infection Control in Healthcare Personnel:
Infrastructure and Routine Practices for Occupational Infection Prevention and
Control Services
8) The Core Elements of Antibiotic Stewardship
for Nursing Homes
9) The
Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A: Policy
and Practice Actions to Improve Antibiotic Use
10) Nursing
Home Antimicrobial Stewardship Guide
11) Toolkit
3. Minimum Criteria for Common Infections Toolkit
12) TB
Infection Control in Health Care Settings
13) Interim
Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread
in Nursing Homes
14) Implementation
of Personal Protective Equipment (PPE) in Nursing Homes to Prevent Spread of
Novel or Targeted Multidrug-resistant Organisms (MDROs)
15) Hospital
Respiratory Protection Program Toolkit: Resources for Respirator Program
Administrators
16) Respiratory
Protection Guidance for the Employers of Those Working in Nursing Homes,
Assisted Living, and Other Long-Term Care Facilities During the COVID-19
Pandemic
17) Guidelines
for Environmental Infection Control in Health-Care Facilities
e) Testing
The facility shall have a testing plan and response
strategy in place to address infectious disease outbreaks. Pursuant to the
plan and response strategy, the facility shall test residents and facility
staff for infectious diseases listed in Section 690.100 of the Control of
Communicable Diseases Code in a manner that is consistent with current
guidelines and standards of practice. Each facility shall conduct testing of
residents and staff for the control or detection of infectious diseases when:
1) The
facility is experiencing an outbreak; or
2) Directed
by the Department or the certified local health department where the chance of
transmission is high, including, but not limited to, regional outbreaks,
epidemics, or pandemics. For the purposes of this Section, "outbreak"
has the same meaning as defined in the Control of Communicable Diseases Code.
3) Documentation
A) For
residents, document in each resident's record any time a test was completed,
including the result of the test, or whether testing was refused or
contraindicated.
B) For
staff members, document in each staff member's confidential medical file (as
distinct from their personnel file) any time a test was completed, including
the result of the test, or whether testing was refused or contraindicated.
C) For
students, student interns, and volunteers, document in each individual's
confidential medical file any time a test was completed, including the result
of the test or whether testing was refused or contraindicated (in the event
that no confidential medical file is maintained, the program for students,
student interns, and volunteers shall include a process for documenting these
results).
4) Upon
confirmation that a resident, staff member, volunteer, student, or student
intern tests positive with an infectious disease, or displays symptoms
consistent with an infectious disease, each facility shall take immediate steps
to prevent the transmission by implementing practices that include but are not
limited to cohorting, isolation and quarantine, environmental cleaning and
disinfecting, hand hygiene, and use of appropriate personal protective
equipment.
5) Each
facility shall have written procedures for addressing residents, staff members,
volunteers, students, and student interns who refuse testing or are unable to
be tested.
f) Each
facility shall make arrangements with a testing laboratory to process any
specimens collected under subsection (e) and ensure that complete information
is submitted with each specimen, including name, address, date of birth, sex,
race, ethnicity, email address, telephone number, and attending physician (if
applicable).
g) For
testing done under subsection (e), each facility shall report to the
Department, on a form and manner as prescribed by the Department, the number of
residents, staff members, volunteers, students, and student interns tested, and
the number of positive, negative and indeterminate cases.
h) Certified facilities shall comply with 42
CFR 483.80(h).
i) Facilities
shall not restrict visitation without a reasonable clinical or safety cause and
shall facilitate in-person visitation whenever feasible, in accordance with
Department and CDC guidance for infection prevention.
(Source:
Amended at 46 Ill. Reg. 8192, effective May 6, 2022)
SUBPART D: PERSONNEL
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.770 ELECTRONIC MONITORING
Section 390.770 Electronic
Monitoring
A facility shall comply with Section 2-116 and subsections
3-318(a)(8) and (9) of the Act and with the Authorized Electronic Monitoring in
Long-Term Care Facilities Act.
(Source: Added at 46 Ill. Reg. 8192,
effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.810 GENERAL
Section 390.810 General
a) Sufficient staff in numbers and qualifications shall be on
duty all hours of each day to provide services that meet the total needs of the
residents. (B)
b) The number and categories of personnel to be provided shall be
based on the following:
1) Number of residents.
2) Amount and kind of nursing care, program services,
supervision, and personal care needed to meet the particular needs of the residents
at all times.
3) Size, physical condition, and the layout of the building
including proximity of service areas to the resident's rooms.
(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.820 CATEGORIES OF PERSONNEL
Section 390.820 Categories of
Personnel
Categories of personnel to be
provided shall include but are not limited to the following:
a) an administrator as set forth in Subpart B. (B)
b) nursing personnel as set forth in Subpart E. (B)
c) a Resident Services Director who is a Qualified Mental
Retardation Professional as defined in Section 390.330, who is assigned
responsibility for the coordination and monitoring of each resident's overall plan
of care (Individual Habilitation Plan). This person shall have at least one
year experience working with developmentally disabled residents. The administrator
or an individual on the professional staff of the facility may fill this
assignment to assure that residents' plans of care (Individual Habilitation
Plan) 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 (Individual Habilitation
Plan). This person shall have at least one year experience working with
developmentally disabled residents.(B)
d) recreational activity personnel as set forth in Section
390.1100(c)(1) (B)
e) dietary personnel as set forth in Sections 390.1810 through
Section 390.1820. (B)
f) a staff member suited by training and experience to be
responsible for social services and for the integration of social services with
other elements of the plan of care (Individual Habilitation Plan). (B)
(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.830 CONSULTATION SERVICES
Section 390.830 Consultation
Services
a) The facility shall have all arrangements for each
consultant's services in a written agreement setting forth the services to be
provided. These agreements shall be updated annually.
b) The facility shall designate a staff member to provide social
services to residents. If the staff member designated to provide social
services is not a social worker, the facility shall have an effective
arrangement with a social worker to provide social service consultation.
c) The facility shall designate a staff member to be the
director of the activities program. If the activity director is not a
Registered Occupational Therapist, a Therapeutic Recreation Specialist, or a
social worker, the facility shall have a written agreement with a person from
one of those disciplines, to provide adequate and sufficient consultation to
the Activity Director to assure that programming meets the assessed needs of
the residents.
d) The facility shall designate a staff member skilled in record
maintenance and preservation to be responsible for maintaining and preserving
records. If the designated person is not a health information management
consultant, then that person shall receive adequate consultation from a health
information management consultant.
e) The facility shall arrange for a consultant pharmacist as set
forth in Section 390.1410.
f) The facility shall arrange for a medical advisory committee as
set forth in Section 390.1020(b).
g) The facility shall arrange for an advisory dentist as set
forth in Section 390.1050(a).
(Source: Amended at 26 Ill. Reg. 10645, effective July 1, 2002)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.840 EMPLOYEE ASSISTANCE PROGRAM
Section 390.840 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, during any benefit open enrollment period, by an information
form about the respective programs that a nurse shall sign during onboarding at
the facility, and upon request of the employee.
d) The
signed information form shall be added to the nurse's personnel file. The
facility may provide this information to nurses electronically. (Section
3-613 of the Act from PA 102-1007)
(Source: Added at 48 Ill. Reg. 2635,
effective January 30, 2024)
SUBPART E: HEALTH AND DEVELOPMENTAL SERVICES
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.1010 SERVICE PROGRAMS
Section 390.1010 Service
Programs
a) The facility shall provide, either directly or through
arrangements with an outside resource, as needed by the individual resident,
all services necessary to maintain and promote good physical health and development.
These services shall consist of, at a minimum, the following: (B)
1) Medical Services as described in Section 390.1020. (B)
2) Physician Services described as in Section 390.1030. (B)
3) Nursing Services described in Section 390.1040. (B)
4) Dental Services as described in Section 390.1050. (B)
5) Physical and Occupational Therapy Services as described in
Section 390.1060. (B)
6) Psychological Services as described in Section 390.1070. (B)
7) Social Services as described in Section 390.1080. (B)
8) Speech Pathology and Audiology Services as described in
Section 390.1090. (B)
9) Recreational and Activity Services as described in Section
390.1100. (B)
10) Educational Services as described in Section 390.1110. (B)
11) Work Activity and Prevocational Training Services as
described in Section 390.1120. (B)
b) These services shall be expressed in a written individual
habilitation plan. The individual habilitation plan is a total program plan of
care for each individual resident that is developed on the basis of all
assessment results.
c) Each resident shall have an individual habilitation plan
developed within 14 days of admission. This plan shall be reviewed and updated
approximately six weeks following admission and every six months thereafter or
more frequently as necessary, to assure continuing appropriateness of goals,
consistency of management methods with goals and objectives, and the
achievement of progress towards goals.
d) The individual habilitation plan shall be developed by an
appropriately constituted interdisciplinary team and state specific objectives
to reach identified goals.
e) Each goal and objective shall:
1) reflect the residents needs as identified by assessment data;
2) be stated in terms of a single outcome;
3) be expressed in terms that provide measurable indices of
progress;
4) be sequenced within a developmental progression, when
applicable;
5) be assigned priorities;
6) project a date for initiation of service;
7) have a targeted date of attainment;
8) specify activities for achievement of the objectives;
9) be written in terms that are understandable to all concerned;
10) identify the individual responsible for delivering the
services.
f) The residents' response to programs designed to achieve the
objectives shall be documented and available to staff.
g) Problems or changes that call for review of the individual
habilitation plan by the interdisciplinary team shall be documented.
(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.1020 MEDICAL SERVICES
Section 390.1020 Medical
Services
a) General Medical Services
1) The facility shall have a written program of medical services
approved in writing by the medical advisory committee that reflects the
philosophy of care provided, the policies relating to this, 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.
2) A medical advisory committee composed of at least a physician,
administrator and the director of nursing shall be responsible for advising the
administrator and the licensee on the overall medical management of the
residents and the staff in the facility. If the facility employs a house
physician, the physician shall be a member of this committee. The written
program of medical services shall also include the structure and function of
the medical advisory committee.
b) Medical Emergencies
1) The medical advisory committee shall develop policies and
procedures to be followed during medical emergencies including, but not limited
to, foreign body aspiration, poisoning, acute trauma (fractures, burns, and
lacerations), cardiac arrest, acute coronary, acute cardiac failure, asthmatic
or allergic reactions, acute convulsion, shock, diabetic coma, insulin shock,
and acute respiratory distress.
2) The facility shall maintain in a suitable location the
equipment necessary to be used during emergencies, including, but not limited
to, a portable oxygen kit, including a face mask or cannula; an airway; and
tongue blades.
3) At least one staff person shall be on duty at all times who
has been properly trained to handle medical emergencies.
(Source: Amended at 29 Ill.
Reg. 12988, effective August 2, 2005)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.1025 LIFE-SUSTAINING TREATMENTS
Section 390.1025
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 implementing of such rights. Included within
this policy shall be:
1) implementation of Living Wills or Powers of Attorney for
Health Care in accordance with the Living Will Act (Ill. Rev. Stat. 1991, ch.
110½, pars. 701 et seq.) [755 ILCS 35] and the Powers of Attorney for Health
Care Law (Ill. Rev. Stat. 1991, ch. 110½, pars. 804-1 et seq.) [755 ILCS 45];
2) the implementation of physician orders limiting
resuscitation such as those commonly referred to as
"Do-Not-Resuscitate" orders. This policy may only prescribe the
format, method of documentation and duration of any physician orders limiting
resuscitation. Any orders under this policy shall be honored by the facility.
(Section 2-104.2 of the Act);
3) procedures for providing life-sustaining treatments available
to residents at the facility;
4) procedures detailing staff's responsibility with respect to
the provision of life-sustaining treatment when a resident has chosen to
accept, reject, or limit life-sustaining treatment, or when a resident has
failed or has not yet been given the opportunity to make these choices;
5) procedures for educating both direct and indirect care staff
in the application of those specific provisions of the policy for which they
are responsible.
b) For the purposes of this Section:
1) "Agent" means a person acting under a Health Care
Power of Attorney in accordance with the Powers of Attorney for Health Care
Law.
2) "Life-sustaining treatment" means any medical
treatment, procedure, or intervention that, in the judgment of the attending
physician, when applied to a resident, would serve only to prolong the dying
process. Those procedures can include, but are not limited to, cardiopulmonary
resuscitation (CPR), assisted ventilation, renal dialysis, surgical procedures,
blood transfusions, and the administration of drugs, antibiotics, and
artificial nutrition and hydration. Those procedures do not include performing
the Heimlich maneuver or clearing the airway, as indicated.
3) "Surrogate" means a surrogate decision maker acting
in accordance with the Health Care Surrogate Act (Ill. Rev. Stat. 1991, ch.
110½, 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 by a resident, an agent, or a surrogate pursuant
to subsection (c) of this Section must be recorded in the resident's medical
record. Any subsequent changes or modifications must also be recorded in the
medical record.
e) The facility shall honor all decisions made by a resident, an
agent, or a surrogate pursuant to subsection (c) of this Section and may not
discriminate in the provision of health care on the basis of such decision or
will transfer care in accordance with the Living Will Act, the Powers of
Attorney for Health Care Law, the Health Care Surrogate Act or the Right of
Conscience Act (Ill. Rev. Stat. 1991, ch. 111½, pars. 5301 et seq.) [745 ILCS
70].
f) The resident, agent, or surrogate may change his or her
decision regarding life-sustaining 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) of this
Section, and in the absence of any physician's order to the contrary, then the
facility's policy with respect to the provision of life-sustaining treatment
shall control until and if such a decision is made by the resident, agent, or
surrogate in accordance with the requirements of the Health Care Surrogate Act.
(Source: Added at 17 Ill. Reg. 16167, effective January 1, 1994)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.1030 PHYSICIAN SERVICES
Section 390.1030 Physician
Services
a) General Requirements for Physician Services
1) The services of a physician licensed to practice medicine in
Illinois shall be available to every resident in the facility. (A, B)
2) Physician services are to include a complete physical
examination at least annually and formal arrangements to provide for medical
and behavior emergencies on a 24 hour seven day week basis. (B)
b) The resident shall be permitted his choice of a physician. If
the resident is a minor or under guardianship, the appropriate person shall
have this privilege.
c) The resident shall be seen by a physician as often as
necessary to assure adequate medical care. (Medicare/Medicaid requires
certification visits.) (A, B)
d) Physicians shall participate, when appropriate, in the
continuing interdisciplinary evaluation of individual residents, for the
purposes of initiating, monitoring, and following-up of individualized
habilitation programs for treatment.
e) Physician Signature Requirements
1) All physician orders, plans of treatment, Medicare/Medicaid
Certification and recertification statements and similar documents must have
the original written signature of the physician.
2) The use of a physician's rubber stamp signature with or without
initials is not acceptable.
f) Each resident admitted shall have a complete physical
examination, including stool culture, within two weeks prior to admission.
There shall be another physical examination (which need not include a stool
culture) conducted by the physician who will be attending the resident in the
facility within 72 hours after admission to the facility unless the preadmission
examination has been conducted by the same physician. In any case, the facility
shall have the results of a stool culture before a resident is admitted. This examination
shall include an evaluation of the resident's condition, including height and
weight, and recommendations for care of the resident including personal care needs
and permission for participation in the activity and developmental program. This
examination shall also include documentation of the presence or the absence of
tuberculosis infection by tuberculin skin test in accordance with Section
390.1035. The report shall also include 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.)
The report shall also include orders from the physician regarding weighing of
the resident, and the frequency of such weighing, if ordered. (See Section
390.1620(a)) (B)
g) The admission information for a resident shall include summary
of present medical findings, medical history, mental and physical functioning
capacity, diagnosis and prognosis when available and; it shall also include
orders for medications, treatments, restorative (re)habilitation services,
diet, specific procedures recorded for the health and safety of the resident,
activities and plans for continuing care and discharge. If this information is
not received with the resident at the time of admission, it must be received
within 48 hours.
h) All admissions to or continued care in the facility shall be
upon the recommendation of a physician.
i) The provisions of subsections (f), (g) and (h) of this
Section will not apply in the use of emergency admissions. In such a case, the
physician shall meet the criteria in these standards within 72 hours.
j) Physician Notification
1) The facility shall immediately notify the physician of any
significant accident, injury, or unusual 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. (B)
2) 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.
k) At the time of an accident, immediate first aid treatment
shall be provided by personnel trained in medically approved first aid
procedures. (B)
(Source: Amended at 15 Ill. Reg. 1878, effective January 25, 1991)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.1035 TUBERCULIN SKIN TEST PROCEDURES
Section 390.1035 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. 8021, effective July 15, 1999)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.1040 NURSING SERVICES
Section 390.1040 Nursing
Services
a) The facility shall have a written program of Nursing Services,
providing for a planned medical program, encompassing nursing treatments,
rehabilitation and habilitation nursing, skilled observations, and ongoing
evaluation and coordination of the resident's individual habilitation plan.
b) There shall be a sufficient number of nursing and auxiliary
personnel on duty 24 hours each day to provide adequate and properly supervised
nursing services to meet the nursing needs of the residents. There shall be at
least one registered professional nurse on duty seven days a week, for 8
consecutive hours. There shall be at least one registered professional nurse
or licensed practical nurse on duty at all times and on each floor housing
residents. Nursing staff personnel shall include registered professional
nurses, licensed practical nurses, and auxiliary personnel as defined in
Section 390.330.
c) There shall be a director of nursing who shall be a registered
professional nurse.
d) The director of nursing shall have knowledge and training in
nursing service administration, restorative and habilitative nursing.
e) The director of nursing 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.
1) A facility may, with written approval from the Department,
have two registered professional nurses share the duties of this position if it
is unable to obtain a full-time person. Such an arrangement will be granted
approval only through written documentation that the facility was unable to
obtain the full-time services of a qualified individual to fill this position.
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 number and availability of registered professional
nurses in the area. The Department will grant approval only when such
documentation indicates that there were no qualified applicants who were
willing to accept the job on a full-time basis, and the pool of registered professional
nurses available in the area cannot be expected to produce, in the near future,
a qualified person who is willing to work full-time. If two persons are to
share the position, one shall be designated the Director of Nursing Services
and the other shall be designated the Assistant Director of Nursing Services.
Both of these persons shall be registered professional nurses.
2) In facilities with a capacity of less than 50 beds, this
person (or these persons), may also provide direct patient care, and this
person's time may be included in meeting the staff-to-resident ratio
requirements.
f) In facilities with 100 occupied beds or more, there shall be
an assistant director of nursing who is a registered professional nurse
licensed to practice in Illinois. The assistant must meet the qualifications
specified in subsection (d).
g) The assistant director of nursing shall be a full-time
employee who is on duty a minimum of 36 hours, four days per week. The
assistant director of nursing is not required to work on the day shift but may
be assigned to any shift.
h) The assistant director of nursing shall assist the director of
nursing in carrying out the director's responsibilities.
i) The responsibilities of the director of nursing shall
include, at a minimum, the following:
1) Assigning and directing the activities of nursing and
auxiliary service personnel.
2) Planning an up-to-date resident care plan for each resident in
cooperation with the interdisciplinary team based on individual needs and goals
to be accomplished, physician's orders, and personal care and nursing needs.
Services such as nursing, developmental, activities, dietary, and such other
modalities as are ordered by the physician, shall be reflected in the
preparation of the resident care plan. The plan shall be in writing and shall
be reviewed and modified in keeping with the care needed as indicated by the
resident's condition. The plan shall be reviewed every three months.
3) 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.
4) Participating in planning and budgeting for nursing services
including purchasing of necessary equipment and supplies.
5) Developing and maintaining nursing service objectives,
standards of nursing practice, written policies and procedures, and written job
descriptions for each level of nursing and auxiliary personnel.
6) Coordinating health services and nursing services with other
resident care services such as medical, pharmaceutical, dietary activities, and
any other restorative and habilitative services offered.
7) Planning and implementation of in-service education, embracing
orientation, skill training, and ongoing education for all nursing personnel
covering all aspects of resident care and programming. The educational program
shall include training and practice in activities and restorative and
habilitative nursing techniques through out-of-facility or in-facility training
programs. The director of nursing may conduct these programs personally or see
to it that they are carried out.
8) Participating in the development and implementation of
resident care policies and bringing resident care problems, requiring changes
in policy, to the attention of the facility's policy development group. (See
Section 390.610(a).)
9) Participating in the screening of prospective residents and
their placement in terms of services they need and nursing competencies
available.
j) Nursing care (including personal, habilitative and
rehabilitative care measures) shall be practiced on a 24 hour, seven day a week
basis in the care of residents. Those procedures requiring medical approval
shall be ordered by the attending physician.
k) Nursing care shall include at a minimum the following:
1) Proper administration of all medications including oral,
rectal, hypodermic, and intra-muscular.
2) Proper administration of all treatments, including: enemas,
irrigations, catheterizations, applications of dressing or bandages,
supervision of special diets, restorative and habilitative measures, and other
treatments involving a like-level of skill.
3) Proper documentation of all objective observations of changes
in a resident's condition, including mental and emotional changes, as a means
for analyzing and determining care required and the need for further medical,
nursing or psychosocial evaluation and treatment shall be provided.
l) Each resident shall have their temperature taken daily unless
otherwise ordered by the physician. If the temperature varies two degrees from
the normal for the resident, the physician shall be notified.
m) Skin care shall be given to prevent pressure sores, heat rashes
or other skin breakdown. Each resident with pressure sores, heat rashes or
other skin breakdown shall be checked at least every two hours and given care
as needed including clothing and diaper changes. Skin care shall be given with
each diaper change.
n) Skin care should be provided as follows:
1) Bathing, clean linens, diapers, and clothing each time the bed
or clothing is soiled. Rubber, plastic, or other types of linen protectors
(newspapers not acceptable) shall be properly cleaned and completely covered to
prevent direct contact with the resident. If rubber, plastic, or other type of
waterproof materials are used for protective pants, they shall not come in
direct contact with the resident. Special attention shall be given to the skin
to prevent irritations, skin rashes, or ulcerations.
2) Assistance in being up and out of bed as much as the condition
of the resident permits. The resident may be denied this assistance only upon
the written order of the resident's physician. If the resident is unable to
change position, the resident's position shall be changed every two hours or
more as necessary.
o) All necessary precautions shall be taken to ensure the safety
of residents at all times, including, but not limited to use of nonslip wax on
floors; proper maintenance for all equipment, adaptive equipment and assistive
devices; and proper use of side rails on beds and restraints.
p) Each resident shall perform all of the following personal care
functions independently if possible. If unable to do so, assistance shall be
provided by staff.
1) Bathe as often as necessary, but at least daily.
2) Change clothing as often as necessary, but at least daily.
3) Shampoo hair as often as necessary, but at least weekly.
4) Clean and trim fingernails and toenails as often as necessary
but at least weekly.
5) Perform oral hygiene as often as necessary, but at least
daily.
6) Provide commercial sanitary napkins to each female resident during
menses. Frequent cleansing of the perineal area shall be performed.
q) Haircuts shall be provided as needed. Socially acceptable
hair styles and the wishes of the resident must be taken into consideration.
r) Each resident shall dress in street clothing and be out of
bed at all times other than regularly scheduled sleeping or napping hours,
unless contraindicated.
s) Each resident shall be weighed upon admission and at least
once a week thereafter unless otherwise ordered in writing by the physician.
Any significant change shall be reported to the attending physician and
dietitian.
t) Each resident shall be encouraged and, if necessary, assisted
in maintaining good body alignment while lying in bed, sitting or standing,
through proper positioning and turning.
u) Each resident shall be assisted in maintaining maximum joint
range of motion, and active range of motion through proper exercises.
v) Each resident shall be trained and encouraged to adopt food
habits as near as possible to normal. Residents shall receive solids, unless
otherwise ordered in writing by the physician. Each resident shall eat in as
upright a position as possible and out of bed unless contraindicated.
w) Each incontinent resident shall be assisted in regaining bowel
and bladder patterns through proper bowel and bladder training or retraining.
The use of indwelling catheters shall be discouraged.
x) All residents shall be encouraged and, when necessary, taught
to function at their maximum level in all activities of daily living for as
long as and to the degree that they are able.
y) All residents shall be assisted and encouraged with daily
ambulation unless otherwise ordered by the physician.
z) All residents shall be taught and assisted with safe transfer
activities in an effort to help them retain, regain, or gain their maximum
level of independence.
aa) Facility staffing shall be based on all the needs of the
residents and comply with the requirements of this Section. Facilities
shall provide each resident, regardless of age, no less than 4.0 hours of
nursing and personal care time each day. (Section 2-218 of the Act)
1) In a facility whose residents participate in regularly
scheduled therapeutic programs outside the facility, such as school or
sheltered workshops, the minimum hours of care that must be provided are
reduced proportionately.
2) It is the responsibility of each facility to determine the
staffing needed to meet the needs of its residents. A facility's failure to
comply with Section 2-218 of the Act, shall constitute a Type "B"
violation. (Section 2-218 of the Act)
3) The director of nursing shall not be included in hours of
personal and habilitative care provided.
4) The facility shall schedule personnel in such a manner that
the needs of all residents are met. At least 30 percent of the minimum
required hours shall be on the day shift, at least 30 percent of the minimum
required hours shall be on the evening shift, and at least ten percent of the
minimum required hours shall be on the night shift. The total percentage must
add up to 100 percent each day. At least 12.5 percent of the hours of care
provided on each shift must be by licensed nursing personnel. Licensed nursing
personnel may be used to replace other personal and habilitative care staff if
the needs of the residents are met. Personal and habilitative care staff may
include, in addition to licensed nurses, DSPs, aides, orderlies, therapists,
teachers, and any other person providing direct habilitative care to residents.
5) Staffing Calculations
A) When computing the number of staff hours needed per shift, any
figure less than .25 will be dropped from the computation and any figure of .75
or higher will be rounded to the next higher number. Figures that fall between
.25 and .75 will require at least the amount of coverage indicated: .25 will
require two hours of coverage; .3 will require two and one half hours of
coverage; .5 will require four hours of coverage; .6 will require five hours of
coverage; .74 will require six hours of coverage; .75 or higher will require
eight hours of coverage.
B) These hours may be provided by: a part-time person working
those hours only on that shift each day; a full-time person working a shift
that spans two regular shifts (such as from 12 noon to 8 P.M.); or by an
additional full-time person on the shift. However, these figures represent
minimum staffing requirements, and it is recommended that a full-time person be
provided.
bb) In addition to the other requirements of this Section, the
following also apply:
1) There shall be a licensed nurse designated as being in charge
of nursing services on all shifts when neither the director of nursing nor
assistant director of nursing are on duty. If registered professional nurses
and licensed practical nurses are on duty on the same shift, this person shall
be a registered professional nurse. This person may be a charge nurse on one of
the nursing units.
2) There shall be at least one person awake, dressed and on duty
at all times in each separate nursing unit.
3) There shall be at least one registered professional nurse on
duty seven days per week, 8 consecutive hours per day.
4) There shall be at least one registered professional nurse or
licensed practical nurse on duty at all times.
5) There shall be at least one registered professional nurse or
licensed practical nurse on duty on each floor housing residents.
6) The need for licensed nurses on each nursing unit will be
determined on an individual case basis, dependent upon the individual
situation. If such additional staffing is required, the Department will inform
the facility in writing of the kind and amount of additional staff time
required, and the reason why it is needed.
7) The need for an additional licensed nurse to serve as a
"house supervisor" will be determined on an individual case basis.
If the Department determines that there is a need for a registered professional
nurse on certain shifts whose sole duties will consist of supervising the
nursing services of the facility, the Department shall notify the facility in
writing regarding this determination. This person shall not perform the duties
of a charge nurse while serving as the "house supervisor".
(Source: Amended at 46 Ill. Reg. 8192, effective May 6, 2022)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.1050 DENTAL CARE SERVICES
Section 390.1050 Dental Care
Services
a) Every facility shall have an advisory dentist. The advisory
dentist shall have a contractual relationship to the facility, setting forth
the preventive and therapeutic oral health services to be provided to residents.
(B)
b) There shall be education and training in the maintenance of
oral health which includes a dental hygiene program that includes imparting
information regarding nutrition and diet control measures to residents and staff;
instruction of residents and staff in living units in proper oral hygiene
methods; and instruction of parents or surrogates in the maintenance of proper
oral hygiene, where appropriate (as in the case of residents leaving the
facility). (B)
c) There shall be comprehensive diagnostic services for all
residents (diagnostic for residents from birth to two years of age only if
medically indicated) which include a complete extra and intra oral examination utilizing
all diagnostic aids necessary to properly evaluate the residents' oral condition
within a period of one month following admission unless examined within six
months before admission and results received by facility with the results of said
examination entered in the resident's dental record as a separate part of the
resident's permanent medical chart. (B)
d) There shall be comprehensive treatment services for all
residents which include, but are not limited to the following: (B)
1) Provision for dental treatment
2) Provision for emergency treatment on a 24 hour, seven days a
week basis, by a qualified dentist.
3) A recall system that will assure that each resident is
reexamined at specified intervals in accordance with their needs, but at least
annually. Needed dental treatment shall be provided.
e) The direct care staff shall receive in-service education at
least annually. This will be provided by the dentist or he may utilize a dental
hygienist. (B)
1) Direct care staff shall be educated in ultrasonic and manual
denture and partial denture cleaning techniques.
2) Direct care staff shall be educated in proper brushing and
oral health care for residents who are unable to care for their own health.
3) Direct care staff shall be educated in examining the mouth in
order to recognize abnormal conditions for necessary referral.
4) Direct care staff shall be educated regarding nutrition and
diet control measures and the effect on dental health.
5) Supplemental dental training films shall be included with any
other health training films seen on a rotating basis.
f) The facility's dental program shall provide for proper daily
personal dental hygiene care which includes, but is not limited to, the
following: (B)
1) Assistance in cleaning the mouth with electric or hand brush
if resident is unable to do so.
2) Proper cleaning of dentures and partials.
g) The dental program shall provide for inservice education to
residents and staff under direction of dental staff including, but not limited
to, the following: (B)
1) Information regarding nutrition and diet control measures
which are dental health oriented.
2) Instruction in proper oral hygiene methods.
3) Instruction concerning the importance of maintenance of proper
oral hygiene and where appropriate including family members or surrogates (as
in the case of residents leaving the long-term care facility).
h) Each facility shall have a denture and dental prosthesis
marking system which takes into account the identification marking system
contained in Section 49 of the Illinois Dental Practice Act (Ill. Rev. Stat.,
1987, ch. 111, par. 2349). Policies and Procedures shall be written and
contained in the facility's Policies and Procedure Manual. It shall include, at
a minimum, provisions for: (B)
1) Marking individual dentures or dental prosthesis, if not
marked prior to admission to the facility, within ten days of admittance; and
2) Individually marked denture cups for denture storage at night.
(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.1060 PHYSICAL AND OCCUPATIONAL THERAPY SERVICES
Section 390.1060 Physical and
Occupational Therapy Services
a) The facility shall provide physical therapy and occupational
therapy directly or by arrangements with an outside resource for those
residents who need such services. The treatment training programs should be designed
to preserve and improve abilities for independent function, such as range of motion,
strength, tolerance, coordination, and activities of daily living; and to prevent,
insofar as possible, irreducible or progressive disabilities, through means
such as the use of orthotic and prosthetic appliances, assistive and adaptive
devices, positioning, behavior adaptation, and sensory stimulation. (B)
b) Each resident shall be evaluated within 30 days of admission
regarding the need for such services and the results of such evaluation shall
be entered in the medical record.
c) The therapist shall function closely with the resident's
primary physician and with other medical specialists and treatment training
progress shall be recorded regularly, evaluated periodically, and used as the
basis for continuation or change of the resident's program.
d) Physical and occupational therapy services shall be provided
as needed by the residents through personal contact of the therapists directly
with the residents and indirectly with persons involved with the residents'
treatment programs. (B)
e) Evaluation results, treatment objectives, plans, procedures,
and continuing observations of treatment progress shall be recorded accurately,
summarized, communicated, and included in the resident's record.
f) Physical therapists and occupational therapists shall
participate, when appropriate, in the continuing interdisciplinary evaluation
of individual residents for the purpose of initiation, monitoring, and
follow-up of habilitation programs.
(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.1070 PSYCHOLOGICAL SERVICES
Section 390.1070 Psychological
Services
a) The facility shall provide psychological services either
directly or indirectly by arrangements with an outside resource. These services
should be provided to the residents as needed both directly through personal
contact with the psychologist and indirectly through the psychologist's
consultation with other persons involved in the resident's treatment program.
(B)
b) Each resident shall be evaluated within 30 days of admission
regarding the need for such services and results of such evaluation shall be
entered in the medical record.
c) Psychologists shall participate, when appropriate, in the
continuing interdisciplinary evaluation of individual residents for the purpose
of initiation, monitoring, and follow-up of individual habilitation programs.
d) The psychologist shall report and disseminate the evaluation
results in such a manner that the information, useful to the staff working with
the resident, will be promptly provided and that accepted standards of
confidentiality will be maintained.
e) The facility shall employ sufficient, appropriately qualified
staff, and necessary supporting personnel, to carry out the various
psychological service activities in accordance with the needs of the following functions:
1) Psychological services to residents including evaluation,
consultation, therapy, and program development.
2) Administration and supervision of psychological services.
3) Staff training.
(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.1080 SOCIAL SERVICES
Section 390.1080 Social
Services
a) The facility shall provide Social services, needed by the
resident. These services shall be provided to the residents by or with
consultation of a qualified social worker through the use of social work
methods directed toward: (B)
1) Maximizing the social functioning of each resident.
2) Enhancing the coping capacity of the resident or his family.
3) Asserting and safeguarding the human and civil rights of the
residents and their families, and fostering the human dignity and personal
worth of each resident.
b) The resident and his family shall be helped by social workers
during the evaluation process, which may or may not lead to admission, to
consider alternative services, based on the resident's status and salient
family and community factors, and to make a responsible choice as to whether
and when residential placement is indicated.
c) Each resident shall be evaluated within 30 days of admission
regarding the need for such services and the results of such evaluation shall
be entered in the medical record.
d) Social workers shall participate, when appropriate, in the
continuing interdisciplinary evaluation of individual residents for the
purposes of initiation, monitoring, and follow-up of individualized
habilitation programs.
e) As appropriate during the developmentally disabled person's
admission to and while receiving services in the facility, the social worker
shall provide liaison between him, the facility, the family, and the community,
so as to help the staff to:
1) Individualize and understand the needs of the resident and his
family in relation to each other.
2) Understand social factors, including staff-resident
relationships, in the resident's day-to-day behavior.
3) Prepare the resident for changes in his living situation.
f) Social workers shall help the family to develop constructive
and personally meaningful ways to support the resident's experience in the
facility through:
1) Collateral counseling concerned with problems associated with
changes in family structure and functioning.
2) Referral to specific services, as appropriate.
3) Help the family to participate in planning for the resident's
return to home or other community placement.
g) The facility shall employ sufficient, appropriately qualified
staff, and necessary supporting personnel to carry out the various social
service activities to meet the program needs of the residents. (B)
h) If the facility designates a social worker who does not meet
the definition of "qualified social worker" in Section 390.330, then
that person shall receive adequate consultation from a person who meets the
definition of "qualified social worker" in Section 390.330.
(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.1090 SPEECH PATHOLOGY AND AUDIOLOGY SERVICES
Section 390.1090 Speech
Pathology and Audiology Services
a) The facility shall provide speech pathology and audiology
services as needed by the residents, either directly, or indirectly by
arrangements with an outside resource. These services shall be provided both directly
by speech pathologists, audiologists and other personnel and indirectly through
consultation with other persons involved in implementing residents communication
improvement programs. (B)
b) Each resident shall be evaluated within 30 days regarding the
need for such services and the results of such evaluation shall be entered in
the medical record.
c) The following services are to be provided each resident as
indicated by screening and evaluation results:
1) Comprehensive audiological assessment of residents, as
indicated by screening results, to include tests of puretone air and bone
conduction, speech audiometry, and other procedures, as necessary, and to include
assessment of the use of visual cues.
2) Assessment of the use of amplification.
3) Provision for procurement, maintenance, and replacement of
hearing aids, as specified by a qualified audiologist.
4) Comprehensive speech and language evaluation of residents, as
indicated by screening results, which include appraisal of articulation, voice,
rhythm, and language.
5) Participation when appropriate in the continuing
interdisciplinary evaluation of individual residents for purposes of
initiation, monitoring, and follow up of individualized habilitation programs.
6) Treatment services including: Direct counseling with
residents, consultation with appropriate staff for speech improvement and
speech education activities, and collaboration with appropriate staff to
develop specialized programs for developing the communication skills of
individuals in comprehension (for example, speech, reading, auditory training, and
hearing aid utilization) as well as expression (for example, improvement in articulation,
voice, rhythm, and language).
7) Participation in inservice programs for direct care and other
staff.
8) Report evaluation and assessment results accurately and
systematically, and in such manner as to, where appropriate, provide
information useful to other staff working directly with the resident and to
provide evaluative and summary reports for inclusion in the resident's unit
record.
9) Continuing observations of treatment progress shall be
recorded accurately, summarized, communicated and utilized in evaluating
progress.
d) There shall be provided sufficient, appropriately qualified
staff, and necessary supporting personnel, to carry out the various speech
pathology and audiology services, in accordance with stated goals and
objectives. (B)
e) Staff who assume independent responsibilities for clinical
services shall meet the requirements as defined in Section 390.330. (B)
f) Adequate direction shall be provided personnel, volunteers, or
supportive personnel utilized in providing clinical services.
g) Space, facilities, equipment, and supplies shall be adequate
for providing efficient and effective speech pathology and audiology services.
(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.1100 RECREATIONAL AND ACTIVITY SERVICES
Section 390.1100 Recreational
and Activity Services
a) General Requirements for Recreational and Activity Services
1) The facility shall provide recreational and activity services
as necessary to meet the needs of the residents. These services shall be
coordinated with other services and programs provided the residents, in order
to make fullest possible use of both community and facility resources and to
maximize benefits to the residents.
2) Each resident shall be evaluated within 30 days of admission
regarding the need for services and the results of such evaluation shall be
entered in the medical record.
b) There shall be a specific planned program of group and
individual activities designed to encourage restoration to self-care and
maintenance of normal activity which is geared to the individual resident's
needs. Activities shall be available daily and for a reasonable amount of time.
Residents shall be given an opportunity to contribute to planning, preparation,
conducting, cleanup, and critique of the program. (B)
c) Planning and Direction of Activity Programs
1) There shall be a trained staff person responsible for planning
and directing the activity program. This person shall be on duty for a
sufficient amount of time to provide a program that meets the residents' needs
and interests. Additional activity personnel shall be provided as necessary to
meet the needs of the residents and the program. (B)
2) The staff person responsible for planning and directing the
recreational services shall participate in the continuing interdisciplinary
evaluation of individual residents needs for the purpose of initiating,
monitoring, and follow-up of these programs.
d) There shall be written permission, with any contraindications
stated, given by the resident's physician for the resident to participate in
the activity program. Standing orders will be acceptable with individual
contraindications noted.
e) The recreational and activity program shall include, as
appropriate to the residents, the following program areas, at a minimum:
1) Recreational activities (examples: age appropriate games, both
quiet and active; parties; outside entertainment).
2) Arts and crafts (suitable to meet residents' needs).
3) Religious activities (examples: Bible study or discussion;
Bible quizzes and games; hymn singing; grace at meals). These are in addition
to routine religious services.
4) Service activities for community and facility (examples:
assist with community fund drives; projects for orphanages; care of one's own
area in the facility; helping to fold linen).
5) Social activities (examples: grooming and social graces;
planned group discussion; quizzes and word games; resident council; newsletter).
6) Community activities (examples: residents' participation in
community activities such as plays; church events; band concerts; tours; Girl
Scouts and Boy Scouts).
f) A planned volunteer or auxiliary program that assists with the
activities program shall be encouraged. It shall be under the direction of a
staff member in a supervisory capacity.
g) Documentation of residents' response to program shall be part
of the residents' record as set forth in Section 390.1620(b)(2).
h) Equipment and supplies in sufficient quantity and variety
shall be provided to carry out the stated objectives of the activities
programs.
(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.1110 EDUCATIONAL SERVICES
Section 390.1110 Educational
Services
a) The facility shall provide either directly or indirectly
through arrangements with outside resources, educational programming to all
residents.
b) The individual educational program for each resident shall
meet those provisions of the School Code (Ill. Rev. Stat. 1987, ch. 122, pars.
1-1 et seq.) which are appropriate to meet the educational needs of that
resident.
c) Each individual educational program shall be written and
entered in the resident's record.
(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER d: LONG-TERM CARE FACILITIES
PART 390
MEDICALLY COMPLEX FOR THE
DEVELOPMENTALLY DISABLED FACILITIES CODE
SECTION 390.1120 WORK ACTIVITY AND PREVOCATIONAL TRAINING SERVICES
Section 390.1120 Work
Activity and Prevocational Training Services
a) Where appropriate, providers should cooperate with state and
community agencies in assisting individual residents to avail themselves of
specialized work activity programs, prevocational and work adjustment training,
sheltered workshop programs, and other similar programs that are provided
outside of the facility. (B)
b) Appropriate records shall be maintained for each resident
functioning in these programs. These shall show appropriateness of the program
for the individual, resident's response to the program and any other pertinent
observations and shall become a part of the resident's record.
c) Residents shall not be used to replace employed staff. (B)
(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)
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