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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

Section 390.284  Calculation of Penalties (Repealed)

 

(Source:  Repealed at 43 Ill. Reg. 3564, effective February 26, 2019)

 

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)

 

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)

 

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)

 

Section 390.290  Quarterly List of Violators (Repealed)

 

(Source:  Repealed at 24 Ill. Reg. 17283, effective November 1, 2000)

 

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)

 

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)

 

Section 390.315  Supported Congregate Living Arrangement Demonstration (Repealed)

 

(Source:  Repealed at 43 Ill. Reg. 3564, effective February 26, 2019)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

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)

 

Section 390.1130  Communicable Disease Policies

 

a)         The facility shall comply with the Control of Communicable Diseases Code (77 Ill. Adm. Code 690).

 

b)         A resident who is suspected of or diagnosed as having any communicable, contagious, or infectious disease shall be placed in isolation, if required, in accordance with the Control of Communicable Diseases Code.  If the facility believes that it cannot provide the necessary infection control measures, it must initiate an involuntary transfer and discharge pursuant to Article III, Part 4 of the Act.  In determining whether a transfer or discharge is necessary, the burden of proof rests on the facility.

 

c)         All illnesses required to be reported under the Control of Communicable Diseases Code and Control of Sexually Transmissible Diseases Code (77 Ill. Adm. Code 693) shall be reported immediately to the local health department and to the Department.  The facility shall furnish all pertinent information relating to such occurrences.  In addition, the facility shall also inform the Department of all incidents of scabies and other skin infestations.

 

(Source:  Added at 29 Ill. Reg. 12988, effective August 2, 2005)

 

Section 390.1140  Vaccinations

 

a)         A facility shall annually administer or arrange for a vaccination against influenza to each resident, in accordance with the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention that are most recent to the time of vaccination, unless the vaccination is medically contraindicated or the resident has refused the vaccine. 

 

b)         Residents admitted after November 30, during the flu season, and until February 1 shall, as medically appropriate, receive an influenza vaccination prior to or upon admission or as soon as practicable if vaccine supplies are not available at the time of the admission, unless the vaccine is medically contraindicated or the resident has refused the vaccine.

 

c)         A facility shall document in the resident's medical record that an annual vaccination against influenza was administered, refused or medically contraindicated.

 

d)        A facility shall provide or arrange for administration of a pneumococcal vaccination to each resident in accordance with the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, who has not received this immunization prior to or upon admission to the facility unless the resident refuses the offer for vaccination or the vaccination is medically contraindicated.

 

e)         A facility shall document in each resident's medical record that a vaccination against pneumococcal pneumonia was offered and administered, refused, or medically contraindicated.  (Section 2-213 of the Act)

 

(Source:  Amended at 39 Ill. Reg. 5503, effective March 25, 2015)

 

Section 390.1150  Language Assistance Services

 

A facility shall provide language assistance services in accordance with the Language Assistance Services Act [210 ILCS 87] and the Language Assistance Services Code (77 Ill. Adm. Code 950).

 

(Source:  Added at 29 Ill. Reg. 12988, effective August 2, 2005)

 

Section 390.1310  Restraints

 

a)         Pursuant to Section 2-106(b) of the Act, the facility shall have a written policy to address the use of restraints and seclusion.  Each policy shall include periodic review of the use of restraints, including, but not limited to leg restraints, arm restraints, hand mitts, soft ties or vests, wheelchair safety bars and lap trays, and all facility practices that meet the definition of a physical restraint in Section 2-106 of the Act and Section 390.330, including, but not limited to, tucking in a sheet so tightly that a bed-bound resident cannot move; bed rails used to keep a resident from getting out of bed; chairs that prevent rising; or placing a resident who uses a wheelchair so close to a wall that the wall prevents the resident from rising.  Adaptive equipment is not considered a restraint.  Wrist bands or devices on clothing that trigger electronic alarms to warn staff that a resident is leaving a room do not, in and of themselves, restrict freedom of movement and should not be considered as physical restraints. Written policies, to the extent practicable, should be consistent with the requirements for participation in the federal Medicare program. (Section 2-106(b) of the Act)

 

b)         No physical restraints with locks shall be used.

 

c)         Neither restraints nor confinements shall be employed for the purpose of punishment or for the convenience of any facility personnel. (Section 2-106(b) of the Act)

 

d)         The use of chemical restraints is prohibited.

 

e)         A restraint may be used only for specific periods, if it is the least restrictive means necessary to attain and maintain the resident’s highest practicable physical, mental or psychosocial well being, including brief periods of time to provide necessary life saving treatment. (Section 2-106(c) of the Act)

 

f)         A facility may not issue orders for the use of restraints on a standing or as needed basis.

 

g)         A resident placed in a restraint must be checked at least every 30 minutes by staff trained in the use of restraints, released from the restraint as quickly as possible, and a record of these checks and usage must be kept.

 

h)         Restraints shall be designed and used in a way that does not cause physical injury to the resident and that results in the least possible discomfort.

 

i)          Barred enclosures shall not be more than three feet in height and must not have tops.

 

(Source:  Amended at 46 Ill. Reg. 8192, effective May 6, 2022)

 

Section 390.1312  Nonemergency Use of Physical Restraints

 

a)         The use of high chairs, playpens, cribs or youth beds for children up until their fourth birthday shall not be considered a physical restraint.

 

b)         No restraints or confinements shall be employed except as ordered by a physician who documents the need for such restraints or confinements in the resident’s clinical record.  (Section 2-106(b) of the Act)  Criteria for determining whether physical restraints are needed for a resident shall include, but not be limited to, whether:

 

1)         The assessment of the resident's capabilities and an evaluation and trial of less restrictive measures has led to the determination that the use of less restrictive measures would not attain or maintain the resident’s highest practicable physical, mental or psychosocial well being;

 

2)         The assessment of a specific physical condition or medical treatment indicates the condition or medical treatment requires the use of physical restraints;

 

3)         Consultation with appropriate health professionals such as registered professional nurses, occupational or physical therapists indicates that the use of less restrictive measures or therapeutic interventions has proven ineffective; and

 

4)         Demonstration by the care planning process that using a physical restraint as a therapeutic intervention will promote the care and services necessary for the resident to attain or maintain the highest practicable physical, mental, or psychosocial well being. (Section 2-106(c) of the Act)

 

c)         A physical restraint may be used only with the informed consent of the resident, the resident's guardian, or other authorized representative. (Section 2-106(c) of the Act)  Informed consent includes information about potential negative outcomes of physical restraint use, including incontinence, decreased range of motion, decreased ability to ambulate, symptoms of withdrawal or depression, or reduced social contact.

 

d)         The informed consent may authorize the use of a physical restraint only for a specified period of time.  The effectiveness of the physical restraint in treating medical symptoms or as a therapeutic intervention and any negative impact on the resident shall be assessed by the facility throughout the period of time the physical restraint is used.

 

e)         After 50 percent of the period of physical restraint use authorized by the informed consent has expired, but not less than five days before it has expired, information about the actual effectiveness of the physical restraint in treating the resident's medical symptoms or as a therapeutic intervention and about any actual negative impact on the resident shall be given to the resident, resident's guardian, or other authorized representative before the facility secures an informed consent for an additional period of time. Information about the effectiveness of the physical restraint program and about any negative impact on the resident shall be provided in writing.

 

f)         A physical restraint may be applied only by staff trained in the application of the particular type of restraint.  (Section 2-106(d) of the Act)

 

g)         Whenever a period of use of a physical restraint is initiated, the resident shall be advised of his or her right to have a person or organization of his or her choosing, including the Guardianship and Advocacy Commission, notified of the use of the physical restraint, whether or not the guardian approved the notice.  A period of use is initiated when a physical restraint is applied to a resident for the first time under a new or renewed informed consent for the use of physical restraints.  If the resident so chooses, the facility shall make the notification within 24 hours, including any information about the period of time that the physical restraint is to be used.  Whenever the Guardianship and Advocacy Commission is notified that a resident has been restrained, it shall contact the resident to determine the circumstances of the restraint and whether further action is warranted.  (Section 2-106(e) of the Act)  If the resident requests that the Guardianship and Advocacy Commission be contacted, the facility shall provide the following information, in writing, to the Guardianship and Advocacy Commission:

 

1)         The reason the physical restraint was needed;

 

2)         The type of physical restraint that was used;

 

3)         The interventions utilized or considered prior to physical restraint and the impact of these interventions;

 

4)         The length of time the physical restraint was to be applied; and

 

5)         The name and title of the facility person who should be contacted for further information.

 

h)         Whenever a physical restraint is used on a resident whose primary mode of communication is sign language, the resident shall be permitted to have his or her hands free from restraint for brief periods each hour, except when this freedom may result in physical harm to the resident or others.  (Section 2-106(f) of the Act)

 

i)          The plan of care shall contain a schedule or plan of rehabilitative/habilitative training to enable the most feasible progressive removal of physical restraints or the most practicable progressive use of less restrictive means to enable the resident to attain or maintain the highest practicable physical, mental or psychosocial well being.

 

j)          A resident wearing a physical restraint shall have it released for a period of not less than 10 minutes during each two-hour period in which the restraint is employed, or more often if necessary.  During these times, residents shall be given the opportunity for motion and exercise or shall be assisted with ambulation, as their condition permits, and provided a change in position, skin care and nursing care, as appropriate. A record of this activity during a period of restraint shall be kept in the resident's medical record.

 

k)         No form of seclusion shall be permitted.

 

(Source:  Amended at 46 Ill. Reg. 8192, effective May 6, 2022)

 

Section 390.1314  Emergency Use of Physical Restraints

 

a)         If the resident needs emergency care, physical restraints may be used for brief periods to permit medical treatment to proceed unless the facility has notice that the resident has previously made a valid refusal of the treatment in question.  (Section 2-106(c) of the Act)

 

b)         For this Section only, "emergency care" means the unforeseen need for immediate treatment inside or outside the facility that is necessary to:

 

1)         Save the resident's life;

 

2)         Prevent the resident from doing serious mental or physical harm to himself/herself; or

 

3)         Prevent the resident from injuring another individual.

 

c)         If a resident needs emergency care and other less restrictive interventions have proven ineffective, a physical restraint may be used briefly to permit treatment to proceed.  The attending physician shall be contacted immediately for orders.  If the attending physician is not available, the facility's advisory physician or Medical Director shall be contacted.  If a physician is not immediately available, a registered professional nurse with supervisory responsibility may approve, in writing, the use of physical restraints.  A confirming order, which may be obtained by telephone, shall be obtained from the physician as soon as possible, but no later than within 8 hours.  The effectiveness of the physical restraint in treating medical symptoms or as a therapeutic intervention and any negative impact on the resident shall be assessed by the facility throughout the period of time the physical restraint is used.  The resident must be in view of a qualified staff person at all times until either the resident has been examined by a physician or the physical restraint has been removed.  The resident's needs for toileting, ambulation, hydration, nutrition, repositioning, and skin care must be met while the physical restraint is being used.

 

d)         Authorizations to use or extend restraints as an emergency shall be in effect no longer than 12 consecutive hours and shall be obtained as soon as the client is restrained or stable.

 

e)         The emergency use of a physical restraint shall be documented in the resident's record, including:

 

1)         The behavior incident that prompted the use of the physical restraint;

 

2)         The date and times the physical restraint was applied and released;

 

3)         The name and title of the person responsible for the application and supervision of the physical restraint;

 

4)         The action by the resident's physician upon notification of the physical restraint use;

 

5)         The new or revised orders issued by the physician;

 

6)         The effectiveness of the physical restraint in treating medical symptoms or as a therapeutic intervention and any negative impact on the resident; and

 

7)         The date of the scheduled care planning conference or the reason a care planning conference is not needed, in light of the resident's emergency need for physical restraints.

 

f)         The facility's use of physical restraints shall comply with Sections 390.1312(e) through (k).

 

(Source:  Amended at 46 Ill. Reg. 8192, effective May 6, 2022)

 

Section 390.1316  Unnecessary, Psychotropic, and Antipsychotic Drugs

 

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

 

1)         "Adverse consequence" – unwanted, uncomfortable, or dangerous effects that a medication may have, such as impairment or decline in an individual’s mental or physical condition or functional or psychosocial status. It may include, but is not limited to, various types of adverse medication reactions and interactions (e.g., medication-medication, medication-food, and medication-disease).

 

2)         "Antipsychotic medication" – a medication that is used to treat symptoms of psychosis such as delusions, hearing voices, hallucinations, paranoia, or confused thoughts. Antipsychotic medications are used in the treatment of schizophrenia, severe depression, and severe anxiety. Older antipsychotic medications tend to be called typical antipsychotics. Those developed more recently are called atypical antipsychotics.

 

3)         "Dose" – the total amount/strength/concentration of a medication given at one time or over a period of time. The individual dose is the amount/strength/concentration received at each administration. The amount received over a 24-hour period may be referred to as the daily dose.

 

4)         "Duplicative therapy" – multiple medications of the same pharmacological class or category or any medication therapy that substantially duplicates a particular effect of another medication that the individual is taking.

 

5)         "Emergency" – has the same meaning as in Section 1-112 of the Act and Section 390.330.  (Section 2-106.1(b) of the Act)

 

6)         "Excessive dose" – the total amount of any medication (including duplicative therapy) given at one time or over a period of time that is greater than the amount recommended by the manufacturer's label, package or insert, and the accepted standards of practice for a resident's age and condition.

 

7)         "Gradual dose reduction" – the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.

 

8)         "Informed consent" – documented, written permission for specific medications, given freely, without coercion or deceit, by a capable resident, or by a resident's authorized representative, after the resident, or the resident's authorized representative, has been fully informed of, and had an opportunity to consider, the nature of the medications, the likely benefits and most common risks to the resident of receiving the medications, any other likely and most common consequences of receiving or not receiving the medications, and possible alternatives to the proposed medications.

 

9)         "Licensed nurse" – an advanced practice registered nurse or a registered professional nurse, as defined in the Nurse Practice Act.

 

10)         "Psychotropic medication" – medication that is used for or listed as used for psychotropic, antidepressant, antimanic or antianxiety behavior modification or behavior management purposes in the Prescribers Digital Reference database, the Lexicomp-online database, or the American Society of Health-System Pharmacists database.  Psychotropic medication also includes any medication listed in 42 CFR 483.45(c)(3). (Section 2-106.1(b) of the Act)

 

b)         A resident shall not be given unnecessary medications.  An unnecessary medication is any medication used:

 

1)         In an excessive dose, including in duplicative therapy;

 

2)         For excessive duration;

 

3)         Without adequate monitoring;

 

4)         Without adequate indications for its use;

 

5)         In the presence of adverse consequences that indicate the medications should be reduced or discontinued (Section 2-106.1(a) of the Act); or

 

6)         Any combination of the circumstances listed in subsections (b)(1) through (5).

 

c)         Residents shall not be given antipsychotic drugs unless antipsychotic medication therapy is ordered by a physician or an authorized prescribing professional, as documented in the resident's comprehensive assessment, to treat a specific symptom or suspected condition as diagnosed and documented in the clinical record or to rule out the possibility of one of the conditions in accordance with Appendix C.

 

d)         Residents who use antipsychotic medications shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue these drugs in accordance with Appendix C.  In compliance with subsection 2-106.1(b) of the Act and this Section, the facility shall obtain informed consent for each dose reduction.

 

e)         Psychotropic medication shall not be administered without the informed consent of the resident, the resident's guardian, or other authorized representative.  (Section 2-106.1(b) of the Act)  Additional informed consent is not required for reductions in dosage level or deletion of a specific medication, pursuant to subsection (f).  Informed consent is required for a medication administration program of sequentially increased doses or combination of medications to establish the lowest effective dose that will achieve the desired therapeutic outcome, pursuant to subsection (f).  The most common side effects of medications shall be described.

 

f)         Protocol for Securing Informed Consent for Psychotropic Medication

 

1)         Pursuant to Section 2-106.1(b) of the Act, no resident shall be administered psychotropic medication prior to a discussion between the resident or the resident's authorized representative, or both, and the resident's physician or a physician the resident was referred to, a registered pharmacist who is not a dispensing pharmacist for the facility where the resident lives, or a licensed nurse about the most common possible risks and benefits of a recommended medication, and the use of standardized consent forms designated by the Department.  (Section 2-106.1(b) of the Act)

 

2)         Prior to initiating any detailed discussion designed to secure informed consent, a licensed health care professional shall inform the resident or the resident's authorized representative that:

 

A)        The resident's physician has prescribed a psychotropic medication for the resident, and that informed consent is required from the resident or the resident's authorized representative before the resident may be given the medication;

 

B)        The resident's informed consent may be withdrawn at any time; and

 

C)        The resident may refuse to take the medication, even if informed consent was previously given. 

 

3)         The discussion shall include information about:

 

A)        The name of the medication;

 

B)        The condition or symptoms that the medication is intended to treat, and how the medication is expected to treat those symptoms;

 

C)        How the medication is intended to affect those symptoms;

 

D)        Other common effects or side effects of the medication, and any reasons (e.g., age, health status, other medications) that the resident is more or less likely to experience side effects;

 

E)        Dosage information, including how much medication would be administered, how often, and the method of administration (e.g., orally or by injection; with, before, or after food);

 

F)         Any tests and related procedures that are required for the safe and effective administration of the medication;

 

G)        Any food or activities the resident should avoid while taking the medication;

 

H)        Any possible alternatives to taking the medication that could accomplish the same purpose; and

 

I)         Any possible consequences to the resident of not taking the medication.

 

4)         Pursuant to Section 2-105 of the Act, the discussion designed to secure informed consent shall be private, between the resident or the resident's authorized representative, or both, and the resident's physician, or a physician the resident was referred to, or a registered pharmacist who is not a dispensing pharmacist for the facility where the resident lives, or an advanced practice or registered professional nurse. 

 

5)         In addition to the oral discussion, the resident or the resident's authorized representative shall be given the information in subsection (f)(3) in writing.  The information shall be in plain language, understandable to the resident or the resident's authorized representative.  If the written information is in a language not understood by the resident or the resident's authorized representative, the facility shall provide an interpreter capable of communicating with the resident or the resident's authorized representative and the authorized prescribing professional conducting the discussion.  The authorized prescribing professional shall guide the resident through the written information.  The written information shall include a place for the resident or the resident's authorized representative to give, or to refuse to give, informed consent.  The written information shall be placed in the resident's record. Informed consent is not secured until the resident or the resident's representative has given written informed consent.

 

6)         Regardless of the availability of the resident's authorized representative, the resident shall be notified and present at any discussion required by this Section.  The resident shall be given, at a minimum, written information about the medication and an oral explanation of common side effects of the medication to facilitate the resident in identifying the medication and in communicating the existence of side effects to the direct care staff. 

 

7)         The maximum possible time period for informed consent shall be one year.

 

8)         A resident or the resident's authorized representative shall not be asked to consent to the administration of a new psychotropic medication in a dosage or frequency that exceeds the maximum recommended daily dosage as found in the Prescribers Digital Reference database, the Lexicomp-online database, or the American Society of Health-System Pharmacists database unless the reason for exceeding the recommended daily dosage is explained to the resident or the resident's authorized representative by the resident's physician, or a physician the resident was referred to, or a registered pharmacist who is not a dispensing pharmacist for the facility where the resident lives, or an advanced practice or registered professional nurse, and the reason for exceeding the recommended daily dosage is justified by the prescribing prescriber in the clinical record.  The dosage and frequency shall be reviewed and re-justified by the licensed prescriber on a weekly basis and reviewed by a consulting pharmacist.  The justification for exceeding the recommended daily dosage shall be recorded in the resident's record and shall be approved within seven calendar days after obtaining informed consent, in writing, by the medical director of the facility.

 

9)         The facility shall obtain informed consent using forms provided by the Department on its official website, or on forms approved by the Department, pursuant to subsection 2-106.1(b) of the Act.  The facility shall document on the consent form whether the resident is capable of giving informed consent for medication therapy, including for receiving psychotropic medications. If the resident is not capable of giving informed consent, the identity of the resident's authorized representative shall be placed in the resident's record.

 

g)         In addition to any other requirement prescribed by the Act or this Part, a facility that is found to have violated this Section or the federal certification requirement that informed consent be obtained before administering a psychotropic medication shall for three years after the notice of violation be required to:

 

1)         Obtain the signatures of two licensed health care professionals on every form purporting to give informed consent for the administration of a psychotropic medication, certifying the personal knowledge of each health care professional that the consent was obtained in compliance with the requirements of this subsection, or

 

2)         Videotape or make a digital video record of the procedures followed by the facility to comply with the requirements of this subsection.  (Section 2-106.1(b) of the Act)

 

(Source:  Amended at 46 Ill. Reg. 8192, effective May 6, 2022)

 

Section 390.1320  Behavior Management

 

a)         Behavior management shall be conducted under the direction of a psychologist or Qualified Mental Retardation Professional with a behavior science education and one year of experience in behavior management.

 

b)         The facility shall have written policies and procedures concerning behavior management as needed to meet the needs of the residents.  These policies shall be directed to maximizing the growth and development of the resident and shall emphasize positive approaches.  These policies shall contain at a minimum:

 

1)         A hierarchy of available methods from least to most restrictive.

 

2)         Policies that define the use of Individual Behavior Programs, the persons qualified to authorize them, and a mechanism for monitoring and controlling their use.

 

c)         An Individual Behavior Program shall be developed for each resident, if deemed necessary by the facility's  psychologist or Qualified Mental Retardation Professional.  All Individual Behavior Programs shall be designed to facilitate the development of adaptive behaviors, replace maladaptive behaviors with those that are more adaptive and appropriate, and channel maladaptive behavior into more appropriate modes of expression. They shall utilize the least restrictive methods that are effective.  When positive reinforcement is used solely for the purpose of improving adaptive or acceptable behavior, an Individual Behavior Program is not required.

 

d)         Each Individual Behavior Program shall be reviewed and approved by the interdisciplinary team, which must include, for this review, a psychologist or a Qualified Mental Retardation Professional with a behavior science education and one year of experience in behavior management.

 

e)         Each Individual Behavior Program shall specify:

 

1)         the behavior objectives of the program;

 

2)         the method to be used;

 

3)         the schedule for the use of the method;

 

4)         the person responsible for the program;

 

5)         the data to be collected to assess progress toward the objectives.

 

f)         Each Individual Behavior Program shall be available in the appropriate program and living areas, and to the resident and his family.

 

g)         The facility shall not permit residents to discipline other residents.

 

h)         The facility shall maintain records of significant maladaptive behavior and the action taken by staff as a consequence of such behavior.

 

i)          When food is provided as part of a behavior management program, its effect on nutrition  and dental status shall be determined and considered.  Such programs shall not employ, or result in, denial of a nutritionally  adequate diet.

 

j)          When time out is used for behavior management:

 

1)         It may be utilized only as an integral part  of an Individual Behavior Program.

 

2)         It may not include the use of seclusion.

 

3)         The resident may be retained in a given area for a brief period of time. An open-top enclosure in which the resident can move freely and can see either over or through the sides may be utilized.  A chair or mat must be provided, as appropriate.

 

4)         Time out for more than 15 minutes at any one time, for more than a total of 30 minutes in any one hour period, or for more than a total of two hours in any eight hour period, shall be effected only upon the written order, on each occasion, of the facility administrator or other designated supervisory or professional personnel.  Consecutive periods of time out separated by less than five minutes shall be considered as a single period of time out.  The order shall state in detail the reason for the time out and may not be for a period of more than one hour.  No order for further time out may be written unless the facility administrator or designated supervisory personnel on duty at the time has reviewed the situation with the staff and has documented the need for another period of time.

 

5)         When time out exceeds 15 minutes at any one time, the situation shall be reviewed at least every 15 minutes by the facility administrator or designated supervisory personnel.

 

6)         A staff member shall be assigned to visually check on each person in time out at least every 15 minutes.

 

7)         A record must be kept for each period of time out.  Each time a resident is placed in time out, entries shall be made, either in a separate log kept for this purpose or in the resident's record.  For time out periods of 15 minutes or less, the following entries shall be made:  name, number of periods of time out in a specified block of time (not to exceed four hours).  For time out periods of more than 15 minutes, the following entries shall be made:  resident's name, time in, time out, name of authorized person signing written order for time out, reason resident was placed in time out, and signature of staff member requesting time out.  Staff members assigned to 15 minute checks must sign the log as the time checks are made, recording the time and the resident's condition.

 

8)         All safety precautions shall be observed so that the resident cannot injure himself while in "time out."

 

k)         When behavior management is used to alleviate significant, chronic maladaptive behavior in a resident, it may be utilized only as an integral part of an Individual Behavior Program.

 

l)          No form of seclusion shall be permitted.

 

(Source:  Amended at 20 Ill. Reg. 12101, effective September 10, 1996)

 

Section 390.1330  Behavior Emergencies (Repealed)

 

(Source:  Repealed at 20 Ill. Reg. 12101, effective September 10, 1996)

 

Section 390.1410  Medication Policies and  Procedures

 

a)         Every facility shall adopt written policies and procedures for properly and promptly obtaining, dispensing, administering, returning, and disposing of drugs and medications.  These policies and procedures shall be consistent with the Act and this Part, shall be in compliance with all applicable federal, State and local laws, and shall be followed by the facility.  Medication policies and procedures shall be developed with the advice of a pharmaceutical advisory committee that includes at least one licensed pharmacist, one physician, the administrator and the director of nursing.  This committee shall meet at least quarterly. 

 

b)         For the purpose of this Subpart, "licensed prescriber" means a physician; a dentist; a podiatrist; an optometrist certified to use therapeutic ocular pharmaceutical agents; a physician assistant to whom prescriptive authority has been delegated by a supervising physician; or an advanced practice nurse practicing under a valid collaborative agreement.

 

c)         All legend medications maintained in the facility shall be on individual prescription or from the licensed prescriber's personal office supply, and shall be labeled as set forth in Section 390.1440. A licensed prescriber who supplies medicine from his or her personal office supply shall comply with Sections 33 and 54.5 of the Medical Practice Act of 1987 [225 ILCS 60/33 and 54.5]; or Section 51 of the Illinois Dental Practice Act [225 ILCS 25/51]; or the Podiatric Medical Practice Act of 1987 [225 ILCS 100]; or Section 15.1 of the Illinois Optometric Practice Act of 1987 [225 ILCS 80/15.1]; or Section 15-20 of the Nursing and Advanced Practice Nursing Act [225 ILCS 65/15-20]; or Section 7.5 of the Physician Assistant Practice Act of 1987 [225 ILCS 95/7.5]. 

 

d)         All medications administered shall be recorded as set forth in Section 390.1620. Medications shall not be recorded as having been administered prior to their actual administration to the resident. 

 

e)         The staff pharmacist or consultant pharmacist shall participate in the planned in-service education program of the facility on topics related to pharmaceutical services.

 

f)         A pharmacist shall obtain a Division III license to operate an on-premises pharmacy in accordance with the rules of the Illinois Department of Professional Regulation (68 Ill. Adm. Code 1330).

 

g)         No facility shall maintain a stock supply of controlled drugs or legend drugs, except for those in the emergency medication kit, as described in this Section. 

 

h)         A facility may stock drugs that are regularly available without prescription.  These shall be administered to a resident only upon the written order of a licensed prescriber.  Administration shall be from the original containers, and shall be recorded in the resident's clinical record. 

 

i)          A facility may keep convenience boxes containing medications to be used for initial doses.

 

1)         The contents and number of convenience boxes shall be determined by the pharmaceutical advisory committee.  The contents shall be listed on the outside of each box.

 

2)         Each  convenience box shall be the property of and under the control of the pharmacy that supplies the contents of the box, and it shall be kept in a locked medicine room or cabinet. 

 

3)         No Schedule II controlled substances shall be kept in convenience boxes.

 

j)          The contents and number of emergency medication kits shall be approved by the facility's pharmaceutical advisory committee, and shall be available for immediate use at all times in locations determined by the pharmaceutical advisory committee.

 

1)         Each emergency medication kit shall be sealed after it has been checked and refilled. 

 

2)         Emergency medication kits shall also contain all of the equipment needed to administer the medications.

 

3)         The contents of emergency medication kits shall be labeled on the outside of each kit.  The kits shall be checked and refilled by the pharmacy after use and as otherwise needed.  The pharmaceutical advisory committee shall review the list of substances kept in emergency medication kits at least quarterly.  Written documentation of this review shall be maintained. 

 

k)         The following requirements shall be met when controlled substances are kept as part of the emergency medication kits:

 

1)         If an emergency medication kit is not stored in a locked room or cabinet, or if the kit contains controlled substances that require refrigeration, then the controlled substances portion of the kit shall be stored separately in a locked cabinet or room (or locked refrigerator or locked container within a refrigerator, as appropriate) and labeled with a list of the substances and a statement that they are part of the emergency medication kit.  The label of the emergency medication kit shall list the substances and the specific location where they are stored. 

 

2)         Controlled substances for emergency medication kits shall be obtained from a federal Drug Enforcement Administration registered hospital, pharmacy, or licensed prescriber.

 

3)         Only the director of nursing, registered nurse on duty, licensed practical nurse on duty, consultant pharmacist or licensed prescriber shall have access to controlled substances stored in emergency medication kits. 

 

4)         No more than ten different controlled substances shall be kept as part of an emergency medication kit, and there shall be no more than three single doses of any one controlled substance.

 

5)         Controlled substances in emergency medication kits may be administered only by persons licensed to administer medications, in compliance with 21 CFR 1306.11 and 1306.21 and the Illinois Controlled Substances Act [720 ILCS 570]. 

 

6)         A proof-of-use sheet shall be stored with each controlled substance.  Entries shall be made on the proof-of-use sheet by the nursing staff or licensed prescriber when any controlled substance from the kit is used.  The consultant pharmacist shall receive and file for two years a copy of all completed proof-of-use sheets. 

 

7)         Whenever the controlled substance portion of an emergency medication kit is opened, the consultant pharmacist shall be notified within 24 hours.  During any period when this kit is opened, a shift count shall be done on all controlled substances until the kit is closed or locked, or the controlled substance is replaced.  Shift counts are not mandatory when the kit is sealed.  Forms for shift counts shall be kept with the controlled substances portion of the emergency medication kit. 

 

8)         The consultant pharmacist shall check the controlled substances portions of emergency medication kits at least monthly and so document on the outside of the kit. 

 

9)         Failure to comply with any provision of this Section, or with any applicable provision of State or federal statutes or State regulations pertaining to controlled substances, shall result in loss of the privilege of having or placing controlled substances in emergency medication kits until the facility can demonstrate that it is in compliance with such regulations.  This is in addition to the usual methods of corrective action available to the Department, such as fines and other penalties.

 

l)          Oxygen may be administered in a facility.  The oxygen supply shall be stored and handled in accordance with the National Fire Protection Association (NFPA) Standard No. 99:  Standard for Health Care Facilities (2002, no later amendments or editions included) for nonflammable medical gas systems.  The facility shall comply with directions for use of oxygen systems as established by the manufacturer and by the applicable provisions of the NFPA Life Safety Code (see Section 390.340) and NFPA 99.

 

1)         Facilities shall store medical grade products separately from industrial grade products.  The storage area for medical grade products shall be well defined with one area for receiving full medical gas vessels and another for storing empty vessels.

 

2)         All personnel who will be handling medical gases shall be trained to recognize the various medical gas labels.  Personnel shall be trained to examine all labels carefully.

 

3)         If the facility's supplier uses 360-degree wrap-around labels to designate medical oxygen, personnel shall be specifically trained to make sure each vessel they connect to the oxygen system bears such a label.

 

4)         All facility personnel responsible for changing or installing medical gas vessels shall be trained to connect medical gas vessels properly.  Personnel shall understand how vessels are connected to the oxygen supply system and shall be alerted to the serious consequences of changing connections.

 

5)         If a medical gas vessel fitting does not seem to connect to the oxygen system fitting, the supplier shall be contacted immediately.  The vessel shall be returned to the supplier to determine the fitting or connection problem.

 

6)         Once a medical gas vessel has been connected to the oxygen supply system, but prior to introducing the product into the system, a trained facility staff member shall ensure that the correct vessel has been connected properly.

 

(Source:  Amended at 27 Ill. Reg. 5947, effective April 01, 2003)

 

Section 390.1420  Compliance with Licensed Prescriber's  Orders

 

a)         All medications shall be given only upon the written, facsimile or electronic order of a licensed prescriber.  The facsimile or electronic order of a licensed prescriber shall be authenticated by the licensed prescriber within 10 calendar days, in accordance with Section 390.1610.  All such orders shall have the handwritten or electronic signature of the licensed prescriber.  (Rubber stamp signatures are not acceptable.)  These medications shall be administered as ordered by the licensed prescriber and at the designated time.

 

b)         Telephone orders may be taken by a registered professional nurse, licensed practical nurse or licensed pharmacist.  All such orders shall be immediately written on the resident's clinical record or a telephone order form and signed by the nurse or pharmacist taking the order.  These orders shall be countersigned by the licensed prescriber within 10 calendar days.

 

c)         The staff pharmacist or consultant pharmacist shall review the medical record, including licensed prescriber orders and laboratory test results, at least monthly and, based on  their clinical experience and judgment, and Section 390.Appendix C, determine if there are irregularities that would cause adverse reactions, allergies, interactions, contraindications, medication errors or ineffectiveness.  This review shall be documented in the clinical record.  Portions of this review may be done outside the facility.  Any irregularities noted shall be reported to the attending physician, the advisory physician, the director of nursing and the administrator, and shall be acted upon.

 

d)         A medication order not specifically limiting the time or number of doses shall be automatically stopped in accordance with written policy approved by the pharmaceutical advisory committee.

 

e)         The resident's licensed prescriber shall be notified of medications about to be stopped so that the licensed prescriber may promptly renew such orders to avoid interruption of the resident's therapeutic regimen.

 

f)         The licensed prescriber shall approve the release of any medications to the resident, or person responsible for the resident's care, at the time of discharge or when the resident is going to be temporarily out of the facility at medication time.  Disposition of the medications shall be noted in the resident's clinical record.

 

(Source:  Amended at 46 Ill. Reg. 8192, effective May 6, 2022)

 

Section 390.1430  Administration of Medication

 

a)         All medications shall be administered only by personnel who are licensed to administer medications, in accordance with their  respective licensing requirements.  Licensed practical nurses shall have successfully completed a course in pharmacology or have at least one year's full-time supervised experience in administering medications in a health care setting if their duties include administering medications to residents.

 

1)         Medications shall be administered as soon as possible after doses are prepared at the facility and shall be administered by the same person who prepared the doses for administration, except under single unit dose packaged distribution systems. 

 

2)         Each dose administered shall be properly recorded in the clinical record by the person who administered the dose.  (See Section 390.1620.)

 

3)         Self-administration of medication shall be permitted only upon the written order of the licensed prescriber. 

 

b)         The facility shall have medication records that shall be used and checked against the licensed prescriber's orders when administering medications to assure proper administration of medicine to each resident.  Medication records shall include or be accompanied by recent photographs or other means of easy, accurate resident identification.  Medication records shall contain resident's name, diagnoses, known allergies, current medications, dosages, directions for use, and, if available, a history of prescription and non-prescription medications taken by the resident during the 30 days prior to admission to the facility.

 

c)         Medications prescribed for one resident shall not be administered to another resident. 

 

d)         If, for any reason, a licensed prescriber's medication order cannot be followed, the licensed prescriber shall be notified as soon as is reasonable, depending upon the situation, and a notation made in the resident's record.

 

e)         Medication errors and drug reactions shall be immediately reported to the resident's physician, licensed prescriber if other than a physician, the consulting pharmacist and the dispensing pharmacist (if the consulting pharmacist and the dispensing pharmacist are not associated with the same pharmacy).  An entry shall be made in the resident's clinical record, and the error or reaction shall also be described on an incident report. 

 

f)         Nurses' stations shall be equipped as per Section 390.2660 or Section 390.2960 and shall have all necessary items readily available for the proper administration of medications.

 

g)         Current medication references shall be  available, such as the current edition of "Drug Facts and Comparisons", "Hospital Formulary", "USP-DI (United States Pharmacopeia-Drug Information)", "Physician's Desk Reference" or other suitable references.

 

(Source:  Amended at 27 Ill. Reg. 5947, effective April 01, 2003)

 

Section 390.1440  Labeling and Storage of Medications

 

a)         All medications for all residents shall be properly labeled and stored at or near the nurses' station in a locked cabinet, in a locked medication room, or in one or more locked mobile medication carts of satisfactory design for such storage.  (See subsections (f) and (g) of this Section.) 

 

1)         These cabinets, rooms, and carts shall be well lighted and of sufficient size to permit storage without crowding. 

 

2)         All mobile medication carts shall be under the visual control of the responsible nurse at all times when not stored safely and securely.

 

b)         All medications for external use shall be kept in a separate area in the medicine cabinet, medicine room or mobile medication cart. 

 

c)         All poisonous substances and other hazardous compounds shall be kept in a separate locked container away from medications. 

 

d)         Biologicals or medications requiring refrigeration shall be kept in a separate, securely fastened and locked box within a refrigerator or a locked refrigerator, at or near the nurses' station or in a refrigerator within a locked medication room. 

 

e)         The key or access code to the medicine cabinet, medicine  room or mobile medication cart shall be the responsibility of, and in the possession of, the persons authorized to handle and administer medications at all times.

 

f)         The label of each individual multidose medication container filled by a pharmacist shall clearly indicate the resident's full name; licensed prescriber's name; prescription number, name, strength and quantity of drug; date this container was last filled; the initials  of the pharmacist and, if applicable, the pharmacy technician filling the prescription; the identity of the pharmacy; the refill date; and any necessary special instructions.  If the individual multidose medication container is filled by a licensed prescriber from his or her own supply, the label shall clearly indicate all of the preceding information and the source of supply; it shall exclude identification of the pharmacy, pharmacist and prescription number.

 

g)         Each single unit or unit dose package shall bear the proprietary and nonproprietary name of the drug, strength of dose and total contents delivered, lot or control number, and expiration date, if applicable.  The names of the resident and the licensed prescriber do not have to be on the label of the package, but they must be identified with the package in such a manner as to assure that the drug is administered to the right resident.  Appropriate accessory and cautionary statements and any necessary special instruction shall be included, as applicable.  Hardware for storing and delivering the medications shall be labeled with the identity of the dispensing pharmacy.  The pharmacist shall provide written verification of the date the medications were dispensed and the initials (or unique identifier) of the pharmacist who reviewed and verified the medications.  The pharmacist need not store such verification at the facility but shall readily make it available to the Department upon request.  The lot or control number need not appear on unit dose packages if the dispensing pharmacy has a system for identifying those doses recalled by the manufacturer/distributor or if the dispensing pharmacy will recall and destroy all dispensed doses of a recalled medication, irrespective of a manufacturer's/distributor's specifically recalled lot. 

 

h)         Medication in containers having soiled, damaged, incomplete, illegible, or makeshift labels shall be returned to the issuing pharmacist, pharmacy, or dispensing licensed prescriber for relabeling or disposal.  Medications whose directions for use have changed since the medication was originally dispensed and labeled may be retained for use at the facility in accordance with the licensed prescriber's current medication order.  Medications in containers having no labels shall be destroyed in accordance with federal and State laws. 

 

i)          The medications of each resident shall be kept and stored in their originally received containers.  Medications shall not be transferred between containers, except that a licensed nurse, acting as the agent of the resident, may remove previously dispensed medication from original containers and place it in other containers to be sent with a resident when the resident will be out of the facility at the time of scheduled administration of medication.  When medication is sent out of the facility with the resident, it shall be labeled by the nurse with the name of the resident, name and strength of the medication, instructions for administration and any other appropriate information. 

 

(Source:  Amended at 27 Ill. Reg. 5947, effective April 01, 2003)

 

Section 390.1450  Control of Medications

 

a)         The facility shall comply with all federal and State laws and State regulations relating to the procurement, storage, dispensing, administration, and disposal of medications.

 

b)         All Schedule II controlled substances shall be stored so that two separate locks, using two different keys, must be unlocked to obtain these substances.  This may be accomplished by several methods, such as locked cabinets within locked medicine rooms; separately locked, securely fastened boxes (or drawers) within a locked medicine cabinet; locked portable medication carts that are stored in locked medicine rooms when not in use; or portable medication carts containing a separate locked area within the locked medication cart, when such cart is made immobile.

 

c)         Disposal of Medications

 

1)         All medications having an expiration date that has passed, and all medications of residents who have been discharged or who have died shall be disposed of in accordance with the written policies and procedures established by the facility in accordance with Section 390.1410.  Medications shall be transferred with a resident, upon the order of the resident's physician, when a resident transfers to another facility.  All discontinued medications, with the exception of those products regulated and defined as controlled substances under Section 802 of the federal Controlled Substances Act (21 USC 802), shall be returned to the dispensing pharmacy.

 

2)         Medications for any resident who has been temporarily transferred to a hospital shall be kept in the facility.  Medications may be given to a discharged resident only upon the order of the licensed prescriber.

 

d)         Inventory Controls

 

1)         For all Schedule II controlled substances, a controlled substances record shall be maintained that lists on separate sheets, for each type and strength of Schedule II controlled substance, the following information:  date, time administered, name of resident, dose, licensed prescriber's name, signature of person administering dose, and number of doses remaining.

 

2)         The pharmaceutical advisory committee may also require that other medications shall be subject to such inventory records.

 

(Source:  Amended at 27 Ill. Reg. 5947, effective April 01, 2003)

 

Section 390.1610  Resident Record Requirements

 

a)         Each facility shall have a medical record system that retrieves information regarding individual residents.

 

b)         The facility shall keep an active medical record for each resident.  This resident record shall be kept current, complete, legible and available at all times to those personnel authorized by the facility's policies, and to the Department's representatives.

 

c)         Record entries shall meet the following requirements:

 

1)         Record entries shall be made by the person providing or supervising the service or observing the occurrence that is being recorded.

 

2)         All entries into the medical record shall be authenticated by the individual who made or authored the entry.  "Authentication", for purposes of this Section, means identification of the author of a medical record entry by that author and confirmation that the contents are what the author intended.

 

3)         Medical record entries shall include all notes, orders or observations made by direct resident care providers and any other individuals authorized to make such entries in the medical record, and written interpretive reports of diagnostic tests or specific treatment including, but not limited to, radiologic or laboratory reports and other similar reports.

 

4)         Authentication shall include the initials of the signer's credentials. If the electronic signature system will not allow for the credential initials, the facility shall have a means of identifying the signer's credentials.

 

5)         Electronic Medical Records Policy.  The facility shall have a written policy on electronic medical records.  The policy shall address persons authorized to make entries, confidentiality, monitoring of record entries, and preservation of information.

 

A)        Authorized Users.  The facility shall develop a policy to assure that only authorized users make entries into medical records and that users identify the date and author of every entry in the medical records.  The policy should allow written signatures, written initials supported by a signature log, or electronic signatures with assigned identifiers, as authentication by the author that the entry made is complete, accurate and final.

 

B)        Confidentiality.  The facility policy shall include adequate safeguards to ensure confidentiality of patient medical records, including procedures to limit access to authorized users.  The authorized user must certify in writing that he or she is the only person with authorized user access to the identifier and that the identifier will not be shared or used by any other person.  A surveyor or inspector in the performance of a State-required inspection may have access to electronic medical records, using the identifier and under the supervision of an authorized user from the facility.  A surveyor or inspector may have access to the same electronic information normally found in written patient records.  Additional summary reports, analyses, or cumulative statistics available through computerized records are the internal operational reports of the facility's Quality Assurance Committee.

 

C)        Monitoring.  The facility shall develop a policy to periodically monitor the use of identifiers and take corrective action as needed.  The facility shall maintain a master list of authorized users past and present and maintain a computerized log of all entries.  The logs shall include the date and time of access and the user ID under which access occurred.

 

D)        Preservation.  The facility shall develop a plan to ensure access to medical records over the entire record retention period for that particular piece of information.

 

d)         All physician's orders, plans of treatment, Medicare or Medicaid certification, recertification statements, and similar documents shall have the authentication of the physician.  The use of a physician's rubber stamp signature, with or without initials, is not acceptable.

 

e)         The record shall include medically defined conditions and prior medical history, medical status, physical and mental functional status, sensory and physical impairments, nutritional status and requirements, special treatment and procedures, mental and psychosocial status, discharge potential, rehabilitation potential, cognitive status and drug therapy.

 

f)         An ongoing resident record including progression toward and regression from established resident goals shall be maintained.

 

1)         The progress record shall indicate significant changes in the resident's condition.  Any significant change shall be recorded upon occurrence by the staff person observing the change.

 

2)         Recommendations and findings of direct service consultants, such as providers of social, dental, dietary or habilitation services, shall be included in the resident's progress record when the recommendations pertain  to an individual resident.

 

g)         A medication administration record shall be maintained that contains the date and time each medication is given, name of drug, dosage, and by whom administered.

 

h)         Treatment sheets shall be maintained recording all resident care procedures ordered by each resident's attending physician.  Physician ordered procedures that shall be recorded include, but are not limited to, the prevention and treatment of decubitus ulcers, weight monitoring to determine a resident's weight loss or gain, catheter/ostomy care, blood pressure monitoring, and fluid intake and output.

 

i)          The records maintained for each resident shall be adequate for:

 

1)         Planning and continuously evaluating each resident's habilitation program,

 

2)         Furnishing evidence of each resident's progress and response to the habilitation program, and

 

3)         Protecting each resident's legal rights.

 

j)          The facility may use universal progress notes in the medical records.

 

k)         Each facility shall have a policy regarding the retirement and destruction of medical records.  This policy shall specify the time frame for retiring a resident's medical record, and the method to be used for record destruction at the end of the record retention period.  The facility's record retirement policy shall not conflict with the record retention requirements contained in Section 390.1650 of this Part.

 

l)          Discharge information shall be completed within 48 hours after the resident leaves the facility.

 

1)         Within 48 hours after the resident leaves the facility the resident care staff shall record the date, time, condition of the resident, to whom released, and the resident's planned destination (home, another facility, undertaker).  This information may be entered onto the admission record form.

 

2)         The discharge information shall also include reasons for discharge, diagnosis, individual habilitation plan, physical, pertinent medical and social histories, orders and staff recommendations for immediate care to ensure the optimal continuity of care for the resident.

 

m)        At the time of discharge, the facility shall provide those responsible for the resident's post-discharge care with a discharge summary.  A copy of this discharge summary shall be retained as a part of the resident record.

 

n)         When a resident is temporarily transferred to another location, the facility shall provide the temporary caretaker with medical and other information necessary and useful in the care and treatment of the resident.

 

o)         At least six months prior to a resident's 18th birthday, the facility shall complete a report regarding the resident's guardianship status and any actions needed to establish guardianship.

 

p)         Each resident record is the property of the facility.  The facility shall be responsible for securing resident record information against loss, defacement, tampering or use by unauthorized persons.

 

(Source:  Amended at 23 Ill. Reg. 8021, effective July 15, 1999)

 

Section 390.1620  Content of Medical Records

 

a)         No later than the time of admission, the facility shall enter the following information onto the identification sheet or admission sheet for each resident:

 

1)         Name, sex, date of birth and Social Security Number,

 

2)         Whether the resident has been previously admitted to the facility,

 

3)         Date of current admission to the facility,

 

4)         State or country of birth,

 

5)         Religious affiliation (if any),

 

6)         Name, address and telephone number of any referral agency, state hospital, zone center or hospital from which the resident has been transferred (if applicable),

 

7)         Name and telephone number of the resident's personal physician.

 

8)         Name and telephone number of the resident's next of kin or responsible relative,

 

9)         Race and origin,

 

10)         Father's name and mother's maiden name, Social Security numbers, birthplaces, address and marital status of resident's parents,

 

11)         Name, address and telephone number of the resident's dentist, and

 

12)         The diagnosis applicable at the time of admission.

 

b)         The following information shall be obtained and entered in the resident's record at the time of admission:

 

1)         Height, weight, color of hair and eyes, and identifying marks, and recent photograph,

 

2)         Reason for admission of referral, as well as any prognosis that is available,

 

3)         Type and legal status of admission,

 

4)         Legal competency status,

 

5)         Language spoken or understood,

 

6)         Results of the preadmission evaluation conducted pursuant to Section 390.630(a) of this Part, previous histories and any other previous evaluations available.

 

7)         At the time of admission, the facility shall obtain a history of prescription and non-prescription medications taken by the resident during the 30 days prior to admission to the facility (if available).

 

c)         Within 14 days of admission, each resident's record shall contain an individual habilitation plan which shall be reviewed and updated in accordance with the requirements specified in Section 390.1010(c) of this Part.

 

d)         Within one month of admission, each resident's record shall contain a statement of prognosis that can be used for programming and placement.

 

e)         In addition to the information that is specified above, each resident's medical record shall contain the following:

 

1)         Medical history and physical examination form that includes conditions for which medications have been prescribed, physician findings, all known diagnoses and prognosis, if available.  This shall describe those known conditions that the medical and resident care staff should be apprised of regarding the resident.  Examples of diagnoses and conditions that are to be included are allergies, epilepsy, diabetes and asthma.

 

2)         A physician's order sheet that includes orders for all medications, treatments, therapy and habilitation services, diet, activities and special procedures or orders required for the safety and well-being of the resident.

 

3)         Nurse's notes that describe the nursing care provided, observations and assessment of symptoms, reactions to treatments and medications, progression toward or regression from each resident's established goals, and changes in the resident's physical or emotional condition.  (B)

 

4)         An ongoing record of notations describing significant observations or developments regarding each resident's condition and response to treatments and programs.

 

A)        Physicians and other consultants who provide direct care or treatment to residents shall make notations at the time of each visit with a resident.

 

B)        Significant observations or developments regarding resident responses to activity programs, social services, dietary services, work programs and nursing and personal care shall be recorded as they are noted.  If no significant observations or developments are noted for a month, an entry shall be made in the record of that fact.

 

5)         Any laboratory and x-ray reports ordered by the resident's physician.

 

6)         Documentation of visits to the resident by a physician and to the physician's office by the resident.  The physician shall record, or dictate and sign, the results of such visits, such as changes in medication, observations and recommendations made by the physician during the visits, in the record.

 

7)         The results of the physical examination conducted pursuant to Section 390.1030(f) of this Part.

 

8)         Upon admission from a hospital or state facility, a hospital summary sheet or transfer form that includes the hospital diagnosis and treatment, and a discharge summary.  This transfer information, which may be included in the transfer agreement, shall be signed by the physician who attended the resident while in the hospital.

 

9)         Reports of overall reviews and evaluations of each resident's individualized program plan.  These reports shall identify the developmental progress and status of each resident, and shall be completed at least semi-annually by each professional discipline providing services to the resident.

 

10)         Any correspondence pertaining to the resident's program.

 

11)         Records of significant behavior incidents, reactions to any family visits and contacts, and attendance at programs.

 

12)         An update of the information recorded at the time of admission.  This update shall be performed at least once every 12 months, with changes in information relevant to the resident's personal physician and responsible relative to be recorded as they occur.

 

13)         Appropriate authorizations and consents.

 

14)         Weekly record of resident's weight, unless a different interval is ordered by the physician.

 

15)         Records on leaves and temporary transfers, which shall include date, time, condition of resident, to whom released, planned destination, anticipated date of return, and any special instructions on medication dispensed.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.1630  Confidentiality of Resident's Records

 

a)         All information contained in a resident's record, including information contained in an automated data bank, shall be considered confidential.  The facility shall permit the appropriate State and federal agencies (such as Illinois Departments of Public Aid, Public Health, and Mental Health and Developmental Disabilities, and the U.S. Department of Health and Human Services) to have access to resident records.

 

b)         The facility shall develop and implement written policies governing access to, duplication of, and dissemination of information from medical records.

 

c)         The facility shall obtain written consent of the resident, or, if a guardian, the resident's guardian, prior to any release of any resident record information to persons not authorized to receive the information.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.1640  Records Pertaining to Resident's Property

 

a)         The facility shall maintain a record of any resident's belongings, including money, valuables and personal property, accepted by the facility for safekeeping.  This record shall be initiated at the time of admission and shall be updated on an ongoing basis and made part of the resident's record.

 

b)         When purchases are made for a resident from the resident's personal monies, receipts shall be obtained and retained that verify the date, amount, and items purchased.

 

c)         A separate bookkeeping system shall be maintained by the facility which accounts for all transactions affecting each resident's account. Each individual resident, or the individual resident's representative, shall have access to the record of that individual resident's account.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.1650  Retention and Transfer of Resident Records

 

a)         Records of discharged residents shall be placed in an inactive file and retained as follows:

 

1)         Records for any resident who is discharged prior to being 18 years old shall be retained at least until the resident reaches the age of 23.

 

2)         Records of residents who are over 18 years old at the time of discharge shall be retained for a minimum of five years.

 

b)         After the death of a resident, the resident's record shall be retained for a minimum of five years.

 

c)         It is suggested that the administrator check with legal counsel regarding the advisability of retaining resident records for a longer period of time, and the procedures to be followed in the event the facility ceases operation.

 

d)         When a resident is transferred to another facility, the transferring facility shall send with the resident a reason for transfer, summary of treatment and results, laboratory findings, and orders for the immediate care of the resident.  This information may be presented in a transfer form or an abstract of the resident's medical record.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.1660  Other Resident Record Requirements

 

This Section contains references to rules located in other Subparts that pertain to the content and maintenance of medical records.

 

a)         The resident's record shall include facts involved if the resident's discharge occurs despite medical advice to the contrary, as required by Section 390.630(d) of this Part.

 

b)         The resident's record shall include information regarding the physician's notification and response regarding any serious accident or injury, or significant change in condition, as required by Section 390.1030(j) of this Part.

 

c)         The resident's record shall contain the physician's permission, with contraindications noted, for participation in the activity program, as required by Section 390.1100(d) of this Part.

 

d)         The records of residents participating in work activity or prevocational training programs shall document the appropriateness of the program for the resident and the resident's response to the program, as described in Section 390.1120(b) of this Part.

 

e)         The resident's record shall identify the reasons for any order and use of safety devices or restraints, as required by Section 390.1310(e) of this Part.

 

f)         The resident's record shall contain any orders specifying the use of mechanical or chemical restraints in a behavior emergency, as specified in Section 390.1330(c) of this Part.

 

g)         Telephone orders shall be transcribed into the resident's medical record or a telephone order form and signed by the nurse taking the order, as described in Section 390.1420(a) of this Part.

 

h)         Documentation of the review of medication orders shall be entered in the resident's medical record as described in Section 390.1420(b) of this Part.

 

i)          The resident's medical record shall include notations indicating any release of medications to the resident or person responsible for the resident's care, as described in Section 390.1420(e) of this Part.

 

j)          Instances of inability to implement a physician's medication order shall be noted in the resident's medical record, as described in Section 390.1430(d) of this Part.

 

k)         Medication errors and drug reactions shall be noted in the resident's medical record as described in Section 390.1430(e) of this Part.

 

l)          The resident's record shall include the physician's diet order and observations of the resident's response to the diet, as described in Section 390.1840(a) and (c) of this Part.

 

m)        The resident's record shall contain any physician determinations that limit the resident's access to the resident's personal property, as described in Section 390.3210(b) of this Part.

 

n)         The facility shall comply with Section 390.3210(g) of this Part, which requires that any medical inadvisability regarding married residents residing in the same room be documented in the resident's record.

 

o)         The facility shall maintain a record  of approval granted for children of both sexes over the age of six who occupy the same room, as described in Sections 390.660(c), 390.2660(b)(5), and 390.2960(a)(5) of this Part.

 

p)         The facility shall permit each resident, resident's parent, guardian or representative to inspect and copy the resident's medical records as provided by Section 390.3220(g) of this Part.

 

q)         Any resident transfer or discharge mandated by the physical safety of other residents shall be documented in the resident's medical record as required by Sections 390.3300(d) and (g) of this Part.

 

r)          Summaries of discussions and explanations of any planned involuntary transfers or discharged shall be included in the medical record of the resident that is to be involuntarily transferred or discharged, as described in Section 390.3300(j) of this Part.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.1670  Staff Responsibility for Medical Records

 

The facility shall designate a staff member skilled in record maintenance and preservation who shall be responsible for maintaining and preserving medical records.  If the designated person is not a health information management consultant, then the designated person shall receive consultation from a health information management consultant in order to meet the medical record requirements of this Part.

 

(Source:  Amended at 26 Ill. Reg. 10645, effective July 1, 2002)

 

Section 390.1680  Retention of Facility Records

 

The facility shall retain the records referenced in this Section for a minimum of three years.  It is suggested that the administrator check with legal counsel regarding the advisability of retaining records for a longer period of time, and the procedures to be followed in the event the facility ceases operation.  The records for which this requirement applies are as follows:

 

a)         The annual financial statement described in Section 390.210 of this Part.

 

b)         The minutes of resident advisory council meetings required by Section 390.650(j) of this Part.

 

c)         The records of in-service training required by Section 390.670(b)(4) of this Part.

 

d)         Copies of reports of serious incidents or accidents involving residents required by Section 390.700 of this Part.

 

e)         Records of the emergency medication kit review by the pharmaceutical advisory committee required by Section 390.1410(i)(3) of this Part.

 

f)         The reports of findings and recommendations from consultants required in Section 390.1690(a) of this Part.

 

g)         Copies of the quarterly reports for all employees that are filed for Social Security and Unemployment Compensation as required by Section 390.1690(d) of this Part.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.1690  Other Facility Record Requirements

 

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

 

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

 

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

 

d)         The facility shall make available to the Department upon request copies of the quarterly reports for all employees that are filed for Social Security and Employment Compensation.

 

e)         Rules located in other Sections of this Part that pertain to the content and maintenance of facility records are as follows:

 

1)         The facility shall file an annual financial statement as described in Section 390.210 of this Part.

 

2)         Records and daily time schedules shall be kept on each employee as set forth in Section 390.670(a) and (b) of this Part.

 

3)         The facility shall maintain a controlled substances record as described in Section 390.1450(d) of this Part.

 

4)         Menu and food purchase records shall be maintained as set forth in Section 390.1880(d) and (f) of this Part.

 

5)         The facility shall maintain a file of all reports of serious incidents or accidents involving residents as required by Section 390.700 of this Part.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.1810  Director of Food Services

 

a)         A full-time person, qualified by training and experience, shall be responsible for the total food and nutrition services of the facility. This person shall be on duty a minimum of 40 hours each week.

 

1)         This person shall be either a dietitian or a dietetic service supervisor.

 

2)         The person responsible for the food service may assume some cooking duties but only if these duties do not interfere with the responsibilities of management and supervision.

 

b)         If the person responsible for food services  is not a dietitian, the person shall have frequent and regularly scheduled consultation from a dietitian. Consultation,  given in the facility, shall include training, as needed, in areas such as menu planning and review, food preparation, food storage, food service, safety, food sanitation, and use of food equipment.  Clinical management of therapeutic diets shall also be included in consulting, covering areas such as tube feeding; nutritional status and requirements of residents, including weight, height, hematologic and biochemical assessments; physical limitations; adaptive eating equipment; and clinical observations of nutrition, nutritional intake, resident's eating habits and preferences, and dietary restrictions.

 

c)         A minimum of eight hours of consulting time per month shall be provided for facilities with 50 or fewer residents.  An additional five minutes of consulting time per month shall be provided per resident over 50 residents, based on the average daily census for the previous year.

 

(Source:  Amended at 23 Ill. Reg. 8021, effective July 15, 1999)

 

Section 390.1820 Dietary Staff in Addition to Director of Food Services

 

There shall be sufficient number of food service personnel employed and on duty. Their working hours shall be scheduled to meet the total dietary needs of the residents. All dietary employees' time schedules and work assignments shall be posted in the kitchen. Dietary duties and job procedures shall be available in the dietary department for employees' knowledge and use. (B)

 

(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.1830  Hygiene of Dietary Staff

 

Food service personnel shall be in good health.  Food service personal shall practice hygienic food handling techniques and good personal grooming.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.1840  Diet Orders

 

a)         Two or more copies of a current diet manual shall be available and in use. One copy shall be located in the kitchen for use by dietary personnel. Other copies shall be located at each nurses' station for use by physicians when prescribing diets.

 

b)         Physicians shall write a diet order, in the medical  record, for each resident indicating whether the resident is to have a general or a therapeutic diet. The diet  shall be served as ordered.

 

c)         A written diet order shall be sent to the food service department when each resident is admitted and each time that the resident's diet is changed.  Each change shall be ordered by the physician.  The diet order shall include, at a minimum, the following information:  name of resident, room and bed number, type of diet, consistency if other than regular consistency, date diet order is sent to dietary, name of physician ordering the diet, and the signature of the person transmitting the order to the food service department.

 

d)         The resident shall be observed to determine acceptance of the diet, and these observations shall be recorded in the medical record.  Any significant changes in weight shall be  reported to the dietitian.

 

e)         A therapeutic diet means a diet ordered by the physician as part of treatment for a disease or clinical condition, to eliminate or decrease certain substances in the diet (e.g., sodium) or to increase certain substances in the diet (e.g., potassium), or to provide food in a form that the resident is able to eat (e.g., mechanically altered diet).

 

f)         All therapeutic diets shall be medically prescribed and shall be planned or approved by a dietitian.

 

g)         The kinds and variations of prescribed therapeutic diets shall be available in the kitchen.  If separate menus are not planned for each specified diet, information for each specified type, in a form easily understood by staff, shall be available in a convenient location in the kitchen.

 

h)         All oral liquid diets shall be reviewed every 48 hours.  Medical soft diets, sometimes known as transitional diets, shall be reviewed every three weeks.  All other therapeutic and mechanically altered diets, including commercially prepared formulas that are in liquid form and blenderized liquid diets, shall be reviewed as needed, or at least every three months.

 

(Source:  Amended at 23 Ill. Reg. 8021, effective July 15, 1999)

 

Section 390.1850  Meal Planning

 

a)         The diet for all residents shall be as prescribed by the attending physician.

 

b)         Nutritional Requirements for Infants and Children

 

1)         The charts in Tables A and B labeled Nutritional Requirements for Infants and Children have been adapted from current recommendations of the Food and Nutrition Board, National Research Council for children with normal growth and developmental patterns.  These recommendations vary for each age group.

 

2)         The Nutritional Requirements are to be used as guidelines only in those cases where the physician does not prescribe a therapeutic diet.  However, the diet of a resident with severe physical abnormalities and irregular growth and developmental patterns may require a considerable variance from the current recommended allowances.  Such variance shall be permitted upon the written order of the attending physician.

 

c)         Meals for the day shall be planned to provide a variety of foods, variety in texture and good color balance. The following meal patterns shall be used.

 

1)         Three meals a day plan

 

A)        Breakfast:  Fruit or juice, cereal, meat (optional, but three to four times per week preferable), bread, butter or margarine, milk, and choice of additional beverage.

 

B)        Main Meal (may be served noon or evening):   Soup or juice (optional appetizer), entree (quality protein), potato or potato substitute, vegetable or salad, dessert (preferably fruit unless fruit is served as a salad or will be served at other meal), bread, butter or margarine, and choice of beverage.

 

C)        Lunch or Supper:  Soup or juice (optional), entree (quality protein), potato or potato substitute (optional if served at main meal), vegetable or salad, dessert, bread, butter or margarine, milk, and choice of additional beverage.

 

2)         Other meal plans may be used if facilities are able to meet residents' needs using such plans.

 

(Source:  Amended at 23 Ill. Reg. 8021, effective July 15, 1999)

 

Section 390.1860 Infant and Therapeutic Diets

 

a)         An infant diet is a diet whether therapeutic or general for residents under the age of 12 months.

 

b)         A therapeutic diet is a diet that varies from the recommended nutritional requirements as specified in Section 390.1850.

 

c)         All diets shall be ordered by a physician and recorded in the resident's medical record and served as ordered. The resident shall be observed to determine acceptance of the diet and these observations shall be recorded in his record. (B)

 

d)         All diet orders (see Section 390. 1840(a) and (b)) transmitted to the Food Service Department shall include, but are not limited to, the following information: name of resident, room and bed number, type of diet, date diet order is sent to dietary, name of physician ordering the diet, and the signature of the person transmitting the order to the food service department.

 

e)         All diets or dietary restrictions shall be planned or approved by a dietitian. (B)

 

f)         The kinds and variations of these prescribed therapeutic diets shall be available in the kitchen. If separate menus are not planned for each specific diet, diet information for each specific type shall be posted in the kitchen.

 

g)         All infant and therapeutic diets, with the exception of liquid and medical soft, shall be reviewed at least every month. Liquid therapeutic diets shall be reviewed every 48 hours. Medical soft diets shall be reviewed every three weeks. This review shall be done by licensed nursing personnel or a qualified dietitian with recommendations to the attending physician. (B)

 

h)         The facility shall have available and in use, two or more copies of a current diet manual recommended by the Department. One copy shall be located in the kitchen for use by dietary personnel; others shall be located at each nurses' station for available use by the physician when prescribing diets.

 

(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.1870 Scheduling Meals

 

a)         A minimum of three meals or their equivalent shall be served daily at regular times with no more than a 14 hour span between a substantial evening meal and breakfast. (B)

 

b)         Snacks of nourishing quality shall be offered between meals when there is a time span of four or more hours between the ending of one meal and the serving of the next. (B) Snacks of nourishing quality shall be offered at bedtime when there is a time span of two or more hours between the ending of the last meal and bedtime. (B)

 

c)         If a resident refuses food served, reasonable and nutritionally appropriate substitutions shall be served. (B)

 

(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.1880  Menus and Food Records

 

a)         Menus, including menus for between meal or bedtime snacks and "sack" lunches, if required, shall be planned at least one week in advance.  Food sufficient to meet the nutritional needs of all the residents shall be prepared for each meal.  When changes in the menu are necessary, substitutions shall provide equal  nutritive value and shall be recorded on the original menu, or in a notebook marked "Substitutions", that is kept in the kitchen.  If a notebook is used to document  substitutions, it shall include the date of the substitution; the meal at which the substitution was made; the menu as  originally written; and the menu as actually served.

 

b)         The menu for the current week shall be dated and available in the kitchen.  Upon the request of the Department, sample menus shall be submitted for evaluation.

 

c)         Menus shall be different for the same day of  consecutive weeks and adjusted for seasonal differences.

 

d)         All menus as actually served shall be kept  on file at the facility for not less than 30 days.

 

e)         Food label information for purchased prepared food, listing food composition and, when available, nutrient content, shall be kept on file in the facility for the current menu cycle.

 

f)         Supplies of staple food for a minimum of a  one week period and of perishable foods  for a minimum of a two day period shall be maintained on the premises.  These supplies shall be appropriate to meet the  requirements of the menu.

 

g)         Records of all food purchased shall be kept  on file in the facility for not less than 30 days.

 

(Source:  Amended at 23 Ill. Reg. 8021, effective July 15, 1999)

 

Section 390.1890 Food Preparation and Service

 

a)         Food shall be prepared by appropriate methods that will conserve their nutritive value, enhance their flavor and appearance. They shall be prepared according to standardized recipes and a file of such recipes shall be available for the cook's use.

 

b)         Foods shall be attractively served at the proper temperatures and in a form to meet individual needs. Foods shall not be mixed for feeding so that residents may develop individual tastes. All solids shall be spoon fed. (B)

 

c)         All residents shall be served in a dining room or multipurpose room in an upright position unless contraindicated by resident's condition. All infants shall be held for each feeding. (B)

 

d)         The method of feeding shall encourage, in each resident, the acquisition of developmentally sequential feeding skills. (B)

 

(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.1900 Preparation of Infant Formula

 

a)         Formula may be prepared by either the facility or by approved outside resources. Approved outside resources are:

 

1)         Those infant formula services which are approved to prepare infant formula for sale or distribution by the health department of the state in which the plant is located if the formula is sold interstate; or

 

2)         If sold only in Illinois, the infant formula service is approved by a local, full-time health department under an ordinance dealing specifically with infant formula preparation to prepare infant formula for sale or distribution.

 

b)         Facilities electing to utilize approved outside sources, must develop procedures to provide for aseptic preparation of formulas during emergency periods. (B)

 

c)         All facilities which prepare their own formula shall provide suitable facilities and equipment for the preparation of milk or milk substitute feedings and water for infants. (B)

 

d)         Formula preparation facilities must be in a medically clean area. Acceptable locations include a "special" formula room and the dietary department. Other areas may be used if isolated from any source of contamination. (B)

 

e)         If the kitchen is used, formulas must be prepared in such a way that food preparation and serving activities do not interfere. (B)

 

f)         There shall be suitable equipment for cleaning and sterilizing formula bottles, nipples, and utensils for cleaning formula bottles, nipples, and utensils for the preparation of formula. Preparation of formulas must be physically or functionally separated from the cleaning of equipment. (B)

 

g)         The formulas shall be prepared by or under the supervision of a registered nurse or the Director of Food Service. (B)

 

h)         Personnel assigned to formula preparation duties shall not be assigned to other duties until the complete cycle (formula preparation through proper storage) has been completed. Personnel not assigned to formula preparation shall be excluded from the immediate preparation area during the period of time formulas are being prepared, bottled, and capped. (B)

 

i)          In the cleanup process, all bottles, caps and nipples shall be thoroughly washed with a bottle brush or mechanical washing unit. Nipples should be inverted in the cleaning process and rinsed in running water, then boiled for five minutes. (B)

 

j)          A 24 hour supply of formula shall be prepared at one time and the formula not used within 24 hours after preparation shall be discarded. Formula shall be poured into individual bottles, nippled, and properly covered at the time of preparation. (B)

 

k)         Bottles and nipples must be washed and sterilized before being returned to the formula preparation room or area. (B)

 

l)          Formulas shall be prepared according to one of three techniques: Terminal Heating Methods, Standard Clean Technique Method, or Aseptic Sterilization. (B)

 

m)        Adequate refrigeration facilities must be provided for storing formulas. Formulas shall be stored at a temperature of 40 degrees Fahrenheit (B)

 

n)         Periodic bacteriological examination of formula is recommended.

 

(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.1910 Food Handling Sanitation

 

Every facility shall comply with the Department's rules entitled "Food Code".

 

(Source:  Amended at 49 Ill. Reg. 7071, effective April 30, 2025)

 

Section 390.1920  Kitchen Equipment, Utensils, and Supplies

 

a)         Each facility shall provide an adequate number of dishes, glassware, and silverware of a satisfactory type to serve all the residents in the facility at each meal.

 

b)         Each facility shall provide a sufficient supply of adaptive food service equipment necessary to meet the need of each resident.

 

(Source: Amended at 14 Ill. Reg. 14904, effective October 1, 1990)

 

Section 390.2010  Maintenance

 

Every facility shall have an effective written plan for maintenance, including sufficient staff, appropriate equipment, and adequate supplies. Each facility shall: (B)

 

a)         Maintain the building in good repair, safe and free of the following: cracks in floors, walls, or ceilings; peeling wallpaper or paint; warped or loose boards; warped, broken, loose, or cracked floor covering, such as tile or linoleum; loose handrails or railings; loose or broken panes; and any other similar hazards. (B)

 

b)         Maintain all electrical, signaling, mechanical, water supply, heating, fire protection, and sewage disposal systems in safe, clean and functioning condition. This shall include regular inspections of these systems. (A, B)

 

c)         Maintain all electrical cords and appliances in a safe and functioning condition. (B)

 

d)         Maintain the interior and exterior finishes of the building as needed to keep it attractive, clean and safe (painting, washing, and other types of maintenance).

 

e)         Maintain all furniture and furnishings in a clean, attractive, and safely repaired condition.

 

f)         Maintain the grounds and other buildings on the grounds in a safe, sanitary and presentable condition. (B)

 

g)         Maintain the grounds free from refuse, litter, insect and rodent breeding areas.

 

h)         The building and grounds shall be kept free of any possible infestations of insects and rodents by eliminating sites of breeding and harborage inside and outside the building; eliminating sites of entry into the building with screens of not less than 16 mesh to the inch and repair of any breaks in construction. (B)

 

(Source:  Amended at 14 Ill. Reg. 14904, effective October 1, 1990)

 

Section 390.2020  Housekeeping

 

a)         Every facility shall have an effective plan for housekeeping including sufficient staff, appropriate equipment, and adequate supplies. Each facility shall: (B)

 

1)         Keep the building in a clean, safe, and orderly condition. This includes all rooms, corridors, attics, basements, and storage areas. (B)

 

2)         Keep floors clean and as nonslip as possible, and free from tripping hazards. Throw rugs and scatter rugs with nonslip type backings may be utilized if they do not constitute a serious tripping hazard.

 

3)         Control odors within the housekeeping staff's areas of responsibility by effective cleaning procedures and by the proper use of ventilation systems. Deodorants shall not be used to cover up persistent odors caused by unsanitary conditions or poor housekeeping practices.

 

b)         Attics, basements, stairways, and similar areas shall be kept free of accumulations of refuse, discarded furniture, old newspapers, boxes, discarded equipment, and other items. (B)

 

c)         Bathtubs, shower stalls, and lavatories shall not be used for laundering, janitorial, or storage purposes.

 

d)         All cleaning compounds, insecticides, and all other potentially hazardous compounds or agents shall be stored in locked cabinets or rooms. (B)

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2030  Laundry Services

 

a)         Every facility shall have an effective means of supplying an adequate amount of clean linen for operation, either through an in-house laundry or a contract with an outside service.

 

1)         An adequate supply of clean linen shall be defined as the three sets of sheets, draw sheets, and pillow cases required to provide for the residents' needs. Additional changes of linen may be required in consideration of the time involved for laundering and transporting soiled linens.

 

2)         If an in-house laundry service is provided, then the following conditions shall exist:

 

A)        The laundry area shall be maintained and operated in a clean, safe and sanitary manner. No part of the laundry shall be used as a smoking or dining area.

 

B)        Written operating procedures shall be developed, posted and implemented which provide for the handling, transport and storage of clean and soiled linens.

 

C)        Laundry personnel must be in good health and practice good personal grooming. Employees must thoroughly wash their hands and exposed portions of their arms with soap and warm water before starting work, during work as often as necessary to keep them clean and after smoking, eating, drinking, using the toilet and handling soiled linens.

 

D)        Clean linen shall be protected from contamination during handling, transport and storage.

 

E)        Soiled linen shall be handled, transported and stored in a manner that protects facility residents and personnel.

 

F)         If supplies and equipment not directly connected with the operation of the laundry are stored in the laundry or its accessory storage and handling areas, they shall be protected from contamination by the soiled linens and shall not contribute to contamination of the clean linens.

 

b)         If an outside laundry service is used, it shall comply with the requirements of in-house laundries and, in addition, shall provide for protection of clean linens during transport back to the facility.

 

c)         If the facility provides laundry service for residents' personal clothing, it must be handled, transported and stored in a manner that will not allow contamination of clean linen or allow contamination by soiled linen. The facility shall assure that the personal clothing of each resident is returned to that individual resident after laundering.

 

(Source:  Amended at 14 Ill. Reg. 14904, effective October 1, 1990)

 

Section 390.2210  Furnishings

 

a)         There shall be safely constructed individual bassinets, cribs, or beds in each bedroom. These shall not be painted with a paint containing lead. Beds or cribs with spokes shall have only narrow openings between the spokes. Each bed shall be of adequate size to accommodate the resident.

 

b)         Each bed shall be provided with satisfactory type springs in good repair and a clean, firm, comfortable mattress of appropriate size for the bed.

 

c)         Each bedroom exterior window shall have a device to insure privacy and light control.

 

d)         A satisfactory reading lamp, or equivalent, shall be provided for each bed unless contraindicated.

 

e)         Each bed shall be provided with a minimum of one clean, comfortable pillow unless contraindicated. There shall be additional pillows available in the facility to satisfactorily serve the needs of the residents.

 

f)         Each lavatory and each bedroom or adjoining bathroom shall be provided with a mirror when appropriate.

 

g)         Each resident area shall be provided with appropriate furnishings and equipment to meet resident needs. These furnishings shall be well constructed, and of satisfactory design, and be appropriate for the residents.

 

h)         Office spaces, nurses' stations, treatment rooms, and other areas shall be satisfactorily furnished with desks, chairs, lamps, cabinets, benches, work tables, and other furnishings essential to the proper use of the area.

 

i)          Each resident shall be provided with an adequate amount of storage space within the resident's bedroom for personal items and clothing. This space shall be easily accessible to the residents when appropriate.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2220  Equipment and Supplies

 

a)         The facility shall provide adequate equipment and supplies including at a minimum the following:

 

1)         An adequate supply of nursing equipment such as individual thermometers, catheters, dressings, scales, hypodermic needles, syringes, and other equipment for giving medicines based on the needs of the residents in the facility.

 

2)         At least one properly operating suction machine and one emergency type oxygen apparatus on each floor or section of the building housing residents.

 

3)         A sufficient quantity of linen such as sheets, diapers, blankets, towels, wash cloths, and plastic sheeting to provide each resident with a daily individual supply.

 

4)         At least one privacy screen available in the facility for emergency use when resident privacy is needed.

 

5)         An emergency first-aid kit or emergency box containing bandages, sterile gauze dressing, bandage scissors, tape, sling, burn ointment, airways, tourniquet, sterile suture set, antiseptic skin cleaner and other equipment deemed necessary by the advisory physician or the medical advisory committee.

 

6)         Proper clothing to assure cleanliness and warmth for each resident.

 

7)         A sufficient number of play pens provided for residents under one year of age and in addition for those over one year of age, if needed for proper care. These shall be safe for use.

 

8)         Washable toys and other developmental toys and equipment provided. These shall be of safe and sanitary design.

 

9)         Cleaning equipment and supplies as set forth in Subpart J.

 

10)        All supplies and special equipment including implements or utensils needed for residents as provided in Sections 390.1910 and 390.1920.

 

b)         The facility shall initiate the procedures and assist the resident in obtaining special equipment designed for an individual resident's exclusive use.

 

c)         The use of latex gloves by facility food service and direct care personnel is prohibited.  If a crisis exists that interrupts a facility's ability to reliably source nonlatex gloves, facility personnel may use latex gloves upon a resident.  However, during the crisis, facility personnel shall prioritize, to the extent possible, using nonlatex gloves for the preparation and handling of food or for treatment of any resident with a self-identified allergy to latex and, for direct care personnel, the treatment of any resident upon whom the latex gloves are to be used who is unconscious or otherwise physically unable to communicate, and whose medical history lacks sufficient information to indicate whether or not the resident has a latex allergy.  (Sections 10(a), 10(c), and 15 of the Latex Glove Ban Act)

 

(Source:  Amended at 49 Ill. Reg. 7071, effective April 30, 2025)

 

Section 390.2230  Sterilization of Supplies and Equipment

 

a)         Every facility shall have and follow an acceptable plan to provide for sterile equipment and supplies, such as needles, syringes, catheters, and dressings. There shall be an autoclave available for sterilizing this type of equipment and supplies. The autoclave should be located in a central sterilization area, clean utility area, or nurses' station. An autoclave will not be required in a facility when other acceptable arrangements have been made, such as: (A, B)

 

1)         Use of individually wrapped sterile dressings, disposable syringes, needles, catheters, and gloves.

 

2)         Formal plan with another facility for the autoclaving of equipment and supplies.

 

3)         Other alternative methods when approved on an individual basis in writing from the Department based on a written request from the facility giving in detail the method proposed to be used and which method meets acceptable criteria for proper sterilization for these items to be sterilized.

 

b)         Every facility shall sanitize bed pans, urinals, wash basins, emesis basins, enema equipment, and similar patient care utensils as follows:

 

1)         Individual bed pans, urinals, wash basins, and similar equipment shall be washed and rinsed after each use, and be sanitized at least weekly. If individual equipment is not provided, the equipment shall washed, rinsed, and be sanitized after each use. (B)

 

2)         Utensils shall be pre-flushed prior to washing. Utensils shall be washed in a hot detergent solution that is maintained clean. After washing, utensils shall be rinsed free of detergents with clean water.

 

3)         Utensils shall be sanitized, either mechanically or manually, through the use of steam, hot water, or chemicals approved by the U.S. Environmental Protection Agency and formulated for the sanitization of patient care utensils. Chemical sanitizers shall be used in accordance with label instructions.

 

4)         Patient care utensil sanitization shall be completed in the soiled utility room. (B)

 

(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2410  Codes

 

Water supply, sewage disposal, and plumbing systems shall comply with all applicable State and local codes and ordinances.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2420  Water Supply

 

a)         Each facility shall be served by water from a municipal public water supply when available. (B)

 

b)         When a municipal public water supply is not available, the water supply shall comply with the Department's rules entitled "Drinking Water Systems" (77 Ill. Adm. Code 900). (B)

 

c)         If water is supplied by a well that is not part of a municipal system, the well shall be constructed and maintained in accordance with the Department's rules entitled "Illinois Water Well Construction Code" (77 Ill. Adm. Code 920) and "Illinois Water Well Pump Installation Code" (77 Ill. Adm. Code 925).

 

d)         Each facility shall have a written agreement with a water company, dairy, or other water purveyor to provide an emergency supply of potable water for drinking and culinary purposes.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2430  Sewage Disposal

 

a)         All sewage and liquid wastes shall be discharged into a public sewage system when available. (B)

 

b)         When a public sewage system is not available, sewage and liquid wastes shall be collected, treated, and disposed of in a private sewage disposal system. The design, construction, maintenance, and operation of the system shall comply with the "Department's rules entitled "Private Sewage Disposal Code" (77 Ill. Adm. Code 905). (B)

 

Section 390.2440  Plumbing

 

Each plumbing system shall comply with the "Illinois Plumbing Code" and the rules promulgated thereunder (77 Ill. Adm. Code 890) effective at the time of construction and approved acceptance by the Department.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2610  Applicability of these Standards

 

a)         This Subpart M applies to all new MC/DD facilities and major alterations and additions to existing MC/DD facilities. (Major alterations are those that are not defined as minor alterations in subsection (i).) MC/DD facilities contemplating construction shall contact the Health Facilities Planning Board for information concerning the current requirements. Projects for which working drawings and specifications have received final approval by the Department prior to the promulgation of these Standards will only be required to meet those Standards that were in effect at the time that the final approval was given.

 

b)         Before commencing construction of a new facility or specified types of alteration or additions to an existing facility involving major construction, as defined in subsection (a), with an estimated cost greater than $100,000, architectural drawings and specifications for the facility shall comply with Section 390.2630 and shall be submitted to the Department for review and approval. Final approval of the drawings and specifications for compliance with design and construction standards shall be obtained from the Department before the alteration, addition, or new construction is begun. Approval will be based upon compliance with Section 390.2630. (Section 3-202.5(a) of the Act)

 

c)         The drawings and specifications shall be submitted to the Department for review and approval prior to beginning of construction. For final approval to remain valid, contracts shall be signed within one year after the date of final approval.

 

1)         The Department will inform an applicant in writing within 10 working days after receiving drawings and specifications and the required fee, if any, from the applicant whether the applicant’s submission is complete or incomplete.  Failure to provide the applicant with this notice within 10 working days will result in the submission being deemed complete for purposes of initiating the 60-day review period under this Part.

 

2)         If the submission is complete and the required fee, if any, has been paid, the Department will approve or disapprove drawings and specifications submitted to the Department no later than 60 days following receipt by the Department.  

 

3)         If the drawings and specifications are disapproved, the Department will state in writing, with specificity, the reasons for the disapproval.  (Section 3-202.5(b) of the Act)

 

d)         The drawings and specifications shall be of sufficient detail, pursuant to Section 390.2630, to enable the Department to render a determination of compliance with design and construction standards under the Act.  If the Department finds the drawings are not of sufficient detail for it to render a determination of compliance, the plans shall be determined to be incomplete and shall not be considered for the purposes of initiating the 60-day review period.

 

1)         If a submission of drawings and specifications is incomplete, the applicant may submit additional information. A final decision of approval or disapproval will be made within 45 days after the receipt of the additional information.

 

2)         If the Department has not approved or disapproved the drawings and specifications within 60 days, the construction, major alteration or addition shall be deemed approved.

 

3)         The entity submitting the drawings and specifications may submit additional information in response to the written comments from the Department or request a reconsideration of the disapproval.  A final decision of approval or disapproval will be made within 45 days after the receipt of the additional information or reconsideration request.  If denied, the Department will state the specific reasons for the denial. (Section 3-202.5(b) of the Act)

 

e)         Any contract modifications that affect or change the function, design, or purpose of a facility shall be submitted to the Department for approval prior to authorizing the modifications. The approval will be based upon compliance with the requirements in this Subpart. Comments or approval will be provided within 30 days after receipt by the Department.

 

f)         The Department will conduct an on-site inspection of the completed project no later than 30 days after notification from the applicant that the project has been completed and all certifications required by the Department have been received and accepted by the Department, except that, during a statewide public health emergency, as defined in the Illinois Emergency Management Agency Act, the Department will conduct an on-site inspection to the extent feasible.  The Department will provide written approval for occupancy to the applicant within five working days after the Department’s final inspection, provided the applicant has demonstrated substantial compliance as defined in subsection (l). (Section 3-202.5(g) of the Act)

 

g)         The Department will provide written approval for occupancy pursuant to the Act and this Section and will not issue a violation to a facility as a result of a licensure or complaint survey based upon the facility’s physical structure if:

 

1)         The Department reviewed and approved or deemed approved the drawings and specifications for compliance with design and construction standards;

 

2)         The construction, major alteration, or addition was built as submitted;

 

3)         The Act or this Part have not been amended since the original approval; and

 

4)         The conditions at the facility indicate that there is a reasonable degree of safety provided for the residents. (Section 3-202.5(c) of the Act)

 

h)         Large and Complex Projects

 

1)         The Department will review all submitted projects to determine if the project will be designated as a large and complex project. 

 

A)        Large and complex projects shall have construction schedules that require more than one year to complete.

 

B)        A number of small independent projects grouped together under one project will not be considered a large and complex project.

 

2)         The Department will determine, based on the scope of work being proposed, whether a submitted project will be designated as a large and complex project.

 

3)         If a project is designated a large and complex project, the facility architect shall submit the following information for Department consideration:

 

A)        Proposed construction schedule; and

 

B)        Proposed interim inspection dates.

 

4)         The Department will develop a tentative interim inspection schedule based on information provided by the facility architect and Department staff availability.

 

5)         The Department will cancel or reschedule any interim inspection based on Department staff availability.

 

i)          Minor alterations or remodeling changes less than $100,000 do not require a plan review fee; however, these projects are required to be reviewed and approved by the Department and shall meet requirements of the Health Facilities and Services Review Board Operational Rules at 77 Ill. Adm. Code 1130.310.  For the purposes of this subsection, minor alterations include:

 

1)         Projects that do not affect the structural integrity of the building;

 

2)         Projects that do not change functional operation;

 

3)         Projects that do not affect fire or life safety; and

 

4)         Projects that do not add beds or facilities beyond those for which the facility is licensed.

 

j)          No system of water supply, plumbing, sewage, garbage or refuse disposal shall be installed, nor any existing system altered or extended until complete plans and specifications for the installation, alteration or extension have been submitted to the Department and have been reviewed and approved. Approval will be based upon compliance with Subpart L and this Subpart.

 

k)         Nothing in this Section shall be construed to apply to maintenance, upkeep, or renovation that does not affect the structural integrity of the building, does not add beds or services over the number for which the facility is licensed, and provides a reasonable degree of safety for the residents. For the purposes of this Section, "reasonable degree of safety" means the maintenance, upkeep, or renovation does not affect fire or life safety features of the facility. (Section 3-202.5(j) of the Act)

 

l)          A facility shall be deemed in substantial compliance if all life and fire safety systems and features are installed and operating in accordance with manufacturer's recommendations and all referenced standards in subsections 390.340(a)(7).  All areas shall be complete and ready for their intended use and shall not pose a fire or safety hazard for the intended occupants of the facility.

 

(Source:  Amended at 49 Ill. Reg. 7071, effective April 30, 2025)

 

Section 390.2620  Codes and Standards

 

a)         Each facility shall comply with the applicable provisions of the following codes and standards. Any incorporation by reference in this Section of federal regulations or of any standards of a nationally recognized organization or association refers to the regulations and standards on the date specified and does not include any amendments or editions subsequent to the date specified.

 

1)         State of Illinois rules

 

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

 

B)        Illinois Accessibility Code (71 Ill. Adm. Code 400), Capital Development Board

 

C)        Food Service Sanitation Code (77 Ill. Adm. Code 750), Department of Public Health

 

D)        Boiler and Pressure Vessel Safety (41 Ill. Adm. Code 2120), Office of the State Fire Marshal

 

2)         Codes and standards

 

A)        NFPA 101: Life Safety Code, Chapter 18 (New Health Care Occupancies), including all appropriate references under Chapter 2 (Definitions), 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 documents shall be applicable for all long-term care facilities.

 

ii)         NFPA 20, Standard for the Installation of Stationary Pumps for Fire Protection

 

ii)         NFPA 22, Standard for Water Tanks for Private Fire Protection

 

iii)        NFPA 24, Standard for the Installation of Private Fire Service Mains and Their Appurtenances

 

iv)        NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites

 

b)         In addition to compliance with the requirements set forth in this Section, all building codes, ordinances and regulations that are enforced by city, county or other local jurisdictions in which the facility is, or will be, located shall be observed.

 

c)         When no local building code exists, the International Building Code shall apply.

 

d)         The local building code or the International Building Code shall apply insofar as neither is in conflict with the requirements set forth in this Part, or with the NFPA 101.

 

(Source:  Amended at 43 Ill. Reg. 3564, effective February 26, 2019)

 

Section 390.2630  Preparation of Drawings and Specifications

 

a)         The preparation of drawings and specifications shall be executed by or be under the immediate supervision of an architect registered in the State of Illinois:

 

b)         The first submission shall be the design development drawings indicating in detail the assignment of all spaces, size or areas and rooms, and indicating in outline, the fixed and movable equipment and furniture, and the outline specifications.

 

c)         The plans shall be drawn at a scale sufficiently large to clearly present the proposed design.

 

d)         The drawings shall include:

 

1)         a plan of each floor including the basement or ground floor,

 

2)         roof plan,

 

3)         plot plan showing roads, parking areas, sidewalks, and other areas,

 

4)         elevations of all facades,

 

5)         sections through the building,

 

6)         identification of all fire and smoke compartmentation.

 

e)         Outline specifications shall provide a general description of the construction including finishes; acoustical material, floor covering; heating and ventilating systems; description of the electrical system including the emergency electrical system and the type of elevators.

 

f)         The total gross floor area and bed count shall be shown on the drawings.

 

g)         A brief narrative of the proposed program shall be submitted with the preliminary drawings and outline specifications.

 

h)         Following approval of the design development drawings and the outline specifications, working drawings and specifications shall be submitted. All working drawings shall be well prepared and clean and distinct prints shall be submitted. Drawings shall be accurately dimensioned and include all necessary explanatory notes, schedules and legends. Working drawings shall be complete and adequate for construction purposes. Drawings shall be prepared for each of the following branches of work: Architectural, Structural, Mechanical, Electrical and Plumbing.

 

1)         The architectural drawings shall show:

 

A)        Site plan showing all topography, newly established levels and grades, existing structures on the site (if any), new buildings and structures, roadways, walks, and the extent of the areas to be landscaped. All structures which are to be removed under the construction contract shall be shown.

 

B)        Plan of each floor and roof.

 

C)        Elevation of each facade.

 

D)        Sections through building.

 

E)        Elevators and dumbwaiters drawings delineating shaft details and dimensions, sizes of cab platforms and doors, travel distances including elevation height of landings, pit sizes, and machine rooms.

 

F)         Kitchen, laundry, clean and soiled utility room, special care areas, and similar areas detailed at a scale to show the locations, type, size and connection of all fixed and movable equipment.

 

G)        Scale details as necessary at a scale sufficiently large to properly indicate details of the work.

 

H)        Schedule of finishes.

 

2)         The structural drawings shall show:

 

A)        Plans of foundations, floors, roofs and all intermediate levels shall show the complete design with sizes, sections, and the relative location of the various members including:

 

B)        Schedule of beams, girders and columns.

 

C)        Notes on design data including the name of the governing building code, values of allowable unit stresses, assumed live loads, wind loads, earthquake load, and soil bearing pressures.

 

D)        Details of special connections, openings, pipe sleeves and expansion joints.

 

E)        Special structures shall include calculations defining load assumption, shear and moment diagrams and horizontal and vertical reactions.

 

3)         Mechanical drawings with specifications shall show the complete heating, cooling and ventilation systems; plumbing, drainage, stand pipe, and sprinkler systems.

 

A)        Heating, Cooling and Ventilation.

 

i)          Pumps, tanks, boilers and piping and boiler room accessories.

 

ii)         Air conditioning systems with required equipment, water and refrigerant piping, and ducts.

 

iii)        Supply and exhaust ventilating systems with connections and piping.

 

iv)        Air quantities for all rooms including supply and exhaust ventilating duct openings.

 

B)        Plumbing, Drainage and Stand Pipe Systems.

 

i)          Size and elevation of: street sewer, house sewer, house drains, street water main and water service into the building.

 

ii)         Location and size of soil, waste, and vent stacks with connections to house drains, cleanouts, fixtures and equipment.

 

iii)        Size and location of hot, cold and circulating mains, branches, and risers from the service entrance, and tanks.

 

iv)        Riser diagram of all plumbing stacks with vents, water risers and fixture connections.

 

v)         Gas, oxygen and similar piped systems.

 

vi)        Stand pipe and sprinkler systems.

 

vii)       All fixtures and equipment that require water and drain connections.

 

4)         Electrical drawings shall show all electrical wiring, outlets, and equipment which require electrical connections.

 

A)        Electrical service entrance with switches and feeders to the public service feeders, characteristics of the light and power current, transformers and their connections.

 

B)        Location of main switchboard, power panels, light panels and equipment. Feeder and conduit sizes shall be shown with schedule of feeder breakers or switches.

 

C)        Light outlets, receptacles, switches, power outlets, and circuits.

 

D)        Telephone layout showing service entrance, telephone switchboard, strip boxes, telephone outlets and branch conduits as approved by the telephone company. Where public telephones are used for inter-communication, provide separate room and conduits for racks and automatic switching equipment as required by the telephone company.

 

E)        Nurses' call systems with outlets for beds and cribs, duty stations, corridor signal lights, annunciators and wiring diagrams.

 

F)         Fire alarm system with stations, signal devices, control board and wiring diagrams.

 

G)        Emergency electrical system with outlets, transfer switch, source of supply, feeders, and circuits.

 

H)        All other electrically operated systems and equipment.

 

5)         When the project is an addition, details and information on the existing building shall be provided as follows:

 

A)        Type of activities within the existing building and distribution of existing beds.

 

B)        Type of construction of existing building and number of stories in height.

 

C)        Plans and details showing attachment of new construction to the existing structure.

 

D)        Mechanical, Electrical and Plumbing systems showing connections to the existing system.

 

E)        The Department may require submission of drawings of all or any part of the existing structure, depending upon the extent of the modification.

 

6)         Specifications shall supplement the drawings and shall:

Describe, except where fully indicated and described on the drawings, the materials, workmanship, kind, sizes, capacities, finishes, and other characteristics of all materials, products, articles and devices.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2640  Site

 

a)         The facility shall be located on a reasonably flat or rolling, well drained site that is not subject to flooding; reasonably free from sources of excessive noise, noxious or hazardous smoke or fumes; not in deteriorated, unpleasant, or potentially hazardous area; and not near uncontrolled sources of insect and rodent breeding.

 

b)         The facility shall be located so that the building or buildings can comply with all applicable local zoning ordinances, building restrictions and fire safety requirements. The Department may have additional requirements if the proposed locations of the building or buildings on the site would result in a hazard to or be detrimental to the health, welfare, or safety of the residents in the facility. These additional requirements shall include, but are not limited to, fences, stairs, and other types of barriers to prevent injury to residents.

 

c)         The facility shall be located in or near a community which can provide the necessary supportive services for the facility such as physician's services, social services, transportation, recreation, religious services, work, medical facilities, public utilities, or other acceptable substitutes; and be located on a well-maintained, all-weather road. In those instances where the community does not provide these services, the facility shall do so.

 

d)         The facility shall be served by a potable water supply with water pressure and volume that is acceptable to the Department. (B)

 

e)         The distance from the fire station, the accessibility of the facility, and capability of the fire department must be approved in writing by the Office of the State Fire Marshal. (B)

 

f)         The facility shall have at least one municipal or private fire hydrant, located within 300 feet of every point on the perimeter of the building and satisfactory for use by the equipment of the fire department serving the building, or have an acceptable equivalent. Additional hydrants may be required if needed to properly protect the residents from fire hazards. Evaluation and written approval must be obtained from the Office of the State Fire Marshal. (B)

 

g)         Plans showing the proposed building location must be submitted to the Illinois Department of Transportation, Division of Water Resources to determine compliance with the "Regulation of Construction within Flood Plains" (92 Ill. Adm. Code 706) and Executive Order 79-4.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2650  Administration and Public Areas

 

a)         Facilities for the physically handicapped (public, staff and residents) shall be provided in administration and public areas as well as in resident areas.

 

b)         Lobby shall include a reception and information counter or desk, waiting space, and public telephones. See the Department's rules entitled "Illinois Plumbing Code" (77 Ill. Adm. Code 890) for drinking fountains and toilet facilities requirements for staff and visitors.

 

c)         General or Individual Office shall have sufficient space to accommodate the following functions: Administrative, Business and Financial Transactions, Professional Staff (such as Director of Nursing, Food Service Supervisor, Activity Director, and Social Service Director), and Professional Consultants (such as Medical Director, Pharmacist, Dietitian, and Social Worker).

 

d)         Multipurpose room shall be provided for conferences, meetings, interviews, and educational purposes.

 

e)         Provide adequate space for recording, reviewing and storing resident records.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2660  Nursing Unit

 

a)         The number of resident beds, cribs or bassinets in a nursing unit shall not exceed 75.

 

b)         General Requirements for Bedrooms

 

1)         Resident bedrooms shall have an entrance  directly off a corridor with an entrance door which swings into the room.

 

2)         The facility shall provide a closet or wardrobe of at least four square feet for each resident.

 

3)         Resident bedroom floors shall be at or above grade level.

 

4)         Each room used as a resident bedroom shall have at least one outside window, with a total window area equal to one-tenth the floor area of the room.

 

5)         There shall be separate bedrooms for males and females over six years of age unless the interdisciplinary team determines that separation is not necessary due to the functional level of individual residents.

 

6)         A handwashing lavatory shall be provided in each bedroom.

 

7)         Resident bedrooms shall have adequate and satisfactory artificial light and be equipped in accordance with Section 390.2740(d)(2).

 

8)         Receptacles shall be provided in accordance with Section 390.2740(e).

 

9)         Nurses' call system shall be provided in accordance with Section 390.2740(g).

 

10)       Visual privacy shall be provided for each resident in multibed rooms in accordance with Section 390.2220(a)(4).  Location of screen or curtain shall not restrict resident access to bathing facilities, toilet or lavatory.

 

11)       Residents shall have access to a bathing/toilet room without entering the general corridor area.

 

12)       No resident bedroom shall be located more  than 120 feet from the  nurses' station, clean utility room, and soiled utility room.

 

13)       Vision panels shall be provided in corridor walls or room doors of each bedroom.

 

c)         Resident Bedrooms

 

1)         Each single bedroom used for a resident shall have at least 100 square feet of usable net floor area, not including any space taken up for closets, wardrobes, bathrooms, and clearly definable entryway areas.

 

2)         Each multiple bedroom for residents shall have the following floor areas, exclusive of closets, wardrobes, bathrooms, and clearly defined entryways:

 

A)        Not less than 80 square feet per bed. Size:  38"-40" x 75"- 84".  No more than 4 beds per room.

 

B)        Not less than 70 square feet per small bed.  Size:  37" to less than 38" x 61" to less than 75".  No more than 4 beds per room.

 

C)        Not less than 65 square feet per large crib.  Size:  30" to less than 37" x 56" to less than 61".

 

D)        Not less than 55 square feet per medium crib.  Size:  27" to less than 30" x 43" to less than 56".

 

E)        Not less than 50 square feet per small crib. Size:  19" to less than 27 x 35" to less than 43".

 

F)         Not less than 30 square feet per bassinet. Size:  Smaller than 19" x 35". All sleeping accommodations shall be adequate in size to allow for the resident's comfort.

 

3)         Multiple resident bedrooms shall not have more than four beds of any size located not more than three deep from the outside wall.

 

4)         Any combination of beds, cribs and bassinets (of any size) may be placed in the same bedroom when appropriate to the functional levels of the residents.  However, no bedroom shall contain more beds, cribs, and bassinets (of any size) than can be contained in 390 square feet of floorspace, except that no more than four beds of any size can be contained in one room and such rooms shall not contain any cribs or bassinets of any size.  In addition, the number of residents in a bedroom shall not exceed eight.

 

5)         The facility shall provide a minimum clearance of three feet at the foot and side of all sleeping accommodations.  Clearance is not required when accommodation is not occupied, however, an exit path must always be maintained in accordance with the requirements of the National Fire Protection Association's Standard No. 101:  Life Safety Code.

 

6)         The minimum dimension of bedrooms shall be ten feet between walls or a wall and any built-in furniture or storage space.

 

d)         Special Care Room

 

1)         The facility shall provide one special care room for each nursing unit, complying with bedroom requirements in subsections (b) and (c) of this Section.

 

2)         The facility shall provide one workroom with observation windows adjacent to special care room.  Space within this room or in separate rooms shall be designed to include all or part of  the following functions:

 

A)        Hygienic care including bathing, complying with this Section.

 

B)        Separated soiled area with hampers for soiled linen, diapers and disposables. This area shall be provided with a double compartment sink with integral drainboard and clinical rim flush sink.

 

C)        Separated clean area with storage cabinets, work counter, refrigerator, formula storage-dispensing and clean linen storage.

 

D)        Gowning for staff.

 

3)         When more than one resident is housed in this room, it may only be used to isolate residents with the same communicable disease.

 

4)         This room shall be located to allow direct appropriate visual supervision from the nurses' station.

 

5)         This room may be included in the authorized maximum bed capacity for the facility.

 

6)         It is permissible for the room to be occupied by residents not in need of special care, provided the resident is clearly informed and understands that he or she will be immediately transferred out of the room any time of day or night, whenever the room is needed to care for a resident requiring special care.

 

e)         Nurses' Station  (B)

 

1)         The facility shall provide a minimum of one nursing station for each nursing unit.  The station shall  have direct access to a corridor, shall be located near the area it will serve, and shall be designed to provide visual control of the area.  It shall be separated satisfactorily from the nurses' utility rooms.

 

2)         One or more nursing units may be combined with a central nursing station if sufficient space is provided for all nursing functions.

 

3)         A toilet room shall be provided near each station for nursing staff.  A lounge with lockers for safekeeping of coats and personal effects shall be provided either within this space or in a convenient central location.

 

f)         Bathing and Toilet Rooms

 

1)         The bathing/toilet room adjacent to resident room shall serve no more than two resident rooms nor more than 16 beds, cribs or bassinets.

 

2)         Fixtures shall be provided as follows:

 

A)        Lavatories:  One per eight.

 

B)        Clinical rim flush sink and water closet for residents capable of using them:  One per eight.

 

C)        Bathing or shower fixtures:  One per ten.

 

3)         The lavatory may be omitted from the bathing/toilet room when installed in the resident room.

 

4)         The facility shall provide a minimum of one bathtub for assisted bathing per nursing unit.  There shall be a clear area at least three feet wide on one long side.

 

5)         The facility shall provide a minimum of one shower stall for assisted showering per nursing unit.  The shower stall shall be at least four feet square with no curb.

 

6)         Other acceptable fixtures for bathing the residents may be provided with Department approval.

 

7)         All plumbing fixtures shall be designed and installed to satisfactorily serve the residents using them.

 

8)         There shall be separate toilet and bathing areas on each floor for males and females over six years of age unless the interdisciplinary team determines that separation is not necessary due to the functional level of individual residents.

 

9)         The facility shall provide one wheelchair toilet room for residents residing in the nursing unit.  This room shall be accessible from the corridor and shall contain a water closet and  lavatory.

 

10)       Wheelchair resident toilet rooms are not required when all resident toilet rooms can accommodate wheelchair residents.

 

11)       Grouped bathing and toilet facilities shall be partitioned or curtained for privacy.

 

g)         Utility Rooms

 

1)         The clean utility room shall have direct access to a corridor or access may be through the nurses' station entrance.  This room shall contain work counters, single or double compartment sink with integral drainboard, storage cabinets, and an autoclave.  (Autoclave may be waived in lieu of other  methods if sterilization is approved by Department.)

 

2)         A clean linen storage room or closet within the clean utility room shall be provided.  If a closed cart system is used, storage may be in an alcove.

 

3)         The soiled utility room shall have direct access to a corridor. This room shall contain work counters, double compartment sink with integral drainboard, storage cabinets with shelves, a clinical rim flush sink, and sanitizer (See Section 390.2230).

 

4)         The charging room for a linen chute shall be large enough to unload the collecting cart with the corridor door closed.

 

h)         A medicine station shall be provided for convenient and prompt 24 hour distribution of medicine to residents.

 

1)         The medicine preparation room shall be under the nursing staff's visual control and contain a work counter, refrigerator, and locked storage for biologicals and drugs.  A sink for handwashing and preparation of medication shall be provided in the medication preparation room.

 

2)         If medicine dispensing carts are used, a specific space shall be provided which may be located in the nurses' station or in an alcove or other space under the direct control of the nursing staff.  A sink for handwashing and preparation of medication shall be provided in the nurses' station.

 

i)          A nourishment station shall be provided with a handwashing sink and equipment including refrigerator, and storage cabinets for serving nourishment between scheduled meals.

 

1)         Commercially prepared formulas can be stored and dispensed from this room or from the special care workroom.

 

2)         Ice for residents' use shall be provided only by icemaker dispenser unit.

 

3)         There shall be a separate room or area for bottle and nipple washing and cleaning, equipped as necessary to carry out proper technique.

 

j)          A room for examination and treatment of residents shall be provided and shall have a minimum floor area of 100 square feet, excluding space for vestibule, closets and work counters (whether fixed or  movable).  The minimum room dimension shall be ten feet. The room shall contain a lavatory or sink equipped for handwashing; a work counter; storage facilities; and as desk, counter, or shelf  space for writing.  When this room is not being used for examination or treatment, it may be used for other functions (such as an office).

 

k)         Equipment storage rooms shall be provided  for storage of equipment such as I.V.  stands, inhalators, air mattresses, walkers, and wheelchairs.

 

l)          Parking space for wheelchairs shall be  provided and located out of path of normal traffic.

 

(Source:  Amended at 18 Ill. Reg. 1453, effective January 14, 1994)

 

Section 390.2670  Dining, Play, Activity/Program Rooms

 

a)         General

 

1)         The combined area of these rooms shall not be less than 40 square feet per resident bed or crib.

 

2)         The activity/program room may be combined with the play room or dining room.

 

3)         These rooms shall be located so that they are not an entrance vestibule from the outside.

 

4)         Playing and feeding functions, if suitable and consistent with the programs, may occur in bedrooms. However, dining rooms, playrooms, and activity rooms may not be used for resident bedrooms.

 

b)         Dining

 

1)         Provide a minimum of one dining room with at least ten square feet per resident bed, crib and bassinet. This area may be reduced to allow for individual feeding.

 

2)         Additional space shall be provided on resident sleeping floors for individual feeding or residents when required due to the functional level of the individual resident as determined by the interdisciplinary team.

 

c)         Play

 

1)         Provide a minimum of one furnished playroom on each floor in multiple story buildings.

 

2)         This room shall have adequate space to permit children to run.

 

3)         Each playroom shall have at least one outside window with a total window area equal to one-tenth the floor area of the room.

 

4)         There shall be satisfactory outdoor play area and equipment to meet the needs of all residents who can be taken outdoors.

 

d)         Activity/Program room and educational rooms shall be provided based on program requirements.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2680  Therapy and Personal Care

 

a)         Physical and occupational therapy facilities shall be provided as may be required by Section 390.1060. The area necessary to provide these services may be part of the 40 square feet in Section 390.2670(a).

 

b)         Space shall be provided with appropriate equipment for hair care and grooming needs of the residents.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2690  Service Departments

 

a)         Dietary facilities shall comply with the standards specified in the Department's rules entitled "Food Service Sanitation" (77 Ill. Adm. Code 750). Food service facilities shall be designed and equipped to meet the requirements of the Narrative Program. These may consist of an on-site conventional food preparing system, a convenience food service system, or an appropriate combination of the two. (B)

 

b)         The kitchen, consisting of food preparation, cooking and serving areas, shall be approximately ten square feet per resident bed, crib or bassinet with a minimum area of at least 200 square feet. It shall be properly located for efficient food service, and be large enough to accommodate the equipment and personnel needed to prepare and serve the number of meals required. (B)

 

c)         The following facilities shall be provided as required to implement the type of food service selected:

 

1)         A control station shall be provided for receiving food supplies.

 

2)         Storage space shall be adequate to provide normal and emergency supply needs, approximately two and one half square feet per resident bed, crib or bassinet for bulk and daily food storage, located in a room convenient to the kitchen.

 

3)         Food Preparation Facilities. Conventional food preparation systems require space and equipment for preparing, cooking, and baking. Convenience food service systems such as frozen prepared meals, bulk packaged entrees, and individual packaged portions, or systems using contractual commissary service require space and equipment for thawing, portioning, heating, cooking, or baking.

 

4)         Handwashing facilities shall be located in the food preparation area.

 

5)         Residents' meal service facilities shall be provided as required for tray assembly and distribution.

 

6)         Warewashing space shall be located in a room or an alcove separate from food preparation and serving areas. Commercial type dishwashing equipment shall be provided. Space shall also be provided for receiving, scraping, sorting, stacking and loading soiled tableware and for transferring clean tableware to the using areas. A handwashing lavatory shall be provided. (B)

 

7)         Potwashing facilities shall be located conveniently for washing and sanitizing cooking utensils. (B)

 

8)         Storage areas shall be provided for cans, carts, and mobile tray conveyors.

 

9)         Waste storage facilities shall be located in a separate room easily accessible to the outside for direct pickup or disposal.

 

10)         Office or desk spaces shall be provided for dietitians and the dietary service manager.

 

11)         Toilets with lavatory shall be accessible to the dietary staff.

 

12)         A janitors' closet for the exclusive use of the food preparation areas shall be located within the dietary department. It shall contain a floor receptor or service sink and storage space for housekeeping equipment and supplies.

 

13)         Self-dispensing icemaking facilities shall be provided.

 

14)         Provide adequate can, cart and mobile tray washing facilities as required.

 

d)         Infant Formula Facilities

 

1)         On-site Formula Preparation

 

A)        Clean-up facilities for washing and sterilizing supplies. These shall consist of a lavatory or sink equipped for handwashing, a bottle washer, work counter space, and an equipment sterilizer.

 

B)        If required by the program, provide a separate room for preparing infant formula. It shall contain a lavatory or sink equipped for handwashing, refrigerator, work counter, formula sterilizer, and storage facilities. It may be located near the nurseries or at another appropriate place within the facility.

 

2)         Commercially prepared formula. If a commercial infant formula is used, the storage and handling may be done in room which has a work counter, a sink equipped for handwashing, and storage facilities.

 

e)         Laundry

 

1)         Provide a laundry room with commercial type equipment designed to meet the needs of the facility unless a commercial laundry service is used.

 

2)         The laundry facilities shall be designed to provide for the processing of linens from soiled linen receiving/sorting through washing, through drying, through clean linen inspection, folding and storage, maintaining a separation between soiled and clean functions.

 

3)         Provide for the storage of laundry supplies and carts.

 

4)         If washers and dryers are provided for personal use of residents, they shall be located in a room separate from the facility's laundry room.

 

f)         Housekeeping and Storage

 

1)         Sufficient janitor's closets shall be provided throughout the facility as required to maintain a clean and sanitary environment. Each shall contain a floor receptor or service sink and storage space for housekeeping equipment and supplies. Space for large housekeeping equipment and for back-up supplies may be centrally located.

 

2)         Provide a total area of approximately ten square feet per resident bed, crib or bassinet for the storage areas designated in this service department. This does not include closets or wardrobes in residents' rooms. Separate storage space with provisions for locking and security control shall be provided for residents' personal effects which are not kept in residents' bedroom.

 

3)         Provide storage rooms for maintenance supplies, yard equipment and similar items.

 

(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2700  General Building Requirements

 

a)         Elevators

 

1)         Have a minimum of one elevator in all buildings of two or more stories in height. The lowest level shall be considered as one story if it is used by residents. (B)

 

2)         If 60 to 200 beds, cribs or bassinets are located above the first floor, at least one additional elevator shall be provided.

 

3)         For facilities with more than 200 beds, cribs or bassinets, the number of elevators shall be determined from a study of the use requirements and the estimated vertical transportation requirements.

 

4)         A minimum of one car shall be of institutional type having inside dimensions that will accommodate a stretcher and attendants and shall be at least five feet by seven feet, six inches. The car door shall have a clear opening of not less than three feet, eight inches.

 

5)         Elevators shall be equipped with an automatic leveling device of the two-way automatic maintaining type.

 

6)         Elevator controls, alarm buttons, and telephones shall be accessible to physically handicapped. Refer to the Capital Development Board's rules entitled "Illinois Accessibility Code" (71 Ill. Adm. Code 400).

 

7)         Elevator call buttons, controls, and door safety stops shall be of a type that will not be activated by heat or smoke. (B)

 

8)         Elevators, except freight elevators, shall be equipped with a two-way special service key operated switch to permit cars to bypass all landing button calls and be dispatched directly to any floor. (B)

 

9)         Fireman's emergency operations shall be furnished in accordance with American National Standards Institute Standard A17.1 Elevator Safety Code. (B)

 

10)         Inspections and tests shall be made and written certification be furnished that the installation meets the requirements set forth in this Section and all applicable safety regulations and codes. (B)

 

b)         Handrails and Grab Bars

 

1)         Handrails shall be provided on both sides of all corridors and ramps used by residents. (B)

 

2)         Handrails shall be provided on all walls of elevator cab. (B)

 

3)         Handrails on stairs used by residents shall be provided on both sides of the stairs including the platforms and landings. (B)

 

4)         Handrail and grab bar dimensions and details shall conform to the Capital Development Board's rules entitled "Illinois Accessibility Code" (71 Ill. Adm. Code 400). (B)

 

5)         Grab bars shall be provided for all resident toilets, showers, and tubs. (B)

 

6)         The ends of handrails and grab bars shall return to the wall. (B)

 

7)         Handrails and grab bars shall be installed at a height to meet the special needs of the residents of each facility. (B)

 

c)         Ceiling Heights

 

1)         All rooms occupied or used by residents shall have ceilings not less than eight feet.

 

2)         Corridors, storage rooms, toilet rooms and other minor rooms shall have ceilings not less than seven feet, eight inches.

 

3)         Suspended tracks, rails and pipes located in the path of traffic shall be no less than six feet eight inches above the floor.

 

4)         Boiler room shall have ceiling clearances not less than two feet six inches above the main boiler header and connecting piping.

 

d)         Doors and Windows

 

1)         Main entrance and all exit doors shall swing outward and be provided with door closers and panic hardware. (B)

 

2)         Door Alarm Systems. See Section 390.2740(f)(1).

 

3)         Locks installed on resident bedroom doors shall be so arranged that they can be quickly and easily unlocked from the corridor side. All such locks shall be arranged to permit exit from the room by a simple operation without the use of a key. The door may be lockable by the occupant if the door can be unlocked from the corridor side and keys are carried by the staff at all times. (B)

 

4)         The doors for the toilet rooms used by residents shall have a minimum door width of three feet. (B)

 

5)         No toilet or bathroom door shall be provided with hardware which could allow a resident to become locked in the room. All toilet or bathroom doors and hardware shall be designed to permit emergency egress to the room. (B)

 

6)         Doors and windows shall fit snugly and be weather tight, yet open and close easily.

 

7)         Outside doors, other than required exits, and operable windows shall be equipped with tight-fitting, 16 mesh screens. Screen doors shall be equipped with self-closing devices.

 

8)         All doors to resident's sleeping rooms shall be provided with automatic closers actuated by smoke detectors in the resident room. The doors shall normally be free swinging in the open and close directions, and be designed so they will remain in any position except when they are actuated by the detector. They shall then close gently and shall latch when closed. When so actuated they shall automatically close again if opened manually. Each door shall be equipped with a light mounted on the wall adjacent to the door. The light shall illuminate if the door has been closed as a result of the actuation of the controlling smoke detector. Each door closer will be activated only when its own detector annuciates a fire. In addition, a centrally located monitor shall contain signals which identify the resident room in which the smoke detector has signaled the alarm. The system shall be wired into the fire alarm system. (B)

 

e)         Floors

 

1)         Floors shall be smooth, free from cracks and finished so that they can be easily and properly cleaned. Floors shall be covered wall to wall with water resistant material in wet areas including but not limited to bathrooms, kitchens, utility rooms. (B)

 

2)         Thresholds and expansion joints shall be flush with the floor to facilitate use of wheelchairs and carts.

 

f)         Mirrors shall be installed above all lavatories except handwashing lavatories in food preparation areas, clean and sterile supply areas and nurses' handwashing sink.

 

g)         Provide paper towel dispensers and waste receptacles at all staff used lavatories.

 

h)         Rooms containing heat-producing equipment (such as boiler or heater rooms and laundry rooms) shall be insulated and ventilated to prevent any floor surface above from exceeding a temperature of ten degrees Fahrenheit above the ambient room temperature.

 

i)          Sound Transmission Limitation

 

1)         Recreation rooms and exercise rooms, and similar spaces where impact noises may be generated, shall not be located directly over resident bed areas unless special provisions are made to minimize such noise.

 

2)         Sound transmission limitations shown in Table C shall apply to partitions, floors, and ceiling construction in resident areas.

 

j)          Hazardous Areas, Fire Extinguishers and Miscellaneous

 

1)         Interior finish flame spread ratings shall be in accordance with the National Fire Protection Association, Life Safety Code Standard 101, Standards for Flame Spread and Smoke Emission Ratings. (B)

 

2)         There shall be at least one approved fire extinguisher in all basements, furnace rooms, and kitchens, laundry rooms and beauty shops. In addition, there shall be on each floor of the building, extinguishers located so a person will not have to travel more than 50 feet from any point to reach one. They shall be inspected annually and recharged when necessary. The date of checking and recharging shall be recorded on a tag attached to the extinguisher. (B)

 

3)         Approved containers with proper covers shall be provided for daily storage of rubbish. (B)

 

4)         Housekeeping throughout the building, including basements, attics, and unoccupied rooms shall be adequately performed to minimize all fire hazards. (B)

 

5)         The facility shall comply with any reasonable additional fire protection measures recommended by the Department over and above these requirements or the Office of the State Fire Marshal if conditions in and around building, including its location, indicate that such additional protection is needed. (B)

 

k)         Have no other business not related to health care conducted in the building that constitutes a hazard or annoyance to the residents. In any case, the business shall be in a segregated portion of the building and shall have a separate entrance. (A, B)

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2710  Structural

 

a)         General Structural Requirements

 

1)         The buildings and all parts thereof shall be of sufficient strength to support all dead, live, and lateral loads without exceeding the working stresses permitted for the materials of their construction in generally accepted good engineering practice. (B)

 

2)         Special provision shall be made for loads which have a greater load than the specified minimum live load, including partitions which are subject to change of location. (B)

 

b)         Construction shall be in accordance with the requirements of National Fire Protection Association Standard 101, Life Safety Code, and the minimum requirements contained herein. (A, B)

 

1)         Foundations shall rest on natural solid ground and shall be carried to a depth of not less than one foot below the estimated frost line or shall rest on leveled rock or load-bearing piles or caissons when solid ground is not encountered. Footings, piers, and foundation walls shall be adequately protected against deterioration from the action of ground water. It is recommended that soil test borings be taken to establish proper soil-bearing values for the soil at the building site.

 

2)         Assumed live loads shall be in accordance with the International Conference Building Officials Uniform Building Code.

 

3)         The fire resistance rating of the structural members shall be as established by National Fire Protection Association Standard 220 (Standard Types of Building Construction).

 

c)         Provisions for Natural Disasters (B)

 

1)         Earthquakes: In regions where local experience shows that earthquakes have caused loss of life or extensive property damage, buildings and structures shall be designed to withstand the force assumptions specified in the International Conference Building Officials Uniform Building Code. (B)

 

2)         Tornadoes and Floods: Special provisions shall be made in the design of buildings, including structural design, in regions where local experience shows loss of life or damage to buildings resulting from hurricanes, tornadoes, or floods. (B)

 

(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2720  Mechanical Systems

 

a)         General Mechanical System Requirements

 

1)         Mechanical systems shall be tested, balanced, and operated to demonstrate that the installation and performance of these systems conform to the requirements of this Section.

 

2)         Upon the completion of the contract, the owner shall be furnished with a complete set of manufacturer's operating and preventative maintenance instructions, a parts list with numbers and descriptions for each piece of equipment, and a copy of the air-balance report. A complete set of these documents shall be kept on the premises.

 

3)         The owner shall be provided with instructions in the operational use of the systems and equipment.

 

b)         Thermal and Acoustical Insulation shall be provided as set forth in the ASHRAE Handbook of Fundamentals and the Handbook of Applications and NFPA 90A.  Commercial kitchen grease hoods shall be insulated according to NFPA 96 and in accordance with the insulation manufacturer's installation instructions.  Domestic water piping that is accessible to residents shall be insulated as required by the Illinois Accessibility Code.  Insulation shall be provided for the following:

 

1)         Boilers, smoke breeching, and stacks;

 

2)         Steam supply and condensate return piping;

 

3)         Hot water piping above 180 degrees Fahrenheit and all water heaters, generators, and convertors;

 

4)         Hot water piping above 125 degrees Fahrenheit that is exposed to contact by residents;

 

5)         Chilled water, refrigerant, and other process piping and equipment operating with fluid temperatures below the ambient dew point;

 

6)         Water supply and drainage piping on which condensate may occur;

 

7)         Air ducts and casings with outside surface temperatures below the ambient dew point; and

 

8)         Other piping, ducts, and equipment as necessary to maintain the efficiency of the system.

 

c)         Insulation may be omitted from hot water and steam condensate piping that is not subject to contact by residents when the insulation is not necessary for preventing excessive system heat loss or excessive heat gain.

 

d)        Insulation, including finishes and adhesives on exterior surfaces of ducts, pipes, and equipment, shall have a flame spread rating of 25 or less and a smoke developed rating of 50 or less as determined by an independent testing laboratory in accordance with the American Society for Testing and Materials Standard E84. Exception: Duct, pipe and equipment coverings shall not be required to meet these requirements if they are located entirely outside of a building, or do not penetrate a wall or roof, or do not create an exposure hazard.

 

e)         Steam and Hot Water Systems. Supply and return mains and risers for cooling, heating, and process steam systems shall be valved to isolate the various sections of each system. Each piece of equipment shall be valved at the supply and return ends.

 

f)         Thermal Hazards. Any surface that is accessible to residents and exceeds a temperature of 140 degrees Fahrenheit (such as radiators, hot water or steam pipes, baseboard heaters, or therapy equipment) shall be provided with partitions, screens, shields, or other means to protect residents from injury. Any protective device shall be designed and installed so that it does not present a fire or safety hazard or adversely affect the safe operation of the equipment.

 

g)         Heating, Ventilating, and Air Conditioning Systems

 

1)         Areas of a facility used by residents of the facility shall be air conditioned and heated by means of operable air-conditioning and heating equipment. The areas subject to this air-conditioning and heating requirement include, without limitation, bedrooms or common areas such as sitting rooms, activity rooms, living rooms, community rooms, and dining rooms. (Section 3-202(8) of the Act)

 

A)        The mechanical system shall be capable of maintaining a temperature of at least 75 degrees Fahrenheit.

 

B)        The air-conditioning system shall be capable of maintaining an ambient air temperature of between 75 degrees Fahrenheit and 80 degrees Fahrenheit.

 

2)         All ventilation supply, return, and exhaust systems shall be mechanically operated.

 

3)         Outdoor air intakes shall be located as far as practical, but not less than 15 feet, from the exhaust outlets of ventilation systems, combustion equipment stacks, plumbing vent stacks, or areas that may collect vehicular exhaust and other noxious fumes, including the exhaust stream from fuel-fired heating, ventilating and air conditioning (HVAC) sections. The bottom of outdoor air intakes serving central systems shall be located as high as practical, but not less than six feet above ground level, or, if installed above the roof, three feet above roof level.  For fuel-fired heating sections of rooftop HVAC units, the exhaust vent may discharge not less than 36 inches above the highest point of the fresh air intake hood in lieu of the 15-foot separation.

 

4)         The ventilation systems shall be designed and balanced to provide the pressure relationships and ventilation rates as required under ANSI/ASHRAE/ASHE Standard 170-2008, Ventilation of Health Care Facilities.

 

5)         A differential pressure measuring device shall be installed across each filter bed serving a central air system.  The device may be a remote readout instrument if the remote readout is readily visible in a location accessible to the maintenance staff, or if the readout is displayed on an interactive screen.

 

6)         Air conditioning and ventilating systems shall be designed, installed, and maintained as required by NFPA 90A.  For areas within the footprint of the facility that are heated by fuel-fired appliances using an air-to-air heat exchanger, no fewer than two carbon monoxide (CO) detectors shall be installed in the area served by each heat exchanger.  One CO detector shall be installed within five feet of a supply duct and one within five feet of a return or exhaust duct.  CO detectors shall be line or system powered and shall signal the building fire alarm system when activated.  If detectors are line powered, a battery back-up or connection to the emergency power system is required.

 

7)         The hood and duct system for cooking equipment used in processes that produce smoke or grease-laden vapors shall comply with NFPA 96. The hood's extinguishment system shall be connected to the building fire alarm system and shall initiate a general alarm when activated.  Duct insulation that is used in lieu of spacing from combustible construction members shall terminate at the top of the hood on the lower end, covering the duct collar, and shall pass through any combustible nailer opening in the roof/ceiling assembly and into the roof jack assembly.  The material used shall be installed exactly as the manufacturer's installations require.

 

8)         The ventilation of the medical gas storage and manifold rooms shall comply with the requirements of NFPA 99, Standard for Health Care Facilities, as applicable, including the gravity option system.  If a concentrator is used simultaneously to fill a portable container and as a patient breathing device, the standards in NFPA 99 governing the use of medical gasses shall be observed.

 

9)         Boiler rooms and other rooms having combustion equipment shall be provided with sufficient outdoor air to maintain combustion rates of equipment and limit temperatures to 20 degrees Fahrenheit over ambient air in adjacent interior spaces.  If sealed combustion units are in use, the discharge line shall remain clear of any adjacent walk paths and not less than 15 feet from any operable fenestration or air intake. NFPA 54 shall apply, including the calculations for combustion air openings. Effective temperature shall be as defined by ASHRAE Handbook of Fundamentals.

 

10)        Rooms containing heat-producing equipment, such as boiler rooms, heater rooms, food preparation centers, laundries, and sterilizer rooms, shall be insulated and ventilated to prevent any floor surface above from exceeding a temperature of 10 degrees Fahrenheit above the ambient room temperature.

 

11)        Access for filter changing shall be provided within equipment rooms.

 

(Source:  Amended at 46 Ill. Reg. 8192, effective May 6, 2022)

 

Section 390.2730  Plumbing Systems

 

a)         All plumbing systems shall be designed and installed in accordance with the requirements of the Department's rules entitled "Illinois Plumbing Code" (77 Ill. Adm. Code 890), except that the number of resident required water closets, lavatories, bathtubs, showers, and other fixtures shall be as required by the standards and the facility program. (B)

 

b)         Plumbing Fixtures

 

1)         Plumbing fixtures shall be of non-absorptive acid-resistant materials.

 

2)         The water supply spout for lavatories and sinks required for filling pitchers for nursing staff and food handlers' handwashing, shall be mounted so that its discharge point is a minimum distance of five inches above the rim of the fixture. (B)

 

3)         Handwashing lavatories used by nursing staff and food handlers, shall be trimmed with valves which can be operated without the use of hands. When blade handles are used for this purpose, the blade handles shall not exceed four and one half inches in length, except the handles on clinical sinks shall not be less than six inches in length.

 

4)         Clinical rim flush sinks shall have an integral trap in which the upper portion of the trap seal provides a visible water surface.

 

5)         The potwashing sink shall be a three compartment sink with one compartment at least 14 inches deep.

 

6)         Shower bases and tub bottoms shall be designed with nonslip surfaces. (B)

 

c)         Water Supply Systems

 

1)         Water supply systems shall be designed to supply water at sufficient pressure and volume to operate all fixtures and equipment during maximum demand periods.

 

2)         Each water service main, branch main, riser and branch to a group of fixtures shall be valved. Stop valves shall be provided at each fixture.

 

3)         Flush valves installed on plumbing fixtures shall be of a quiet operating type, equipped with silencers.

 

4)         Hot water distribution systems shall be arranged to provide hot water of at least 100 degrees Fahrenheit at each hot water outlet at all times.

 

5)         Hot water available to residents at shower, bathing and handwashing facilities shall not exceed 110 degrees Fahrenheit. (A, B)

 

6)         Each hot water system serving resident areas shall include at least one of the following equipment requirements to insure that the water temperature does not exceed 110 degrees Fahrenheit:

 

A)        A thermostatically controlled mixing valve, or

 

B)        An aquastat which limits the water temperature in the water heater to a maximum temperature of 110 degrees Fahrenheit and a solenoid operated shut off valve activated by a sensing element in the water line which shuts off the water and activates an alarm at the nurses station when the water temperature exceeds 110 degrees Fahrenheit. (A, B)

 

d)         Hot Water Heaters and Tanks

 

1)         The hot water heating equipment shall have sufficient capacity to supply water at the temperature and quantities in the following areas:

 

	Resident Service	Dietary	Laundry
gallons/hour/bed	6½	4	4½
Temperature (Degrees Fahrenheit)	110	140*	180

 

*180 degrees Fahrenheit water is required at dishwasher and pot and pan sink. Water temperatures to be taken at the point of use or discharge of the hot water or inlet to processing equipment.

 

2)         Water storage tanks shall be fabricated of corrosion resistant metal or lined with noncorrosive material.

 

e)         Drainage Systems

Insofar as possible drainage piping shall not be installed above the ceiling nor installed in an exposed location in food preparation centers, food serving facilities, food storage areas, and other critical areas. Special precautions shall be taken to protect these areas from possible leakage or condensation from necessary overhead piping systems. (B)

 

f)         Nonflammable Gas System. Nonflammable medical gas systems if installed shall be in accordance with the requirements of National Fire Protection Association Standards 56A and 56F. (B)

 

g)         Clinical Vacuum (Suction) Systems. Clinical vacuum systems if installed shall be in accordance with the requirements of the Compressed Gas Association Pamphlet P-2.l. (B)

 

h)         Fire Extinguishing Systems

 

1)         A complete automatic sprinkler system shall be installed throughout all facilities regardless of construction type. (A, B)

 

2)         All sprinkler and other fire extinguishing systems shall be designed and installed in accordance with National Fire Protection Association Standard 101 and referenced codes. (A, B)

 

3)         All sprinkler systems shall be maintained in accordance with National Fire Protection Association Standard 13A. (A, B)

 

(Source: Amended at 14 Ill. Reg. 14904, effective October 1, 1990)

 

Section 390.2740  Electrical Systems

 

a)         General Electrical System Requirements

 

1)         All material including equipment, conductors, controls, and signaling devices shall be installed to provide a complete electrical system with the necessary characteristics and capacity to supply the electrical facilities required by these standards. All materials shall be listed as complying with available standards of Underwriters' Laboratories, Inc. or other similarly established standards. (B)

 

2)         All electrical installations and systems shall be tested to show that the equipment is installed and operates as planned or specified and be in accordance with these standards. (A, B)

 

b)         Switchboards and Power Panels. Circuit breakers or fusible switches that provide disconnecting means and overcurrent protection for conductors connected to switchboards and panelboards shall be enclosed or guarded to provide a dead-front type of assembly. The main switchboard shall be located in a separate enclosure accessible only to authorized persons. The switchboard shall be convenient for use, readily accessible for maintenance, clear of traffic lanes, and in a dry ventilated space free of corrosive fumes or gases. Overload protective devices shall be suitable for operating properly in ambient temperature conditions.

 

c)         Panelboards. Panelboards serving lighting and appliance circuits shall be located on the same floor as the circuits they serve. This requirement does not apply to emergency system circuits.

 

d)         Lighting

 

1)         All spaces occupied by people, machinery, and equipment within buildings, approaches to and exits from buildings, and parking lots shall have lighting.

 

2)         Resident's rooms shall have general lighting. There shall be lighting for the use of staff. At least one light fixture shall be switched at the entrance to each resident room. All switches for control of lighting in resident's sleeping areas shall be of the quiet operating type.

 

e)         Receptacles (Convenience Outlets)

 

1)         Each resident bed room shall have duplex grounding type receptacles as follows: One located each side of the head of each bed, crib or bassinet; one for television if used; and one on another wall. (B)

 

2)         Resident bathrooms shall have at least one duplex receptacle.

 

3)         See Article 517 of National Fire Protection Association Standard 70 for grounding requirements.

 

4)         All receptacles shall be of the child safety type or shall be protected by five milliampere ground fault interrupters.

 

5)         Duplex receptacles shall be installed approximately 50 feet apart in all corridors and within 25 feet of ends of corridors.

 

f)         Door Alarm System. Each exterior door shall be equipped with a signal that will alert staff if a resident leaves the building. Any exterior door that is supervised during certain periods may have a disconnect device for part-time use. If there is constant 24 hour a day supervision of the door, a signal is not required. (B)

 

g)         Nurses' Calling System

 

1)         Each resident room shall be served by at least one calling station to be used by staff to summon additional assistance. Call shall register at the nurses' station and shall activate a visible signal in the corridor at the resident's door and in the nurse's station. In multicorridor nursing units, additional visible signals shall be installed at corridor intersections. In rooms containing two or more calling stations, identifying lights shall be provided at the nurses' station. (B)

 

2)         An accessible nurses' call station shall be provided at each resident's watercloset, bath, and shower room or area. (B)

 

h)         Fire Alarm System

 

1)         A manually and automatically operated fire alarm system shall be installed. (A, B)

 

2)         Automatic smoke detectors shall be installed in all resident sleeping rooms and at 30 feet on center in all corridors other than sleeping area corridors. (A, B)

 

i)          Emergency Electrical System

 

1)         To provide electricity during an interruption of the normal electric supply, an emergency source of electricity shall be provided and connected to certain circuits for lighting and power. The emergency system shall consist of the life safety branch and the critical branch. (B)

 

2)         The source of this emergency electric service shall be an emergency generating set or an approved dual source of normal power. (B)

 

3)         Life Safety Branch, Automatic Transfer ten Seconds.

 

A)        Illumination of means of egress as necessary for corridors, passageways, stairways, landings and exit doors, and all ways of approach to and through exits. (A, B)

 

B)        Exit signs and exit directional signs. (A, B)

 

C)        Sufficient lighting in dining room and recreation areas to provide illumination to exit ways. (A, B)

 

D)        Fire alarms activated at manual stations, by electric water flow alarm devices in connection with sprinkler systems, and by all automatic detection systems. (A, B)

 

E)        Communication systems, where these are used for issuing instructions during emergency conditions. (A, B)

 

F)         Task illumination and selected receptacles at the generator set location. (B)

 

4)         Critical Branch, Automatic Transfer Ten Seconds

 

A)        Task illumination and selected receptacles in the nurse's station including the medication preparation area. (B)

 

B)        Sump pumps and other equipment required to operate for the safety of major apparatus including associated control systems and alarms. (B)

 

C)        Elevator cab lighting and communication systems. (B)

 

D)        Nurses' call system (B)

 

5)         Critical Branch, Automatic or Manual Systems

Heating equipment to provide heating for patient rooms. EXCEPTION: Where the facility is served by two or more electrical services supplied from separate generators or a utility distribution network having multiple power input sources and arranged to provide mechanical and electrical separation so that a fault between the facility and the generating sources is not likely to cause an interruption of more than one of the facility service feeders. (B)

 

6)         Details

 

A)        The life safety and critical branch shall be in operation within ten seconds after the interruption of normal electric power supply. (B)

 

B)        Receptacles connected to emergency power shall be distinctively marked. (B)

 

C)        Where fuel storage facilities are provided on the site, the fuel tank shall have minimum capacity for 24 hour operation of the generator. (B)

 

(Source: Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2910  Applicability

 

a)         This Subpart N shall apply to all existing facilities and all minor alterations or remodeling changes to existing facilities. See Subpart M for requirements for new construction and major additions and alterations.

 

b)         Minor alterations or remodeling changes less than $100,000 do not require a plan review fee; however, these projects are required to be reviewed and approved by the Department and must meet requirements of the Health Facilities and Services Review Board Operational Rules at 77 Ill. Adm. Code 1130.310.  For the purposes of this subsection, minor alterations include:

 

1)         Projects that do not affect the structural integrity of the building;

 

2)         Projects that do not change the functional operation;

 

3)         Projects that do not affect fire or life safety; and

 

4)         Projects that do not add beds or facilities beyond those for which the facility is licensed.

 

c)         All facilities having architectural drawings and specifications, first approved by the Department for licensure after October l, 1974, must meet the applicable requirements of Subpart M to convert to an MC/DD facility.

 

d)         Descriptions and specifications for emergency repairs or equipment replacements shall be submitted to and approved by the Department prior to commencement as follows:

 

1)         A facility shall submit a detailed description of the emergency repair or equipment replacement project that includes the following:

 

A)        The equipment or system that has failed;

 

B)        An explanation of why the failure of the equipment or system should be considered as an emergency repair or replacement;

 

C)        A detailed description of the proposed corrective action; and

 

D)        A formal request to begin corrective action prior to a plan review.

 

2)         The Department will review the facility's submission within one working day and issue a determination on whether a project submission is required. The Department will consider factors including, but not limited to, facility occupant safety, complexity of the emergency repair or replacement request, location of the emergency repair or replacement in the facility, and anticipated timeframe for completion of emergency repairs and replacements when making a determination.

 

A)        If a project submission is not required, the facility will be notified in writing and the repair or replacement work can proceed.

 

B)        If a project submission is required, the Department will notify the facility and the following shall apply:

 

i)          The Department will issue a letter to the facility indicating the emergency repair or replacement work can begin prior to the completion of a plan review. 

 

ii)         Once the work is substantially completed, a facility shall submit the project to the Department within 14 days for review and comment.

 

iii)        If the plan review identifies noncompliance with requirements of the Act or this Part, the facility will be required to take the necessary corrective actions.

 

iv)        Upon completion of the plan review process, the Department will issue either a temporary or permanent occupancy permit for the facility or schedule an onsite inspection of the work to verify compliance.

 

(Source:  Amended at 46 Ill. Reg. 8192, effective May 6, 2022)

 

Section 390.2920  Codes and Standards

 

a)         Nothing in this Part shall relieve the sponsor from compliance with building codes, ordinances and regulations that are enforced by city, county or other local jurisdictions.

 

b)         NFPA 101:  Life Safety Code, Chapter 19 (Existing Health Care Occupancies) and all appropriate references under Chapter 2 (Definitions) shall apply to and become a part of this Part.  In addition to the publications referenced in Chapter 2, the following documents shall be applicable for all long-term care facilities:

 

1)         NFPA 20, Standard for the Installation of Stationary Pumps for Fire Protection

 

2)         NFPA 22, Standard for Water Tanks for Private Fire Protection

 

3)         NFPA 24, Standard for the Installation of Private Fire Service Mains and Their Appurtenances

 

4)         NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites

 

c)         The following exceptions to the 2012 Life Safety Code are established by the Department:

 

1)         Dead-end corridors longer than 50 feet shall be altered so that exits are accessible in at least two directions from all points in aisles, passageways, and corridors.

 

2)         All corridors shall have a minimum wall-to-wall width of six feet.

 

(Source:  Amended at 43 Ill. Reg. 3564, effective February 26, 2019)

 

Section 390.2930  Preparation of Drawings and Specifications

 

Drawings and specifications prepared for work which is required by these Standards shall be prepared in accordance with Section 390.2630.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2940  Site

 

a)         Each facility shall comply with all applicable zoning ordinances and be located on a reasonably flat or rolling, well-drained site that is: not subject to flooding; reasonably free from sources of excessive noise, noxious or hazardous smoke or fumes; not in a deteriorated, unpleasant, or potentially hazardous area; and not near uncontrolled sources of insect and rodent breeding.

 

b)         Each facility shall be located in or near a community which can provide the necessary supportive services for the facility such as physicians' services, social services, transportation, recreation, religious services, medical facilities, public utilities, or other acceptable substitutes; and be located on a well-maintained, all-weather road. In those instances where the community does not provide these services, the facility shall do so.

 

c)         Each facility shall be served by a potable water supply with water pressure and volume that is acceptable to this Department. (B)

 

d)         Each facility shall have at least one municipal or private fire hydrant, located within 300 feet of the building and satisfactory for use by the equipment of the fire department serving the building, or have an acceptable equivalent. Additional hydrants may be required if needed to properly protect the residents from fire hazards. (B)

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2950  Administration and Public Areas

 

a)         Facilities for the physically handicapped (public, staff and residents) shall be provided in administration and public areas as well as in resident areas.

 

b)         Each facility shall be provided with sufficient administrative office space for clerical, financial, and managerial functions and provide satisfactory space which can be used for privacy in interviewing applicants, for discussion with relatives and other related uses.

 

c)         Each facility shall be provided with satisfactory space or an office for the administrator.

 

d)         Each facility shall be served by reliable telephone service.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2960  Nursing Unit

 

a)         General Requirements for Bedrooms

 

1)         Resident bedrooms shall have an entrance directly off of a corridor with an entrance door that swings into the room.

 

2)         Provide a closet or wardrobe of at least four square feet for each resident.

 

3)         No bedroom floor shall be more than three feet below the adjacent ground level.

 

4)         Each room used as a resident bedroom shall have at least one outside window with a total window area equal to one-tenth the floor area of the room.

 

5)         There shall be separate bedrooms for males and females over six years of age unless the interdisciplinary team determines that separation is not necessary due to the functional level of individual residents.

 

6)         A handwashing lavatory shall be provided in each bedroom.

 

7)         Resident bedrooms shall have adequate and satisfactory artificial light and be equipped in accordance with Section 390.3040(c).

 

8)         Receptacles shall be provided in accordance with Section 390.3040(d).

 

9)         Nurses' call system shall be provided in accordance with Section 390.3040(e). (B)

 

10)         Visual privacy shall be provided for residents in multibed rooms in accordance with Section 390.2220(a)(4). Location of screen or curtain shall not restrict resident access to entry, lavatory, or toilet.

 

11)         Resident toilet rooms shall open directly into a corridor or into a resident's bedroom.

 

b)         Resident Bedroom.

 

1)         Each single resident bedroom used for a resident shall have at least 100 square feet of usable net floor area, not including any space taken up for closets, wardrobes, bathrooms, and clearly definable entryway areas.

 

2)         Each multiple bedroom for residents shall have the following floor areas; exclusive of closets, wardrobes, clearly definable entryways:

 

A)        Not less than 75 square feet per bed. Size 38"-40" x 75"-84".

 

B)        Not less than 65 square feet per small bed. Size: 37" to less than 38" x 61" to less than 75".

 

C)        Not less than 60 square feet per large crib. Size: 30" to less than 37" x 56" to less than 61".

 

D)        Not less than 45 square feet per medium crib. Size: 27" to less than 30" x 43" to less than 56".

 

E)        Not less than 40 square feet per small crib. Size: 19" to less than 27" x 35" to less than 43".

 

F)         Not less than 24 square feet per bassinet. Size: Smaller than 19" x 35".

 

3)         All sleeping accommodations shall be adequate in size considering the resident's age, size, mobility, and functional level.

 

4)         Multiple bedrooms shall not have more than eight residents.

 

5)         Provide a minimum clearance of three feet at the foot and one side of all sleeping accommodations. Clearance is not required when accommodation is not occupied, however, an exit path must always be maintained in accordance with the requirements of the National Fire Protection Association's Standard No. 101:  Life Safety Code.

 

6)         The minimum dimension of bedroom shall be nine feet between walls or a wall with any built-in furniture or storage space.

 

c)         Special Care Room

 

1)         Provide one special care room per facility complying with bedroom requirements subsections (a) and (b) of this Section.

 

2)         Additional rooms may be required depending upon the bed capacity of the facility.

 

3)         Provide a minimum of one workroom adjacent to or between each special care room containing lavatories, water closets or clinical rim flush sinks and all the equipment necessary to maintain a safe standard of special care.

 

4)         This room shall be located to provide proper and efficient supervision of the resident by the nursing staff.

 

5)         When more than one resident is housed in this room, it may only be used to isolate residents with the same communicable disease.

 

6)         This room shall be included in the authorized maximum bed capacity for the facility.

 

7)         It is permissible for the room to be occupied by a resident not in need of special care, provided the resident is clearly informed and understands they will be immediately transferred out of the room any time of day or night, whenever the room is needed to care for a resident requiring special care.

 

d)         Nurses' Station

 

1)         Provide a minimum of one nurses' station for each nursing unit. The station shall have direct access to a corridor, shall be located near the area it will serve, and shall be designed to provide visual control of the area. It shall be separated satisfactorily from the nurses' utility rooms. (B)

 

2)         Each nurses' station shall have a medicine sink with hot and cold running water, a work counter, a medicine cabinet, and necessary equipment and furnishings.

 

3)         Provide a nurses' toilet with handwashing sink convenient to the nurses' station.

 

e)         Bathing and Toilet Rooms

 

1)         The minimum number of fixtures per resident use floor shall be one lavatory, one water closet, and one bathing fixture.

 

2)         Additional fixtures shall be provided on each floor based on the maximum capacity of beds, cribs or bassinets (even though some may not be occupied), as follows:

 

A)        Lavatories: One per eight

 

B)        Clinical rim flush sink or water closet for residents capable of using them: One per eight.

 

C)        Bathing or shower fixtures: One per twelve.

 

3)         Provide on each floor at least one bathing facility or enclosure of not less than eight feet six inches by eight feet six inches with an acceptable system for bathing residents with physical disabilities.

 

4)         If a shower is installed instead of a bathtub, such shower shall have a minimum dimension of four feet wide by three feet six inches deep. These showers shall have a water inlet to which is connected a flexible hose with spray or shower head attached to the end of the hose. If desired, a conventional shower head installation may also be provided but it must be valved off from the lower water inlet.

 

5)         Other acceptable fixtures for bathing the residents may be provided with Department approval.

 

6)         All plumbing fixtures shall be designed and installed to satisfactorily serve the residents using them.

 

7)         There shall be separate toilet and bathing areas on each floor for males and females over six years of age unless the interdisciplinary team determines that separation is not necessary due to the functional level of individual residents.

 

8)         If toilet rooms provided adjacent to bedrooms are not large enough to permit use by wheelchairs, at least one toilet room or enclosure measuring five feet by six feet shall be provided on each floor housing residents. Provide a lavatory usable from a wheelchair in this room.

 

9)         All bath and toilet rooms shall be easily accessible and conveniently located. Group bath and toilet facilities shall be partitioned or curtained for privacy.

 

f)         Utility Rooms

 

1)         Every facility shall have clean and soiled utility functions in separate rooms on each floor having resident beds, cribs or bassinets.

 

2)         Clean Utility Room

 

A)        The clean utility room shall be large enough to contain:

 

i)          a work counter or table;

 

ii)         a sink with drainboard;

 

iii)        ample storage cabinets for clean and sterile supplies and equipment; and

 

iv)        an autoclave, if required, for sterilizing needles, syringes, catheters, dressings, and similar items.

 

B)        The autoclave may be located in the nurses' station area. The autoclave may be waived in lieu of other methods of sterilization approved by the Department.

 

3)         The soiled utility room shall be large enough to contain:

 

A)        a two compartment sink with drainboards;

 

B)        ample storage cabinets;

 

C)        a clinical rim flush sink for: rinsing bed pans, urinals, and linen soiled by solid materials, and similar type procedures; and

 

D)        equipment for sanitizing bed pans, emesis basins, urine bottles, and other utensils, which meets accepted methods and procedures for such sanitation.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2970  Play, Dining, Activity/Program Rooms

 

a)         General Requirements for Play, Dining, Activity and Program Areas

 

1)         The combined area of these rooms shall not be less than 20 square feet per resident beds, cribs or bassinets.

 

2)         The activity/program room may be combined with the playroom or dining room.

 

3)         These rooms shall be located so that they are not an entrance vestibule from the outside.

 

4)         All furniture shall be arranged so that it is not an obstruction to traffic in or out of the facility.

 

5)         Playing and feeding functions, if suitable and consistent with the programs may occur in bedrooms. However, dining rooms, playrooms, and activity rooms may not be used for resident bedrooms.

 

b)         Dining

 

1)         Provide at least one furnished dining room in the facility sufficient in area to allow proper and comfortable service for the residents.

 

2)         A dining room may not be necessary if sufficient space is available for individual feeding of residents when required due to the functional level of the individual residents as determined by the inter- disciplinary team.

 

c)         Play

 

1)         Playroom shall be provided on each floor in multiple story buildings unless a variance to this requirement is approved in writing by the Department. Such a variance may be granted based upon the population and condition of the residents.

 

2)         This room shall have adequate space to permit residents to run.

 

3)         There shall be satisfactory outdoor play area and equipment to meet the needs of all residents who can be taken outdoors.

 

d)         Activity/Program. Additional interior rooms may be used for television, craft, or similar activities.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2980  Treatment and Personal Care

 

Space and appropriate equipment shall be provided to meet the resident's needs for treatment, grooming and hair care.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.2990  Service Department

 

a)         Kitchen

 

1)         Provide a kitchen area, not including food storage area, of approximately ten square feet per resident bed; this may be reduced for a facility with 40 or more beds. Any deviation from this requirement must receive approval from the Department. Such approval will only be granted if it can be shown that sufficient space can be provided to meet the needs of the residents.(B)

 

2)         Provide kitchen equipment in an arrangement for convenient operation, good sanitation, healthful working conditions and control of heat, noise, and odors. (B)

 

3)         Provide appropriate equipment for the preparation and serving of meals. (B)

 

4)         Provide refrigeration of perishable foods. (B)

 

5)         The kitchen shall be provided with a handwashing lavatory. (B)

 

6)         The walls and ceilings of all food handling rooms shall be finished with smooth, washable, light-colored surfaces.

 

7)         All openings to the outside shall be effectively screened during fly seasons, and screen doors shall be equipped with self-closing devices; or a satisfactory alternative method.

 

8)         The kitchen shall be located so that no resident must pass through it to reach a bathroom, resident's bedroom, the living room, dining room, or the out-of-doors. (B)

 

9)         Provide approximately two and one-half square feet per patient bed for bulk and daily food storage located in a room convenient to the kitchen.

 

b)         Formula Area

 

1)         If commercially prepared formulas are used, there shall be clean storage and dispensing areas provided.

 

2)         If the facility is preparing its own formula, the formula area shall contain elbow, foot or knee controlled lavatory, a sink, refrigerator, and an autoclave or other approved system for terminal sterilization. Additional equipment and utensils necessary for carrying on proper techniques in formula preparation and storage shall be provided.

 

3)         The facility shall be a separated room or provide an appropriate area for bottle and nipple washing and cleaning, equipped as necessary to carry out proper technique.

 

c)         Laundry

 

1)         Provide a laundry room equipped with adequate facilities for satisfactorily doing all laundering, unless a commercial laundry service is used.

 

2)         Provide satisfactory and separate areas for soiled holding and sorting and clean linen storage. These may be in the same room if well defined and adequate separation is provided.

 

3)         The laundry facilities shall not be located in a room used by residents, or for food storage, preparation or serving. It shall be located so that soiled linens are not carried through a food handling area to reach it. (B)

 

d)         Storage

 

1)         Provide a total area of approximately seven and one-half square feet per resident bed for the storage area required in this Section.

 

2)         Provide adequate storage space for personal possessions of residents and staff, toys, linens, supplies, and other items. This storage shall be such that it does not constitute a fire or accident hazard and will not be in the way of residents or staff.

 

3)         Provide adequate storage space in the facility, out of the way of residents and staff, to store wheelchairs, walkers, and similar equipment temporarily not being used.

 

4)         Provide closets for cleaning supplies, janitor's sinks, linen closets, storerooms for luggage, and furniture replacements.

 

(Source:  Amended at 14 Ill. Reg. 14904, effective October 1, 1990)

 

Section 390.3000  General Building Requirements

 

a)         Elevators

 

1)         Provide a minimum of one elevator in all  buildings of three or more stories in  height.  Additional elevators shall be provided as determined by the Department,  based on the number, population, and condition of the residents.  The lowest level, if it is used by residents, shall be considered as one story.

 

2)         If 60 to 200 beds,  cribs and bassinets are located above the  second floor, at least one additional  elevator shall be provided.  If over 200 beds, cribs and bassinets are  located above the second floor, the number  of additional elevators shall be determined  by the Department.

 

3)         The administrator of the facility must be  able to demonstrate to the Department the  ability to transfer a resident according to  physician's orders using existing elevators  and elevator doors.

 

b)         Handrails and Grab Bars

 

1)         Handrails shall be provided on both sides of  all corridors, stairs, and ramps.  Handrails  shall be one and one-half inches in  diameter and one and one-half inches  minimum clear of the wall. Refer to the rules of Capital Development Board entitled "Illinois Accessibility Code" (71 Ill. Adm. Code 400) for  other acceptable handrail dimensions and  details.  (B)

 

2)         Grab bars shall be provided at all resident  toilets, showers, tubs, and sitz bath.  Refer to the rules of the Capital Development Board entitled "Illinois Accessibility Code" (71 Ill. Adm. Code 400) for grab bar dimensions and  details.  (B)

 

3)         Handrails and grab bars shall be installed  at a height to meet the special needs of the  residents of each facility.  (B)

 

c)         Ceiling Heights

 

1)         All rooms occupied by or used by residents  shall have not less than eight feet ceiling height.

 

2)         Corridors, storage rooms, toilet rooms and other minor rooms shall have not less than seven feet, eight inches ceiling height.

 

3)         Suspended tracks, rails and pipes located in  the path of traffic shall not be less than  six feet, eight inches above the  floor.

 

d)         Doors and Windows

 

1)         Main entrance and exit doors shall swing  outward and be provided with door closers  and panic-hardware.  (B)

 

2)         Door Alarm System.  (See Section 390.3040(f).)

 

3)         Locks installed on resident bedroom doors  shall be so arranged that they can be  quickly and easily unlocked from the  corridor side.  All such locks shall be  arranged to permit exit from the room by a  simple operation without the use of a key.  The door may be lockable by the occupant if  the door can be unlocked from the corridor  side and the keys are carried by the  attendants at all times.  (B)

 

4)         The doors for the toilet rooms used by  residents shall have a minimum door width of 30 inches.  (B)

 

5)         No toilet or bathroom door shall be provided  with hardware which could allow a resident  to become locked in the room.  All toilet or  bathroom doors and hardware shall be  designed to permit emergency egress from the room.  (B)

 

6)         Thresholds or parting strips in doorways  used by residents shall be in accordance with the rules of the Capital Development Board entitled "Illinois Accessibility Code" (77 Ill. Adm. Code 400).

 

7)         Doors and windows shall fit snugly and be  weather tight, and shall open and close easily.

 

8)         Outside doors, other than required exits,  and operable windows shall be equipped with  tight-fitting, 16-mesh screens.  Screen doors shall be equipped with self-closing  devices.

 

e)         Floors

 

1)         Floors shall be smooth, free from cracks and  finished so that they can be easily and  properly cleaned.  (B)

 

2)         Floors in bathrooms, kitchens, and utility  rooms shall be completely covered with water  resistant material.  (B)

 

f)         Walls and Ceilings

 

1)         Walls and ceilings shall have sound  construction, covered with plaster or sheet  rock or similar material in good repair, and  free from cracks or holes to permit proper  cleaning.

 

2)         Be constructed and maintained so as to  prevent the entrance and harborage of rats,  mice, flies, and other vermin.

 

g)         Exit corridor walls shall be one hour  fire rated construction.  Adjoining open  spaces shall not be greater than six hundred (600) square feet.  Provide direct visual  supervision of these open spaces and equip them with an electrically supervised smoke detection system.  (B)

 

h)         There shall be at least one approved  fire extinguisher in all basements, furnace  rooms, and kitchens.  In addition, there  shall be on each floor of the building extinguishers located so a person will not  have to travel more than 50 feet  from any point to reach one. They shall be  inspected annually and recharged when  necessary.  The date of checking and  recharging shall be recorded on a tag  attached to the extinguisher.  (B)

 

i)          Approved containers with proper covers shall  be provided for daily storage of rubbish.  (B)

 

j)          Housekeeping throughout the building, including basements, attics, and unoccupied  rooms shall be adequately performed to  minimize all fire hazards.  (B)

 

k)         Comply with any reasonable additional fire  protection measures recommended by the  Department over and above these requirements or the Office of the State Fire Marshal if conditions in and around building, including its location, indicate that such additional protection is needed. (B)

 

l)          The building in which a facility is located shall have no other business that is unrelated to health care and that constitutes a hazard or annoyance to the residents.  The business  shall be in a segregated portion of the building and shall have a separate entrance.  (A, B)

 

(Source:  Amended at 16 Ill. Reg. 14329, effective September 3, 1992)

 

Section 390.3010  Structural

 

a)         Buildings and all parts thereof shall be maintained structurally to support all dead, live and lateral loads. (B)

 

b)         Buildings shall be maintained in good repair. Buildings that show signs of distress shall be repaired immediately. (B)

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.3020  Mechanical Systems

 

a)         Mechanical systems shall be maintained to assure proper working order and safe operation. Instructions in the operational use of the systems and equipment shall be available at the facility.

 

b)         Thermal and Acoustical Insulation. Insulation shall be provided for the following:

 

1)         Boilers, smoke breeching, and stacks;

 

2)         Steam supply and condensate return piping;

 

3)         Hot water piping above 180 degrees Fahrenheit and all water heaters, generators, and converters;

 

4)         Hot water piping above 125 degrees Fahrenheit that is exposed to contact by residents;

 

5)         Chilled water, refrigerant, and other process piping and equipment operating with fluid temperatures below the ambient dew point.

 

6)         Water supply and drainage piping on which condensation may occur;

 

7)         Air ducts and casings with outside surface temperature below the ambient dew point; and

 

8)         Other piping, ducts, and equipment as necessary to maintain the efficiency of the system.

 

c)         Insulation may be omitted from hot water and steam condensate piping that is not subject to contact by residents when the insulation is not necessary for preventing excessive system heat loss or excessive heat gain.

 

d)        Insulation on cold surfaces shall include an exterior vapor barrier.

 

e)         Insulation, including finishes and adhesives on exterior surfaces of ducts, pipes, and equipment, shall have a flame spread rating of 25 or less and a smoke developed rating of 50 or less as determined by an independent testing laboratory in accordance with ASTM Standard E 84. Exception: Duct, pipe, and equipment coverings shall not be required to meet these requirements if they are located entirely outside of a building, or do not penetrate a wall or roof, or do not create an exposure hazard.

 

f)         Supply and return mains and risers for cooling, heating and process steam systems shall be valved to isolate the various sections of each system. Each piece of equipment shall be valved at the supply and return ends.

 

g)         Thermal Hazards. Any surface that is accessible to residents and exceeds a temperature of 140 degrees Fahrenheit (such as radiators, hot water or steam pipes, baseboard heaters, or therapy equipment) shall be provided with partitions, screens, shields, or other means to protect residents from injury. Any protective device shall be designed and installed so that it does not present a fire or safety hazard or adversely affect the safe operation of the equipment.

 

h)         Heating,  Ventilating, Air Conditioning Systems

 

1)         Areas of a nursing home used by residents of the nursing home shall be air conditioned and heated by means of operable air-conditioning and heating equipment. The areas subject to this air-conditioning and heating requirement include, without limitation, bedrooms or common areas such as sitting rooms, activity rooms, living rooms, community rooms, and dining rooms. (Section 3-202(8) of the Act)

 

A)        The mechanical system shall be capable of maintaining a temperature of at least 75 degrees Fahrenheit, pursuant to the requirements of Section 390.690(j).

 

B)        The air-conditioning system shall be capable of maintaining an ambient air temperature of between 75 degrees Fahrenheit and 80 degrees Fahrenheit, pursuant to the requirements of Section 390.670(j).

 

2)         Heaters or furnaces of a type to be installed under, in, or on the floor are not permitted.)

 

3)         All ventilation supply, return, and exhaust systems shall be mechanically operated.

 

4)         The kitchen shall be provided with ventilation for reasonable comfort and with sufficient make-up air for the rangehood exhaust.

 

5)         The laundry shall be provided with ventilation for reasonable comfort, with air flowing from clean areas to soiled areas and with exhaust to the outdoors

 

6)         Outdoor intakes shall be located as far as practical, but not less than 15 feet, from the exhaust outlets of ventilation systems, combustion equipment stacks, plumbing vent stacks, or areas that may collect vehicular exhaust and other noxious fumes. The bottom of outdoor air intakes serving central systems shall be located as high as practical, but not less than six feet above ground level, or, if installed above the roof, three feet above roof level.

 

7)         Air conditioning and ventilating systems shall be maintained to comply with the requirements of NFPA 90A.

 

8)         The hood and duct system for cooking equipment used in processes that produce smoke or grease-laden vapors, such as griddle frying or deep frying, shall comply NFPA 96. The hood's extinguishment system shall be connected to the building fire alarm system and shall initiate a general alarm when activated.  Duct insulation that is used in lieu of spacing from combustible construction members shall terminate at the top of the hood on the lower end, covering the duct collar, and shall pass through any combustible nailer opening in the roof/ceiling assembly and into the roof jack assembly.  The material used shall be installed exactly as the manufacturer's instructions require.

 

9)         Boiler rooms and other rooms housing combustion equipment shall be provided with sufficient outdoor air to maintain proper combustion rates of equipment and to limit room temperatures to 20 degrees Fahrenheit over ambient inside air in adjacent interior spaces.  If sealed combustion units are in use, the discharge line is to remain clear of any adjacent walk paths and shall be not less than 15 feet from any operable fenestration or air intakes.  NFPA 54 shall apply, including the calculations for combustion air openings.

 

10)         For areas within the footprint of the facility that are heated by fuel-fired appliances using an air-to-air heat exchanger, not fewer than two carbon monoxide (CO) detectors shall be installed in the area served by each heat exchanger.  One CO detector shall be installed within five feet of a supply duct and one within five feet of a return or exhaust duct.  CO detectors shall be line or system powered and shall signal the building fire alarm system when activated.  If detectors are line powered, a battery back-up or connection to the emergency power system is required.

 

(Source:  Amended at 35 Ill. Reg. 3495, effective February 14, 2011)

 

Section 390.3030  Plumbing Systems

 

a)         General Requirements for Plumbing Systems

 

1)         All plumbing systems shall be designed and installed in accordance with the requirements of the Department's rules entitled "Illinois Plumbing Code" (77 Ill. Adm. Code 890) except that the number of water closets, lavatories, bath tubs, showers and other fixtures shall be as required by these Requirements and the facility program. (B)

 

2)         New and replacement equipment, fixtures and fittings for mechanical, plumbing and electrical systems shall conform to and be installed in accordance with Subpart M of this Part.

 

b)         Plumbing Fixtures

 

1)         Plumbing fixtures shall be of nonabsorptive acid-resistant materials and shall be kept in good repair.

 

2)         Clinical rim flush sinks shall have an integral trap in which the upper portion of the trap seal provides a visible water surface.

 

3)         The kitchen shall be equipped with a two compartment sink for washing pots and pans. One compartment shall contain no less than 14 inches depth of 170 degrees Fahrenheit water. A commercial type dishwasher is recommended.

 

4)         When existing showers or tubs are replaced or additional showers or tubs provided, the shower bases and tub bottoms shall be designed with nonslip surfaces.

 

c)         Water Supply Systems

 

1)         Water supply systems shall be designed to supply potable water at sufficient pressure and volume to operate all plumbing fixtures and equipment during maximum demand periods.

 

2)         It is recommended that each water service main, branch main, riser and branch to a group of fixtures be valved. Stop valves should be provided at each fixture.

 

3)         Hot water distribution systems shall be arranged to provide hot water of at least 100 degrees Fahrenheit at each hot water outlet at all times.

 

4)         Hot water available to residents at shower bathing and handwashing facilities shall not exceed 110 degrees Fahrenheit. (A, B)

 

5)         Protective measures, such as but not limited to, installation of a mixing valve, limited access to controls, and checking water temperatures daily at various points, shall be implemented to insure that the temperature of hot water available to residents at shower, bathing and handwashing facilities shall not exceed 110 degrees Fahrenheit. (A, B)

 

d)         Special precautions shall be taken to protect food preparation, serving or storage areas from possible leakage or condensation from necessary overhead piping systems. (B)

 

e)         All fire extinguishment systems shall be designed and installed in accordance with NFPA 101 and NFPA 13. All fire extinguishment systems shall be maintained in accordance with NFPA 13A. (A, B)

 

(Source:  Amended at 14 Ill. Reg. 14904, effective October 1, 1990)

 

Section 390.3040  Electrical Requirements

 

a)         The electrical installation for existing facilities shall continue to meet all the requirements of the National Electrical Code, effective at the time of approval by the Department of final drawings and specification or the inspection of the building. (A, B)

 

b)         Circuit breakers or fusible switches that provide disconnecting means and overcurrent protection for conductors connected to switchboards and panelboards shall be enclosed or guarded to provide a dead-front type of assembly. Overload protective devices shall be suitable for operating properly in ambient temperature conditions.

 

c)         Lighting.

 

1)         All spaces occupied by people, machinery, or equipment within buildings, approaches to buildings, and parking lots shall have lighting.

 

2)         Resident's rooms shall have general lighting.

 

d)         Receptacles

 

1)         Each resident room shall have adequate duplex type receptacles.

 

2)         All receptacles shall be of the child safety type, or protected by covers.

 

e)         Nurses' Calling System.

 

1)         Each resident room shall be served by at least one calling station to be used by staff to summon additional assistance. Call shall register at the nurses' station and shall activate a visible signal in the corridor at the resident's door.

 

2)         Facilities with an intercommunication system which provides only voice communication between a resident room and the nurses' station may remain in service when approved by the Department.

 

3)         An accessible nurses' call station shall be provided at each resident's water closet, bathing and shower room or area.

 

f)         Door Alarm System. All exterior doors shall be equipped with a signal that will alert the staff if a resident leaves the building. Any exterior door that is supervised during certain periods may have a disconnect device for part-time use. If there is constant 24 hour a day supervision of the door, a signal is not required. (B)

 

g)         Fire Alarm System

 

1)         A manually-operated, electrically-supervised fire alarm system shall be installed. Pre-signal systems are not permitted. (A, B)

 

2)         There shall be an approved fire detection and alarm system throughout the facility. (A, B)

 

3)         The fire alarm signals shall automatically transmit the alarm to any available municipal fire department by direct private line or through an approved central station. (A, B)

 

4)         Fire alarms shall be activated by manual stations and all detection systems and flow alarm devices and sprinkler systems. (A, B)

 

h)         Emergency Electrical Requirements (B)

 

1)         To provide electricity during an interruption of the normal electric supply, an emergency source of electricity shall be provided and connected to certain circuits for lighting and power. (B)

 

2)         The source of this emergency electrical service shall be one of the following: (B)

 

A)        An emergency generating set when the normal service is supplied by only one central station transmission line.

 

B)        Automatic battery operated systems or equipment that will be effective for four or more hours and will be capable of supplying power for lighting for exit signs, exit corridors, stairways, nurses' stations, communication system, and all alarm systems, including the nurses' call system.

 

C)        An approved dual source of normal power. Such a dual source of normal power shall consist of two or more electrical services fed from separate generator sets or a utility distribution network having multiple power input sources and arranged to provide mechanical and electrical separation so that a fault between the facility and the generating sources will not likely cause an interruption of more than one of the facility service feeders. An automatic transfer switch is required between the facility service feeders.

 

3)         Provide emergency electrical service for: (B)

 

A)        illumination of means of egress as necessary for corridors, passageways, stairways, landings and exit doors and all ways of approach to and through exits including outside lights,

 

B)        exit signs and exit directional signs,

 

C)        fire alarm systems and detection systems,

 

D)        communication systems which are used for issuing instructions,

 

E)        task illumination in the nurses station.

 

F)         nurse call system

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.3210  General

 

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

 

b)         A resident shall be permitted to retain and use or wear his or her personal property in his or her immediate living quarters, unless deemed medically inappropriate by a physician and so documented in the resident's clinical record.  (Section 2-103 of the Act)

 

c)         If clothing is provided to the resident by the facility it shall be of a proper fit.  (Section 2-103 of the Act)

 

d)         The facility shall provide adequate and convenient storage space for the personal property of the resident.  (Section 2-103 of the Act) For the purposes of this subsection, "adequate" means storage space that is sufficient to meet the resident's needs and "convenient" means easily accessible and closely situated to the resident's room.

 

e)         The facility shall provide a means of safeguarding small items of value for its residents in their rooms or in any other part of the facility so long as the residents have daily access to such valuables.  (Section 2-103 of the Act)

 

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

 

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

 

h)         The facility administrator shall ensure that married residents residing in the same facility be allowed to reside in the same room within the facility unless there is no room available in the facility or it is deemed medically inadvisable by the residents' attending physician and so documented in the residents' medical records.  (Section 2-108(e) of the Act)

 

i)          There shall be no traffic through a resident's room to reach any other area of the building. 

 

j)          Children under 16 years of age who are related to employees or owners of a facility, and who are not themselves employees of the facility, shall be  restricted to quarters reserved for family or employee use except during times when such children are part of a group visiting the facility as part of a planned program, or similar activity.

 

k)         A resident may refuse to perform labor for a facility. (Section 2-113 of the Act)

 

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

 

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

 

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

 

1)         Immediately notify the Department by telephone of a resident's death within 24 hours after the resident's death;

 

2)         Notify the Department of the death of a facility's resident that does not occur in the facility immediately upon learning of the death;

 

3)         Promptly notify the coroner or medical examiner of a resident's death in a manner and form to be determined by the Department after consultation with the coroner or medical examiner of the county in which the facility is located;

 

4)         Submit written notification to the Department of the death of a resident within 72 hours after the death, including a report of any medication errors or other incidents that occurred within 30 days of the resident's death.  (Section 2-208(a) of the Act) 

 

o)         The facility shall immediately notify the resident's next of kin, guardian, or resident representative of any unusual incident, abuse, or neglect involving the resident. A facility shall immediately notify the Department by telephone of any unusual incident, abuse, or neglect required to be reported pursuant to State law or this Part.  In addition to notice to the Department by telephone, the facility shall submit written notification to the Department, of any unusual incident, abuse, or neglect within one day after the unusual incident, abuse, or neglect within one day after the unusual incident, abuse, or neglect occurring. For purposes of this Section, "unusual incident" means serious injury; unscheduled hospital visit for treatment of serious injury; 9-1-1 calls for emergency services directly relating to a resident threat; or stalking of staff or person served that raises health or safety concerns. (Section 2-208(b) of the Act)

 

p)         A facility's failure to comply with requirements of this Section shall constitute a Type "B" violation.  (Section 2-208(a) of the Act)

 

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

 

r)          No identification wristlets shall be employed except as ordered by a physician who documents the need for such mandatory identification in the resident's clinical record.  When identification bracelets are required, they shall identify the resident's name, and the name and address of the facility issuing the identification wristlet. (Section 2-106a of the Act)

 

(Source:  Amended at 46 Ill. Reg. 8192, effective May 6, 2022)

 

Section 390.3220  Medical Care

 

a)         A resident shall be permitted to retain the services of his or her own personal physician at his or her own expense under an individual or group plan of health insurance, or under any public or private assistance program providing such coverage. (Section 2-104(a) of the Act)

 

b)         The Department shall not prescribe the course of medical treatment provided to an individual resident by the resident's physician in a facility. (Section 3-201 of the Act)

 

c)         Every resident shall be permitted to obtain from his or her own physician or the physician attached to the facility complete and current information concerning his or her medical diagnosis, treatment and prognosis in terms and language the resident can reasonably be expected to understand. (Section 2-104(a) of the Act)

 

d)         Every resident shall be permitted to participate in the planning of his or her total care and medical treatment to the extent that his or her condition permits. (Section 2-104(a) of the Act)

 

e)         No resident shall be subjected to experimental research or treatment without first obtaining his or her informed, written consent. The conduct of any experimental research or treatment shall be authorized and monitored by an institutional review committee appointed by the administrator of the facility where such research and treatment is conducted. (Section 2-104(a) of the Act) 

 

f)         All medical treatment and procedures shall be administered as ordered by a physician. All new physician orders shall be reviewed by the facility's director of nursing or charge nurse designee within 24 hours after such orders have been issued to assure facility compliance with such orders. (Section 2-104(b) of the Act)

 

g)         Every woman resident of child-bearing age shall receive routine obstetrical and gynecological evaluations as well as necessary prenatal care. (Section 2-104(b) of the Act) In addition, women residents shall be referred immediately for diagnosis whenever pregnancy is suspected.

 

1)         "Routine obstetrical evaluations" and "necessary prenatal care" shall include, at a minimum, the following:

 

A)        Early diagnosis of pregnancy;

 

B)        A comprehensive health history, including menstrual history, methods of family planning that the patient has used, a detailed record of past pregnancies, and data on the current pregnancy that allow the physician to estimate the date of delivery;

 

C)        Identification of factors in the current pregnancy that help to identify the patient at high risk, such as maternal age, vaginal bleeding, edema, urinary infection, exposure to radiation and chemicals, ingestion of drugs and alcohol, and use of tobacco;

 

D)        A comprehensive physical examination, including an evaluation of nutritional status; determination of height, weight and blood pressure; examination of the head, breasts, heart, lungs, abdomen, pelvis, rectum, and extremities;

 

E)        The following laboratory tests, as early in pregnancy as possible. Findings obtained from the history and physical examination may determine the need for additional laboratory evaluations:

 

i)          Hemoglobin or hematocrit measurement;

 

ii)         Urinalysis, including microscopic examination or culture;

 

iii)        Blood group and Rh type determination;

 

iv)        Antibody screen;

 

v)         Rubella antibody titer measurement;

 

vi)        Syphilis screen;

 

vii)       Cervical cytology; and

 

viii)      Viral hepatitis (HBsAg) testing;

 

F)         A risk assessment that, based on the findings of the history and physical examination, shall indicate any risk factors that may require special management, such as cardiovascular disease, maternal age less than 15 years, neurologic disorder, or congenital abnormalities;

 

G)        Return visits, the frequency of which will be determined by the patient's needs and risk factors. A woman with an uncomplicated pregnancy shall be seen every four weeks for the first 28 weeks of pregnancy, every two to three weeks until 36 weeks of gestation, and weekly thereafter;

 

H)        Determinations of blood pressure, measured fundal height, fetal heart rate, and, in later months, fetal presentation, and urinalysis for albumin and glucose. Hemoglobin or hematocrit level shall be measured again early in the third trimester;

 

I)         Evaluation and monitoring of nutritional status and habits;

 

J)         Education for health promotion and maintenance;

 

K)        Counseling concerning exercise and child birth education programs;

 

L)        Postpartum review and evaluation four to eight weeks after delivery, including determination of weight and blood pressure and assessment of status of breasts, abdomen, and external and internal genitalia.

 

2)         "Routine gynecological evaluations" shall include, at a minimum, the following:

 

A)        An initial examination, the basic components of which are:

 

i)          History; any present illnesses; menstrual, reproductive, medical, surgical, emotional, social, family, and sexual history; medications; allergies; family planning; and systems review;

 

ii)         Physical examination, including height, weight, nutritional status, and blood pressure; head and neck, including thyroid gland; heart; lungs; breasts; abdomen; pelvis, including external and internal genitalia; rectum; extremities, including signs of abuse; lymph nodes; and

 

iii)        Laboratory tests, including urine screen; hemoglobin or hematocrit determination and, if indicated, complete blood cell count; cervical cytology; rubella titer.

 

B)        Annual updates, including, but not limited to:

 

i)          History, including the purpose of the visit; menstrual history; interval history, including systems review; emotional history;

 

ii)         Physical examination, including weight, nutritional status and blood pressure; thyroid gland; breasts; abdomen; pelvis, including external and internal genitalia; rectum; other areas as indicated by the interval history;

 

iii)        Laboratory, including urine screen; cervical cytology, unless not indicated; hemoglobin or hematocrit determinations; and

 

iv)        Additional laboratory tests, such as screening for sexually transmitted disease, as warranted by the history, physical findings, and risk factors.

 

3)         When a resident is referred for a diagnosis of pregnancy and/or for prenatal care, the facility shall send the health care provider a copy of the resident's medical record, including a list of prescription medications taken by the resident; the resident's use of alcohol, tobacco and illicit drugs, and any exposure of the resident to radiation or chemicals during the preceding three months.

 

h)         Cancer screening.  Cancer screening for women shall include the following:

 

1)         A periodic Pap test.  The frequency and administration of Pap tests shall be according to the guidelines set forth in the Guidelines for Women's Health Care, published by the American College of Obstetricians and Gynecologists; and

 

2)         Mammography.  The frequency and administration of mammograms shall be according to the guidelines set forth in the Guidelines for Women's Health Care.

 

i)          Every resident shall be permitted to refuse medical treatment and to know the consequences of such action, unless such refusal would be harmful to the health and safety of others and such harm is documented by a physician in the resident's clinical record.  (Section 2-104(c) of the Act) (B)

 

j)          Every resident, resident's guardian, or parent if the resident is a minor shall be permitted to inspect and copy all of the the resident's clinical and other records concerning the resident's care and maintenance kept by the facility or by the resident's physician (Section 2-104 (d) of the Act).

 

k)         A resident shall be permitted respect and privacy in his or her medical and personal care program. Every resident's case discussion, consultation, examination and treatment shall be confidential and shall be conducted discreetly, and those persons not directly involved in the resident's care must have his or her permission to be present. (Section 2-105 of the Act)

 

(Source:  Amended at 35 Ill. Reg. 3495, effective February 14, 2011)

 

Section 390.3230  Restraints  (Repealed)

 

(Source:  Repealed at 22 Ill. Reg. 16576, effective September 18, 1998)

 

Section 390.3240  Abuse and Neglect

 

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

 

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

 

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

 

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

 

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

 

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

 

(Source:  Amended at 15 Ill. Reg. 1878, effective January 25, 1991)

 

Section 390.3250  Communication and Visitation

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

h)         Any employee or agent of a public agency, any representative of a community legal services program or any member of a community organization shall be permitted access at reasonable hours to any individual resident of any facility, if the purpose of such agency, program or organization includes rendering assistance to residents without charge, but only if there is neither a commercial purpose nor affect to such access and if the purpose is to do any other than the following:

 

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

 

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

 

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

 

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

 

i)          No visitor shall enter the immediate living area of any resident without first identifying himself and then receiving permission from the resident to enter. The rights of other residents present in the room shall be respected. (B) (Section 2-110(b) of the Act)

 

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

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.3260  Resident's Funds

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

k)         The facility shall:

 

1)         Place any monthly allowance to which a resident is entitled in that resident's personal account, or give it to the resident, unless the facility has written authorization from the resident or the resident's guardian, or if the resident is a minor, the resident's parent, to handle it differently.

 

2)         Take all steps necessary to ensure that a personal needs allowance that is placed in a resident's personal account is used exclusively by the resident or for the benefit of the resident.  "Personal needs allowance", for the purposes of this subsection, refers to the monthly allowance allotted by the Illinois Department of Healthcare and Family Services to medical assistance program recipients; and

 

3)         Where such funds are withdrawn from the resident's personal account by any person other than the resident, require the person to whom funds constituting any part of a resident's personal needs allowance are released, to execute an affidavit that these funds shall be used exclusively for the benefit of the resident. (Section 2-201(9) of the Act)

 

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

 

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

 

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

 

(Source:  Amended at 46 Ill. Reg. 8192, effective May 6, 2022)

 

Section 390.3270  Residents' Advisory Council

 

Each resident shall have the right to participate in a residents' advisory council as indicated in Section 390.650.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.3280  Contract With Facility

 

Each resident shall have the right to contract with the facility as indicated in Section 390.640.

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.3290  Private Right of Action

 

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

 

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

 

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

 

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

 

e)         Any damages recoverable under subsections (b) through (i) of this Section, including minimum damages as provided by this Part, may be recovered in any action which a court may authorize to be brought as a class action pursuant to Part 8 of the Civil Practice law (Ill. Rev. Stat. 1987, ch. 110, pars. 2-801 et seq.). The remedies provided in subsections (b) through (i) of this Section are in addition to and cumulative with any other legal remedies available to a resident. Exhaustion of any available administrative remedies shall not be required prior to commencement of a suit hereunder. (Section 3-604 of the Act)

 

f)         The amount of damages recovered by a resident in an action brought under subsections (b) through (i) of this Section shall be exempt for purposes of determining initial or continuing eligibility for medical assistance under The Illinois Public Aid Code (Ill. Rev. Stat. 1987, ch. 23, pars. 1-1 et seq.), as now or hereafter amended, and shall neither be taken into consideration nor required to be applied toward the payment or partial payment of the cost of medical care or services available under "The Illinois Public Aid Code." (Section 3-605 of the Act)

 

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

 

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

 

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

 

(Source:  Amended at 13 Ill. Reg. 6301, effective April 17, 1989)

 

Section 390.3300  Transfer or Discharge

 

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

 

b)         Each resident's rights regarding involuntary transfer or discharge from a facility shall be as described in subsections (c) through (y).

 

c)         Reasons for Transfer or Discharge

 

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

 

A)        For medical reasons.

 

B)        For the resident's physical safety.

 

C)        For the physical safety of other residents, the facility staff or facility visitors.

 

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

 

2)         Prohibition of Discrimination

 

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

 

B)        A facility which violates this Section shall be guilty of a business offense and fined not less than $500 nor more than $1,000 for the first offense and not less than $1,000 nor more than $5,000 for each subsequent offense. (Section 3-401.1(b) of the Act)

 

C)        A facility of which only a distinct part is certified to participate in the Medical Assistance Program may refuse to retain as a resident any person who resides in a part of the facility that does not participate in the Medical Assistance Program and who is unable to pay for his or her care in the facility without Medical Assistance only if:

 

1)         The facility, no later than at the time of admission and at the time of the resident's contract renewal, explains to the resident (unless the resident is incompetent), and to the resident's representative, and to the person making payment on behalf of the resident for the resident's stay, in writing, that the facility may discharge the resident if the resident is no longer able to pay for care in the facility without Medical Assistance; and

 

2)         The resident (unless incompetent), the resident's representative, and the person making payment on behalf of the resident for the resident's stay, acknowledge in writing that they have received the written explanation. (Section 3-401.1(a-5) of the Act)

 

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

 

1)         When an emergency transfer or discharge is ordered by the resident's attending physician because of the resident's health care needs (Section 3-402(a) of the Act); or

 

2)         When the transfer or discharge is mandated by the physical safety of other residents, the facility staff, or facility visitors, as documented in the clinical record. The Department will immediately offer transfer, or discharge and relocation assistance to residents transferred or discharged under this subsection and may place relocation teams as provided in Section 3-419 of the Act. (Section 3-402(b) of the Act)

 

e)         The notice required by subsection (d) shall be on a form prescribed by the Department and shall contain all of the following:

 

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

 

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

 

3)         A statement in not less than 12-point type, which reads:

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

q)         The Department may transfer or discharge any resident from any facility required to be licensed under this Act when any of the following conditions exist:

 

1)         The facility is operating without a license; (Section 3-415(a) of the Act)

 

2)         The Department has suspended, revoked or refused to renew the license of the facility as provided under Section 3-119 of the Act. (Section 3-415(b) of the Act)

 

3)         The facility has requested the aid of the Department in the transfer or discharge of the resident and the Department finds that the resident consents to transfer or discharge; (Section 3-415(c) of the Act)

 

4)         The facility is closing or intends to close and adequate arrangement for relocation of the resident has not been made at least 30 days prior to closure; or (Section 3-415(d) of the Act)

 

5)         The Department determines that an emergency exists which requires immediate transfer or discharge of the resident. (Section 3-415(e) of the Act)

 

r)          In deciding to transfer or discharge a resident from a facility under subsection (q), the Department shall consider the likelihood of serious harm which may result if the resident remains in the facility. (Section 3-416 of the Act)

 

s)         The Department shall offer transfer or discharge and relocation assistance to residents transferred or discharged under subsections (c) through (q) including information on available alternative placements. Residents shall be involved in planning the transfer or discharge and shall choose among the available alternative placements, except that where an emergency makes prior resident involvement impossible, the Department may make a temporary placement until a final placement can be arranged. Residents may choose their final alternative placement and shall be given assistance in transferring to the alternative placement. No resident may be forced to remain in a temporary or permanent placement. Where the Department makes or participates in making the relocation decision, consideration shall be given to proximity to the resident's relatives and friends. The resident shall be allowed three visits to potential alternative placements prior to removal, except where medically contraindicated or where the need for immediate transfer or discharge requires reduction in the number of visits. (Section 3-417 of the Act)

 

t)          The Department shall prepare resident transfer or discharge plans to assure safe and orderly removals and protect residents' health, safety, welfare and rights. In nonemergencies and where possible in emergencies, the Department shall design and implement such plans in advance of transfer or discharge. (Section 3-418 of the Act)

 

u)         The Department may place relocation teams in any facility from which residents are being discharged or transferred for any reason, for the purpose of implementing transfer or discharge plans. (Section 3-419 of the Act)

 

v)         In any transfer or discharge conducted under subsections (q) through (t) the Department will:

 

1)         Provide written notice to the facility prior to the transfer or discharge. The notice shall state the basis for the order of transfer or discharge and shall inform the facility of its right to an informal conference prior to transfer or discharge under this Section, and its right to a subsequent hearing under subsection (x). If a facility desires to contest a nonemergency transfer or discharge, prior to transfer or discharge it shall, within 4 working days after receipt of the notice, send a written request for an informal conference to the Department. The Department shall, within 4 working days from the receipt of the request, hold an informal conference in the county in which the facility is located. Following this conference, the Department may affirm, modify or overrule its previous decision. Except in an emergency, transfer or discharge may not begin until the period for requesting a conference has passed or, if a conference is requested, until after a conference has been held; and (Section 3-420(a) of the Act)

 

2)         Provide written notice to any resident to be removed, to the resident's representative, if any, and to a member of the resident's family, where practicable, prior to the removal. The notice shall state the reason for which transfer or discharge is ordered and shall inform the resident of the resident's right to challenge the transfer or discharge under subsection (x). The Department shall hold an informal conference with the resident or the resident's representative prior to transfer or discharge at which the resident or the representative may present any objections to the proposed transfer or discharge plan or alternative placement. (Section 3-420(b) of the Act)

 

w)        In any transfer or discharge conducted under subsection (q)(5), the Department shall notify the facility and any resident to be removed that an emergency has been found to exist and removal has been ordered, and shall involve the residents in removal planning if possible. Following emergency removal, the Department shall provide written notice to the facility, to the resident, to the resident's representative, if any, and to a member of the resident's family, where practicable, of the basis for the finding that an emergency existed and of the right to challenge removal under subsection (x). (Section 3-421 of the Act)

 

x)         Within 10 days following transfer or discharge, the facility or any resident transferred or discharged may send a written request to the Department for a hearing under Section 3-703 of the Act to challenge the transfer or discharge. The Department shall hold the hearing within 30 days of receipt of the request. The hearing shall be held at the facility from which the resident is being transferred or discharged, unless the resident or resident's representative, requests an alternative hearing site. If the facility prevails, it may file a claim against the State under the Court of Claims Act for payments lost less expenses saved as a result of the transfer or discharge. No resident transferred or discharged may be held liable for the charge for care which would have been made had the resident remained in the facility. If a resident prevails, the resident may file a claim against the State under the Court of Claims Act for any excess expenses directly caused by the order to transfer or discharge. The Department shall assist the resident in returning to the facility if assistance is requested. (Section 3-422 of the Act)

 

y)         Any owner of a facility licensed under this Act 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 subsection (u). (Section 3-423 of the Act)

 

(Source:  Amended at 46 Ill. Reg. 8192, effective May 6, 2022)

 

Section 390.3310  Complaint Procedures

 

a)         A resident shall be permitted to present grievances on behalf of themself and others to the administrator, the DD Facility Advisory Board established under Section 2-204 of the ID/DD Community Care Act, the residents' advisory council, State governmental agencies or other persons without threat of discharge or reprisal in any form or manner whatsoever. (Section 2-112 of the Act)

 

b)         The facility administrator shall provide all residents or their representatives with the name, address, and telephone number of the appropriate State governmental office where complaints may be lodged. (Section 2-112 of the Act)

 

c)         A person who believes that the Act or this Part may have been violated may request an investigation. The request may be submitted to the Department in writing, by telephone, by electronic means, or by personal visit. An oral complaint will be reduced to writing by the Department. (Section 3-702(a) of the Act)

 

d)         The substance of the complaint will be provided in writing to the licensee, owner or administrator no earlier than at the commencement of the on-site inspection of the facility that takes place pursuant to the complaint. (Section 3-702(b) of the Act)

 

e)         The Department will not disclose the name of the complainant unless the complainant consents in writing to the disclosure or the investigation results in a judicial proceeding, or unless disclosure is essential to the investigation. The complainant will be given the opportunity to withdraw the complaint before disclosure. Upon the request of the complainant, the Department will permit the complainant or a representative of the complainant to accompany the person making the on-site inspection of the facility. (Section 3-702(c) of the Act)

 

f)         Upon receipt of a complaint, the Department will determine whether the Act or this Part has been or is being violated. The Department will investigate all complaints alleging abuse or neglect within seven days after the receipt of the complaint except that complaints of abuse or neglect that indicate that a resident's life or safety is in imminent danger will be investigated within 24 hours after receipt of the complaint. All other complaints will be investigated within 30 days after the receipt of the complaint, except that, during a statewide public health emergency, as defined in the Illinois Emergency Management Agency Act, all other complaints will be investigated within an appropriate time frame to the extent feasible.  (Section 3-702(d) of the Act)

 

g)         The Department employees investigating a complaint will conduct a brief, informal exit conference with the facility to alert its administration of any suspected serious deficiency that poses a direct threat to the health, safety or welfare of a resident to enable an immediate correction for the alleviation or elimination of the threat. Information and findings discussed in the brief exit conference will become a part of the investigating record but will not in any way constitute an official or final notice of violation as provided under Section 3-301 of the Act and Section 390.276 of this Part.  All complaints will be classified as "an invalid report," "a valid report," or "an undetermined report." For any complaint classified as "a valid report," the Department will determine within 30 working days if this Part or provision of the Act has been or is being violated. (Section 3-702(d) of the Act)

 

h)         In all cases, the Department will inform the complainant of its findings within 10 days after its determination unless otherwise indicated by the complainant, and the complainant may direct the Department to send a copy of the findings to another person. The Department's findings will include comments or documentation provided by either the complainant or the licensee pertaining to the complaint. The Department will also notify the facility of findings within ten days after the determination, but the name of the complainant or residents will not be disclosed in this notice to the facility. The notice of findings will include a copy of the written determination; the correction order, if any; the warning notice, if any; inspection report; or the State licensure form on which the violation is listed. (Section 3-702(e) of the Act)

 

i)          A written determination, correction order, or warning notice concerning a complaint, together with the facility's response, will be available for public inspection, but the name of the complainant or resident will not be disclosed without their consent. (Section 3-702(f) of the Act)

 

j)          A complainant who is dissatisfied with the determination or investigation by the Department may request a hearing under subsection (k). The facility will be given notice of the hearing and may participate in the hearing as a party. If a facility requests a hearing under subsection (k) that concerns a matter covered by a complaint, the complainant will be given written notice and may participate in the hearing as a party. A request for a hearing by either a complainant or a facility shall be submitted in writing to the Department within 30 days after the mailing of the Department's findings as described in subsection (h). Upon receipt of the request the Department will conduct a hearing as provided under subsection (k). (Section 3-702(g) of the Act)

 

k)         Any person aggrieved by a decision of the Department rendered in a particular case that affects the legal rights, duties or privileges created under the Act may have the decision reviewed in accordance with Sections 3-703 through 3-712 of the Act.

 

l)          When the Department finds that a provision of Article II of the Act regarding residents' rights has been violated with regard to a particular resident, the Department will issue an order requiring the facility to reimburse the resident for injuries incurred, or $100, whichever is greater.

 

(Source:  Amended at 49 Ill. Reg. 7071, effective April 30, 2025)