Section 2060.315  Quality Improvement

a)         The licensee shall design and utilize a quality improvement plan.  Such plan shall be written and shall contain, at a minimum, a method of evaluation to assess achievement of the organization's mission and the functioning of the organization and its service delivery systems and utilization review process.

b)         The quality improvement plan shall be approved by management or, if applicable, the board of directors of the organization and annually reviewed and revised as necessary.

c)         The evaluation shall contain, at a minimum:

1)         a mission statement for the organization;

2)         specific and measurable goals, objectives, activities and outcome standards that are utilized by the organization to achieve its missions and projected results;

3)         a description of how the organization will review and implement needed changes based on the results of the evaluation;

4)         a method to review use of medication in any level of care;

5)         a method of risk management that, at a minimum, includes:

A)        review and analysis of any incident or significant incident reports as referenced in Section 2060.331 of this Part; and

B)        design and implementation of necessary procedures to address both proactively and reactively any identified risks; and

6)         a method of utilization review to measure appropriate patient placement.

d)         The method of organization evaluation shall be submitted with the application for licensure.  The results of the evaluation shall also be available for inspection by the Department and submitted at the time of application for renewal of licensure.

e)         Utilization Review

1)         For treatment licensees, utilization review shall be conducted at least quarterly and shall be conducted on a minimum 15% sample.  If random sampling at 15% indicates problems, the organization will develop a specific remediation plan to correct the identified problems.  Utilization review shall be conducted in accordance with continued stay and discharge criteria as established in the ASAM Patient Placement Criteria.

2)         For DUI evaluation or designated program intervention licensees, utilization review shall:

A)        be conducted at least quarterly on randomly selected cases consisting of at least 15% (but no less than five and no more than 20) of persons receiving each service; and

B)        be based on the established criteria specified in this Part for the applicable category of intervention license relative to the substance abuse assessment or evaluation and subsequent intervention or referral.

f)         All organizations required to conduct utilization review shall also:

1)         specify all staff participating in utilization review;

2)         specify how conflict of interest shall be addressed in any small organization where professional staff cannot always avoid reviewing their own cases; and

3)         issue a report of finding from utilization review at least quarterly and make such report available to all professional staff.

g)         Treatment licensees who are not otherwise required to report data electronically to the Department shall maintain statistics that, at a minimum, determine the total number of assessments, admissions, and discharges per patient by type of discharge and the average length of stay in each level of care.

h)         DUI risk education services shall not be subject to utilization review as specified in subsection (e).

i)          All treatment and intervention licensees shall develop and maintain a written policy and procedures manual that describes the operation of the organization.  At a minimum, the manual shall explain how the organization will comply with all federal and State regulatory and contractual requirements, any additional requirements from independent accrediting bodies, and any other organizational policies and procedures.  The manual shall be approved by the board of directors of the organization or, if not applicable, the organization representative and annually reviewed and revised as necessary.  The manual shall be submitted to the Department at the time of licensure and upon request from Department staff.  The manual shall also be reviewed during the first year of employment by all staff.  Annually thereafter, the organization shall ensure that all staff shall review updated sections pertinent to such staff.

(Source:  Amended at 25 Ill. Reg. 11063, effective August 14, 2001)