Section 119.260  Administrative requirements

 

a)         Governing body

 

1)         Each program which is owned or operated by any corporation, association, or unit of local government shall have a governing body in which is vested authority and responsibility for the organization, management, control and operation of the program in compliance with the General Not For Profit Corporation Act of 1986 [805 ILCS 105], and with the Department's rules at 59 Ill. Adm. Code 103 (Grants).

 

2)         The names and addresses of all owners or controlling parties (whether they are sole proprietorship, association, partnership, corporation, or subdivisions of other bodies, such as public agencies or religious, fraternal or other charitable organizations) shall be fully disclosed and provided to the Department annually. For corporations, the names and addresses of all officers, directors, and principal stockholders, either beneficial or of record, shall be disclosed.

 

3)         The governing body shall include persons who have no direct or indirect financial interest in the program and who reside in the geographic area served by the program and include persons with developmental disabilities and consumer representatives.

 

4)         The provider shall notify the governing body of the Department's annual survey and other State and local inspections which indicate the outcome and disposition of any findings resulting from a survey.

 

b)         Advisory board

 

1)         A program which is owned or operated by a sole proprietor or partnership shall appoint and maintain an advisory board whose members shall be persons who have no direct or indirect financial interest in the program, and who reside in the geographic area served by the program, and who include persons with developmental disabilities and consumer representatives.

 

2)         The advisory board shall ensure that each program owned or operated by a sole proprietor or partnership shall have a charter, mission statement, goals and objectives.

 

c)         Authorized agency representative

            The provider shall appoint an authorized agency representative whose qualifications and duties are defined in writing and include authority for program administration and management. His or her performance shall be reviewed and documented annually by the governing body.

 

d)         Provider policy requirements

 

1)         The program shall have written policies which shall be reviewed annually, revised as necessary and approved by the governing body or advisory board and shall describe:

 

A)        Goals and objectives reflecting annual and long-range plans;

 

B)        The population served, including age groups, disabilities and the geographic service area;

 

C)        The services provided in response to individual and community needs including:

 

i)          The hours and days of operation;

 

ii)         The methods used to perform initial screening and assessment of individuals;

 

iii)        A description of processes used for development of the services plan;

 

iv)        The use and approval of special training procedures such as time-out, restraint and aversive techniques;

 

v)         Handling emergencies and disasters; and

 

vi)        Maintenance of buildings, vehicles and equipment.

 

2)         Program policy shall ensure the availability of professional, administrative and support staff to assess and address the needs of individuals. This includes personnel and consultants who can communicate, either verbally or non-verbally, with individuals.

 

3)         Program policy shall ensure that Department-authorized consumer-interest groups shall be permitted, with the consent of the individuals, to visit a program.

 

A)        Consumer interest groups must request authorization in writing to visit specific programs.  The request shall be made to the Department and shall specify the program to be visited and the reason for the group's proposed visit.  If the group agrees to the conditions set out below, the request shall contain those agreements.

 

B)        The Department shall authorize a group to visit a program for a period of one year if:

 

i)          The group has as one of its organizational purposes to review public services for mentally disabled individuals;

 

ii)         The group agrees that its visits will not interfere with the program; and

 

iii)        The group agrees to abide by the provisions of the Act concerning records and communications of individuals in programs.

 

C)        The Department shall revoke its authorization or not renew the authorization if it has information that the group has not abided by the conditions set out above.

 

D)        Any group whose authorization has been denied, revoked or not renewed may appeal the decision in writing to the Secretary, who shall review the decision and accept or reverse it within 30 days.  The Secretary shall uphold the decision if he or she finds that the group has not abided by this Part.

 

e)         Personnel requirements

 

1)         Programs shall not discriminate in the hiring or employment of staff on the basis of race, color, age, national origin, sex, religion, or handicap.

 

2)         Personnel policies and procedures shall be in writing and available for review.

 

3)         The program shall have written job descriptions or contractual agreements for every position, including consultant and direct-service volunteer positions, which list the job title, duties and responsibilities, minimum experience and educational requirements, immediate supervisor and subordinates.

 

4)         Staff shall be licensed, registered or certified by the State, if required.

 

5)         When paraprofessional or untrained staff are used in direct services, they shall be supervised by professional staff.

 

6)         A pay plan for all position titles in use shall be available for review by the Department.

 

7)         An agency shall not employ a person in any capacity until the agency has inquired of the Department of Public Health as to information in the Nurse Aide Registry concerning the person.  If the Registry has information substantiating a finding of abuse or neglect against the person, the agency shall not employ him or her in any capacity.

 

f)         Staff and volunteer training

 

1)         Training in principles and practices in the following areas shall be provided to direct service and professional staff:

 

A)        Cardiopulmonary resuscitation (CPR), Heimlich maneuver and first aid;

 

B)        Behavior management;

 

C)        Normalization;

 

D)        Age and cultural appropriateness;

 

E)        Safety, fire, and disaster procedures including:

 

i)          Use of fire-fighting equipment; and

 

ii)         Familiarity with the disaster preparedness plan.

 

F)         Prevention, handling, and reporting of abuse, neglect, exploitation, unusual incidents (see subsection (h) of this Section):

 

G)        Individual rights in accordance with Chapter 2 of the Code and maintaining confidentiality in accordance with the Act;

 

H)        Team planning;

 

I)         Infection control and sanitation; and

 

J)         Food preparation and handling for staff who prepare and serve food to individuals.

 

2)         Training for volunteers working directly with individuals shall be provided in the areas discussed in subsections (f)(1)(A), (E), (F) and (G) of this Section.  The agency shall provide a training program for other volunteers.

 

g)         Quality assurance

 

1)         There shall be a written quality assurance plan and ongoing activities designed to review and evaluate services to individuals, operation of programs and to resolve identified problems.

 

2)         The scope of quality assurance shall include reviewing semi-annually, or more frequently if problems are identified, at least the following:

 

A)        Service planning;

 

B)        The use of special training procedures including behavior management procedures;

 

C)        Unusual incidents relative to services to individuals;

 

D)        Service utilization;

 

E)        Individuals' records ensuring that they meet the requirements of this Part;

 

F)         Subcontracted services to ensure that the needs of individuals are being met; and

 

G)        The status of individuals receiving service.

 

3)         Records of quality assurance reviews and activities shall be filed separately from the records of individuals.

 

h)         Unusual incidents

 

1)         The provider shall have written policies and procedures for handling, investigating, reporting, tracking and analyzing unusual incidents through the provider's management structure, up to and including the authorized agency representative.  The provider shall ensure that staff demonstrate their knowledge of, and follow such policies and procedures that shall include but are not limited to:

 

A)        Rape or sexual assault;

 

B)        Abuse or neglect;

 

C)        Death;

 

D)        Physical injury;

 

E)        Assault;

 

F)         Missing individuals;

 

G)        Theft; and

 

H)        Criminal conduct.

 

2)         Within 24 hours after becoming aware of an incident, the provider shall report to the appropriate law enforcement agencies any incident which is subject to the Criminal Code of 1961 [720 ILCS 5].

 

3)         The provider shall ensure that suspected instances of abuse or neglect against individuals in programs that are certified by the Department are reported to  the Office of Inspector General (Section 6.2 of the Abused and Neglected Long Term Care Facility Residents Reporting Act [210 ILCS 30/6.2]).

 

i)          Individual's record (record)

 

1)         The program shall ensure the confidentiality of an individual's record in accordance with the Act and shall ensure safekeeping of all records against loss or destruction.  Individuals or their guardians shall have access to the individual's record upon request.

 

2)         The program shall maintain a chronological record for each individual. Records shall be located at a site, designated by the program, that is accessible and convenient to staff contributing to the plan.

 

A)        Each entry shall be legible, dated and authenticated by the signature and title of the person making the entry.

 

B)        Corrections shall be initialed and made in such a way as to leave the original incorrect entry legible.

 

C)        When symbols or abbreviations are used, the program shall provide a legend, standardized throughout the program, to explain them.

 

3)         The following information shall be obtained and recorded when an individual enters a program, and shall be updated as necessary:

 

A)        Identifying information including name, date of birth, sex, race, social security number and legal status;

 

B)        The name, address and telephone number of the guardian or the person to be notified in case of an emergency;

 

C)        The language spoken or understood by the individual including, in the case of a hearing impaired or non-verbal individual, the individual's preferred mode of communication, e.g., American sign language, signed English, aural, oral or tactile communications device;

 

D)        Psychological assessments and recommendations;

 

E)        Prescribed medications, allergies to foods, other medications and substances;

 

F)         Physical and dental examinations and medical history;

 

G)        Consent to receive emergency medical services; and

 

H)        Copies of the authorization for release of information.

 

4)         The following shall be entered in the individual's record during the period of service:

 

A)        Prior service history;

 

B)        Initial assessments and plan and the most recent assessments and plan;

 

C)        Documentation of approval and their results when special training procedures are used such as time-out, restraint and aversive procedures; and

 

D)        Chronological progress notes, at least monthly, documenting the individual's involvement in and response to the plan.

 

j)          Financial and operational requirements

            Programs shall comply with 59 Ill. Adm. Code 103 (Grants).

 

(Source:  Amended at 23 Ill. Reg. 10211, effective August 23, 1999)