Section 112.30  Recipient physical and dental examinations and informed consent for services

To provide the highest possible quality of humane and rehabilitative care and treatment for all recipients in the care of the Department and to promote public health and safety, all recipients in Department facilities shall receive comprehensive physical and dental examinations.

a)         Physical examination

1)         Each person admitted to the Department in accordance with the Code [405 ILCS 5] shall have a thorough physical examination on admission and annually thereafter (see Section 1-119(2) of the Code). Persons with mental illness shall be examined within 24 hours in accordance with the Mental Health Standards (Joint Commission on Accreditation of Healthcare Organizations (JCAHO), One Renaissance Boulevard, Oakbrook Terrace, Illinois 60681, 1995) or the Accreditation Manual for Hospitals (Joint Commission on Accreditation of Healthcare Organizations (JCAHO), One Renaissance Boulevard, Oakbrook Terrace, Illinois  60681, 1996).  In accordance with 77 Ill. Adm. Code 350 (Intermediate Care for the Developmentally Disabled Facilities Code) (ICFDD), persons with developmental disabilities shall be examined within 72 hours.  This requirement may be waived in the judgment of the admitting physician only if such an examination was done within three days prior to admission and the results are received by the facility and are entered into the recipient's clinical record.

A)        The examination shall include an evaluation of the recipient's condition, including height, weight, blood pressure and vital signs, diagnoses, plan of medical treatment, recommendations for care, including personal care needs, treatment orders, permission for participation in activity programs, as appropriate, and any other examinations that are required by the accrediting agencies cited in subsection (a)(1) of this Section, as well as the Standards for Services for People with Developmental Disabilities (Accreditation Council for Services for People with Developmental Disabilities (Council) 8100 Professional Place, Suite 204, Landover, Maryland 20785, 1990).  The examination shall also include a visual check of the oral cavity, including lips, teeth, gums and tongue.  Referral to a dental hygienist or dentist shall be completed if clinically indicated.  Plans of medical treatment, recommendations for care and treatment orders shall be recorded in the recipient's individualized services plan as defined in Sections 3-209 and 4-309 of the Code.

B)        The presence or absence of communicable or infectious diseases shall be noted by the examining physician with recommendations given for curing or controlling the disease, as applicable.  Communicable or infectious diseases shall be reported in accordance with Department of Public Health rules:  

i)          77 Ill. Adm. Code 690 (Control of Communicable Diseases Code);

ii)         77 Ill. Adm. Code 693 (Control of Sexually Transmissible Diseases Code); and

iii)        77 Ill. Adm. Code 697 (AIDS Confidentiality and Testing Code).

2)         An electrocardiogram (EKG) shall be provided within three days after admission, excluding Saturdays, Sundays, and holidays, for any recipient age 40 or over, except that an admission EKG need not be repeated on readmission if one was provided within the previous  12 months during a prior admission, unless otherwise clinically indicated by the examining physician.

3)         A Papanicolaou (Pap) smear uterine cytologic examination for cancer shall be offered to all female recipients admitted or readmitted to a Department facility who are 20 years of age and over, or under 20 years of age if sexually active, unless the examining physician considers the examination contraindicated, the examination has been performed within the previous year and the results were normal, or the examination is refused by the recipient on the counsel of the examining physician or on her own judgment.  Results of tests performed outside the facility shall be obtained and entered into the recipient's clinical record.  A Pap smear uterine cytologic examination shall be offered and recommended annually. The examining physician shall document in the recipient's clinical record the results of the Pap smear, whether or not the test was contraindicated, or that the recipient refused the examination.

4)         In the event that the recipient's psychiatric, behavioral, or medical condition is such that the physical examination as described in subsection (a)(1)(A) of this Section cannot be completed within the times stated in subsection (a)(1) of this Section, the examining physician may extend the time frame until the recipient's condition has improved to allow the completion of the examination.  Every 72 hours the examining physician shall record in the recipient's clinical record the condition preventing a complete physical examination and the continuation of the recipient's condition until the physical examination has been completed.  If the recipient's physical examination is delayed in excess of 30 days, such delay shall require notice from the examining physician to the facility director, and a special conference of the treatment team to identify a course of action designed to protect the recipient from inappropriate treatment based on inadequate information.

b)         Dental examination

1)         Persons with developmental disabilities shall have a comprehensive diagnostic dental examination, including extra- and intra-oral examinations within 30 calendar days after admission, unless the admitting physician waives this requirement.  The admitting physician shall record the reason for the waiver in the recipient's clinical record.

A)        The examination report shall include an evaluation of the recipient's dental condition, diagnoses, plan of treatment, recommendations for oral health care and dental hygiene, and treatment orders.

B)        The physician may extend the time for conduct of the dental examination; however, the physician must record the reason for the extension in the recipient's clinical record.  If the recipient's dental examination is delayed in excess of 30 days, such delay shall require notice from the examining physician to the facility director, and a special conference of the treatment team to identify a course of action designed to protect the recipient from inappropriate treatment based on inadequate information.

2)         Persons with mental illness shall have a comprehensive diagnostic dental examination, including extra- and intra-oral examinations, within six months after admission.  If the recipient's condition is such that a dental examination is necessary less than six months after admission, a referral to a dentist or dental hygienist shall be made.

c)         Schedule for examinations and treatment plan

1)         Physical examinations shall be repeated annually.  In accordance with Section 7 of the Mental Health and Developmental Disabilities Administrative Act [20 ILCS 1705/7], dental examinations shall be repeated every 18 months for recipients with mental illness while residing in Department facilities.  In accordance with the Standards for Services for People with Developmental Disabilities (Accreditation Council for Services for People with Developmental Disabilities, 8100 Professional Place, Suite 204, Landover, Maryland 20785, 1990,) dental examinations shall be repeated annually for recipients with developmental disabilities while residing in Department facilities.  These examinations shall be performed by a licensed dentist or a registered hygienist and shall be independent of periodic reviews such as the use of medications, blood levels of drugs and gingivitis checks.

2)         If a recipient has been in the facility or is transferred from another facility, the receiving facility shall perform comprehensive diagnostic examinations if the individualized services plan does not provide a treatment plan for medical and dental services for the recipient.

3)         On completion of the comprehensive diagnostic examinations, a treatment plan for any medical and dental services shall be established as part of the recipient's individualized services plan.

A)        Such a plan will include procedures to address the special dental care needs of recipients who receive medication known to promote tooth decay or gum disease.

B)        Such a plan will include a procedure to address the prevention and treatment of tardive dyskenesia.

d)         Informed consent

            Informed consent is defined as permission for a procedure freely granted by a person or persons authorized by law to give consent to services and treatment plans, i.e., the recipient, guardian (if the recipient is under guardianship) or parent (if the recipient is under age 18).  Informed consent is based on the full disclosure to the authorized person of the information required to make the decision intelligently, including a description of the procedure, the possible benefits and the risks and the alternative(s) to the procedure.

1)         For the purposes of this Section, the person(s) authorized to give consent shall be informed of the treatment plan for medical and dental services, and shall be provided with the information necessary to give informed consent.  The documented agreement to the individualized services plan will obviate the need for specific agreement to the treatment plan for medical and dental services.

2)         The person(s) authorized to give consent shall be informed of the method whereby he or she can exercise the right to refuse medical and dental services.

3)         For services listed below, the person(s) authorized to give consent shall be informed that if an objection is not received prior to performance of services, consent shall be implied for the treatment plan:

A)        Dental - preventive procedures (such as prophylaxis, topical fluoride, periodontal scaling, and gingival curettage,) and restorative procedures (such as, fillings and local anesthesia).

B)        Medical - non-psychotropic medication, endoscopy not involving anesthesia, exercise regimens and sutures.

4)         A written consent, signed by the person authorized to give consent, shall be required for all other procedures, including general anesthesia, surgery (both medical and dental) and radiation therapy.  The written consent shall be specific to the procedure or course of therapy to be used and shall only apply to a particular procedure performed at a particular time or to a course of therapy of which the procedure is a part.  An additional consent shall be obtained for each subsequent procedure.  A consent authorizing a specific Department staff person to perform a procedure is specific to that staff person.

5)         If consent is denied by the person authorized to consent, medical or dental procedures shall not be provided except pursuant to subsection (d)(6) of this Section.  Such refusal shall be documented in the recipient's clinical record.

6)         In accordance with Section 2-111 of the Code, when a medical or dental emergency exists, if the physician or licensed dentist who examines the recipient determines that the recipient is not capable of giving informed consent, essential medical or dental procedures may be provided without consent.  No physician nor licensed dentist shall be liable for a non-negligent good faith determination that a medical or dental emergency exists.  The nature of the emergency shall be documented in the recipient's clinical record and notice shall be given to the recipient, the legal guardian or parent(s).

e)         Communicating examination findings

            Significant or negative examination findings obtained from the recipient's physical examination results of laboratory tests as they become known shall be communicated to the recipient or, if the recipient is under guardianship, to the recipient's guardian, or, if the recipient is a minor to the recipient's parent or guardian.  The fact that such findings were communicated to the recipient, parent or guardian shall be documented in the recipient's clinical record.

(Source:  Amended at 21 Ill. Reg. 2210, effective February 1, 1997)