TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 115 STANDARDS AND LICENSURE REQUIREMENTS FOR COMMUNITY-INTEGRATED LIVING ARRANGEMENTS
SECTION 115.320 ADMINISTRATIVE REQUIREMENTS
Section 115.320 Administrative requirements
a) Governing body
1) Each agency 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 agency and all programs, services, facilities and residences it administers.
2) Each agency shall have provisions for obtaining input from consumers and/or consumer representatives to the governing body.
1) Mental health and developmental disabilities employees shall be licensed or certified as required by Illinois laws.
2) When paraprofessional or untrained employees are used in direct services, they shall be supervised in the provision of services by professional employees.
3) An agency shall not employ an individual in any capacity, until the agency has inquired of the Department of Public Health as to information in the Nurse Aid Registry concerning the individual. If the Registry has information of a substantiated finding of abuse or neglect against the individual, the agency shall not employ him or her in any capacity.
c) General program requirements
Agencies funded by the Department shall meet the following general program requirements for all funded services:
1) Service setting
Services shall be provided in the setting most appropriate to the needs of and reflecting the preferences of the individual. This may include the individual's home, the agency, or the community. All settings shall be used innovatively in order to reach the target populations.
A) Cumulative case records including an individualized service plan shall be maintained for each individual.
B) The individualized service plan shall state the goals for each individual. The individual shall be afforded the opportunity and encouraged to participate in goal/objective selection. Goals/objectives shall include timeframes specified by the agency's professional employees, in consultation with the individual and relevant collaterals. "Individualized service plan", as used herein, refers to and is equivalent to "individual treatment plan" and "individual habilitation plan".
3) Behavior management and human rights review
Each agency is required to establish or ensure a process for the periodic review of behavior intervention and human rights issues involved in the individual's treatment and/or habilitation. Agencies required to have behavior intervention and human rights review policies and procedures under licensure or certification standards shall continue to comply with those standards.
4) Abuse and neglect
Each agency shall have and use a process for reporting and handling instances of abuse and neglect in accordance with applicable standards, regulations and laws that shall include notification of the individual allegedly abused or neglected and his or her guardian or parent of the allegation within 24 hours after receiving the allegation.
5) Admission to programming
A) Agencies shall not discriminate in the admission to and provision of needed services to individuals on the basis of race, color, sex, religion, national origin, ancestry, or disability.
B) Admission policies and procedures shall be set forth in writing and be available for review.
6) Compliance with life safety standards and requirements
All program facilities shall be in compliance with applicable State licensure requirements and local ordinances with regard to fire, building, zoning, sanitation, health, and safety requirements.
7) Personnel requirements
A) A licensed physician (MD or DO) shall assume medical and legal responsibility for medical services offered in any program, including prescription of medications.
B) All services shall be provided by appropriately trained employees, operating under the supervision of qualified clinical professionals.
8) Mandated services
A) Mandated services shall be provided according to the requirements as stated in the Department's rules at 59 Ill. Adm. Code 125 (Recipient Discharge/Linkage/Aftercare).
B) The Department shall monitor the provision of mandated follow-up monitoring services as outlined in 59 Ill. Adm. Code 125.
9) Utilization review
Utilization review is the ongoing review of services delivered, their intensity and their duration, to determine adherence to generally accepted guidelines or standards regarding the individual's assessment, eligibility for service and appropriateness of services rendered. Agencies shall engage in a utilization review process for all program services.
10) Visits to programs
The agency shall ensure that Department-authorized consumer interest groups shall be permitted, with the consent of individuals, to visit agencies and living arrangements owned or leased by an agency.
1) Direct service employees and any other compensated persons with responsibility for direct care of individuals served shall demonstrate competence in training areas listed in subsections (d)(1)(A) through (M) as a part of an orientation program. Anyone specified in this subsection (d)(1) without previous experience in direct service to individuals shall receive training and demonstrate competence prior to unsupervised responsibility for direct service unless trained employees are on site and available for on-the-job training. Direct service providers as specified above who have completed training in the below mentioned areas, and demonstrated competence as documented in their records, shall not be required to repeat that training as part of their orientation. Anyone specified in this subsection (d)(1) who has not demonstrated competence shall receive training until he or she can demonstrate competence in the following areas, as recorded in his or her records. All direct service employees and any other compensated persons, regardless of staffing model, shall receive training and demonstrate competence as documented in employee records in the following training areas:
A) Cardiopulmonary resuscitation (CPR), Heimlich maneuver and first aid;
B) Concepts of treatment, habilitation and rehabilitation including behavior management, normalization, age appropriateness and psycho-social rehabilitation depending on the needs of the individuals served or to be served;
C) Safety, fire, and disaster procedures;
D) Abuse, neglect and unusual incident prevention, handling and reporting;
E) Individual rights in accordance with Chapter II of the Code and maintaining confidentiality in accordance with the Confidentiality Act;
F) The nature and structure of the individual integrated services plan;
G) The type, dosage, characteristics, effects and side effects of medications prescribed for individuals. The agency shall assure that there is sufficient training in this area to provide coverage during expected and unexpected absences of caregivers by others who have been determined competent;
H) Screening for involuntary muscular movement, which may be indicative of tardive dyskinesia;
I) Development and implementation of an individual integrated services plan;
J) Formal assessment instruments used and their role in the development of the services plan;
K) Documentation and recordkeeping requirements with reference to the services plan;
L) Other training which relates specifically to the type of disability or treatment and intervention techniques being used specific to individuals living in CILAs geared toward assisting employees to execute objectives obtained in the services plans;
M) The techniques associated with monitoring and regulating hot water temperatures prior to and during an individual's use to ensure safe hand-washing, hair-washing, bathing and showering procedures; and
N) In CILA programs for persons with developmental disabilities, all unlicensed, direct care employees, prior to assuming responsibility for supervising the self-administration of medication training programs or for administration of medications for persons with developmental disabilities, will successfully complete a Department approved training program provided by an agency Nurse-Trainer pursuant to 59 Ill. Adm. Code 116.
i) All agency Nurse-Trainers will be registered professional nurses.
ii) All agency Nurse-Trainers will be trained by the Department's Master Nurse-Trainer.
2) After completion of training specified in subsection (d)(1) of this Section, each direct service employee shall participate in ongoing employee development activities as outlined in the agency's employee development plan.
3) All training shall be documented and shall be readily available for review by Department surveyors.
4) The agency shall implement a written training plan which lists training to be offered to meet the requirements of this Part, the methods used for completion of any required training, and the process used to determine competency.
e) Volunteer training
The agency shall provide an orientation and training program for volunteers specific to volunteer duties and shall provide supervision as necessary. Volunteers with responsibility for care of individuals served must complete and demonstrate competency in the training areas specified in subsection (d) above.
f) 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 agency's quality assurance program shall be the basis for annually certifying to the Department that individuals are receiving appropriate community-based services consistent with their services plans, that all programs and services are supervised by the agency and comply with this Part.
A) If a certified CILA does not continue to meet standards, the agency shall correct deficiencies within 30 days; or
B) If deficiencies in a certified CILA cannot be corrected within 30 days, the agency shall withdraw certification of the CILA program in question and notify the Department. The agency shall remain responsible for those individuals who live in or lived in the affected CILA.
g) Unusual incidents
1) The agency shall have written policies and procedures for handling, investigating, reporting, tracking and analyzing unusual incidents through the agency's management structure, up to and including the authorized agency representative. The agency shall ensure that employees demonstrate their knowledge of, and follow, such policies and procedures. Unusual incidents shall include, but are not limited to, the following:
A) Sexual assault;
B) Abuse or neglect;
D) Physical injury;
F) Missing persons;
G) Theft; and
H) Criminal conduct.
2) Within 24 hours of occurrence the agency shall report any incident which is subject to the Criminal Code of 1961 [720 ILCS 5] to the local law enforcement agencies.
3) The agency shall ensure that suspected instances of abuse or neglect against individuals in programs which are licensed by the Department are reported to the Office of Inspector General (Section 6.2 of the Abused and Neglected Long Term Facility Residents Reporting Act [210 ILCS 30/6.2]).
h) Individuals' records
1) The agency shall ensure the confidentiality of individuals' records in accordance with the Act and shall ensure safekeeping of all records against loss or destruction.
2) The agency shall maintain a chronological record for each individual. Records shall be located at the program site at which individuals are being served.
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 agency shall provide a legend to explain them which shall be standardized throughout the agency.
3) On an individual's entry into the agency, the following information shall be obtained, recorded and updated as necessary in the individual's record:
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 legal 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 an individual who is hearing impaired, the individual's preferred mode of communication, e.g., American sign language, signed English, aural, oral or tactile communications device;
D) Prescribed medications, reactions and side effects to medications, allergies to foods, other medications and substances;
E) Physical and dental examinations, and medical history;
F) Consent to receive emergency medical services; and
G) 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) Written informed consent by the individual or guardian to participate in a CILA;
B) Prior service history;
C) Initial assessment and individual integrated services plan, and reassessments, and individual integrated services plan as described in Section 115.230;
D) Documentation of approval to use special procedures and the results of their use;
E) Progress notes, which shall be entered chronologically and at least monthly, documenting the individual's involvement in and response to the services plan.
5) Electronic signature or computer-generated signature codes are acceptable as authentication of record content.
A) In order for an agency to employ electronic signatures or computer-generated signature codes for authentication purposes, the agency must adopt a policy that permits authentication by electronic or computer-generated signature.
B) At a minimum, the policy shall include adequate safeguards to ensure confidentiality of the codes, including, but not limited to, the following:
i) Each user must be assigned a unique identifier that is generated through a confidential access code.
ii) The agency must certify in writing that each identifier is kept strictly confidential. This certification must include a commitment to terminate a user's use of a particular identifier if it is found that the identifier has been misused. "Misused" shall mean that the user has allowed another person or persons to use his or her personally assigned identifier, or that the identifier has otherwise been inappropriately used.
iii) The user must certify in writing that he or she is the only person with user access to the identifier and the only person authorized to use the signature code.
iv) The agency must monitor the use of identifiers periodically and take corrective action as needed. The process by which the agency will conduct monitoring shall be described in the policy.
C) A system employing the use of electronic signatures or computer-generated signature codes for authentication shall include a verification process to ensure that the content of authenticated entries is accurate. The verification process shall include, at a minimum, the following provisions:
i) The system shall require completion of certain designated fields for each type of document before the document may be authenticated, with no blanks, gaps or obvious contradictory statements appearing within those designated fields. The system shall also require that correction or supplementation of previously authenticated entries shall be made by additional entries, separately authenticated and made subsequent in time to the original entry.
ii) The system must make an opportunity available to the user to verify that the document is accurate and the signature has been properly recorded.
iii) The agency must periodically sample records generated by the system to verify the accuracy and integrity of the system.
D) Each report generated by a user must be separately authenticated.
i) Financial and operational requirements
Agencies licensed to provide CILAs shall comply with Department rules regulating their contractual and financial relationship with the Department.
(Source: Amended at 24 Ill. Reg. 16313, effective October 12, 2000)