Section 330.110  General Requirements

 

a)         This Part applies to the operator/licensee of facilities, or distinct parts of facilities, that are licensed and classified to provide sheltered care pursuant to the terms and conditions of the 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 will be issued for a period of not less than six 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 two-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 the level of service classification sought for that distinct part.  To protect the health, welfare and safety of residents in a distinct part of the facility who require higher standards, the facility shall comply with additional physical plant standards in any distinct part, to achieve this protection as required by the highest level of care being licensed.  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.  (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.  (Section 3-318(a)(6) of the Act)

 

2)         Open or operate a facility without a license.  (Section 3-318(a)(7) 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 subsection 330.120(d) 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", "Rehabilitation Center", "Skilled Nursing Facility", "Assisted Living or Shared Housing Establishment", 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.

 

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)          The administrator of a facility licensed under the Act and this Part shall give 60 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 the part will require the transfer or discharge of more than 10% of the residents.  Notice shall be given to the Department, to the Office of State Long Term Care Ombudsman, 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.  If the Department suspends, revokes, or denies renewal of the facility's license, then notice shall be given no later than the date specified by the Department.  Notice shall state the proposed date of closing and the reason for closing.  The facility shall submit a closure plan to the Department for approval which shall address the process for the safe and orderly transfer of residents. The approved plan shall be included in the notice.  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.  A facility closing in its entirety shall not admit any new residents on or after the date written notice is submitted to the Department as specified under the Act and this Part.  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 330.4300 of this Part.  (Section 3-423 of the Act)

 

j)          Licensure for more than one level of care

 

1)         A facility may be licensed for more than one level of care. The licensee shall designate the level of care that will be provided in each bedroom. Bedrooms of like licensed levels of care shall be contiguous to each other within each "nursing unit" as defined in Section 330.330. Each nursing unit may have up to two levels of care and shall meet the construction standards for the highest licensed level of care in the nursing unit.

 

2)         If a facility wishes to license a portion of its licensed beds as either ID/DD or MC/DD licensed under the ID/DD Community Care Act or the MC/DD Act, respectively, the beds shall be located in a distinct part (as defined in Section 330.330) of the facility.

 

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.

 

m)         A facility shall comply with the Alzheimer's Disease and Related Dementias Services Act and the Alzheimer's Disease and Related Dementias Services Code.

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.120  Application for License

 

a)         Any person acting individually or jointly with other persons who proposes to build, own, establish, or operate a sheltered care facility shall submit application information on forms provided by the Department.  The applicant shall provide a written description of the proposed program, and other such information as the Department may require in order to determine the appropriate level of care for which the facility should be licensed. 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)         Application for a license to establish or operate a sheltered care facility shall be made in writing and submitted to the Department, with other such information as the Department may require, on forms furnished by the Department.  (Section 3-103(1) of the Act)

 

c)         All license applications shall be accompanied with an application fee of $1,990.    The fee for a 2-year license shall be double the fee for the annual license.  (Section 3-103(2) of the Act)

 

d)         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, 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)         Such 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)

 

e)         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 in such cases.

 

f)         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 six months of any changes in the information originally provided in the application.  (Section 3-103(3) of the Act)

 

g)         The Department may issue licenses or renewals for periods of not less than six  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 in order to distribute the expiration dates of such licenses throughout the calendar year.  The 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 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.130  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 does not have 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 Department shall also be provided with a copy of all new lease agreements or any changes to existing agreements within 30 days of the effective date of such 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 licensing Minimum Standards shall be at least 18 years of age.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.140  Issuance of an Initial License For a New Facility

 

a)         Upon receipt and review of an application for a license made under the Act and inspection of the applicant facility under the Act, the Director will issue a probationary license if they find:

 

1)         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;

 

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, as now or hereafter amended; and

 

3)         The facility is in substantial compliance with the Act and this Part.  (Section 3-109 of the Act)

 

b)         If the applicant has not been previously licensed or if the facility is not in operation at the time application is made, the Department will issue only a probationary license. A probationary license shall be valid for 120 days unless sooner suspended or revoked under Section 3-119 of the Act.  (Section 3-116 of the Act.

 

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, shall 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 fully and completely inspect the facility within appropriate time frames 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 will 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) Under no condition will more than two successive probationary licenses be issued.

 

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 twenty-four consecutive months.

 

(Source:  Amended at 49 Ill. Reg. 802, effective December 31, 2024)

 

Section 330.150  Issuance of an Initial License Due to a Change of Ownership

 

a)         Upon receipt and review of an application for a license made under the Act and inspection of the applicant facility under the Act, the Director will issue a probationary license if they find:

 

1)         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;

 

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, as now or hereafter amended; and

 

3)         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 a 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.  (Section 3-112(a) 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 a license is issued to the new transferee.  (Section 3-112(b) 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 will issue a conditional license and plan of correction as provided in Section 3-311 through 3-317 of the Act.  (Section 3-113(a) of the Act)

 

e)         The license granted to a transferee for a facility that is in receivership shall be subject to any contractual obligations assumed by a grantee under the Equity in Long-term Care Quality Act and to the plan submitted by the receiver for continuing and increasing adherence to best practices in providing high-quality nursing home care, unless the grant is repaid under the Equity in Long-Term Care Quality Act.  (Section 3-113(a) of the Act)

 

f)         The transferee shall submit to the Department a transition plan, signed by both the transferee and the transferor, that includes, at a minimum, a detailed explanation of how resident care and appropriate staffing levels shall be maintained until the license has been obtained and the transfer of the facility operations occurs.  The transition plan shall be submitted at the same time as notice to the Department of the transfer.  The transferor and transferee shall coordinate as necessary to ensure that there are no gaps in care, staffing, and safety during the transition period.  (Section 3-112(c) of the Act)

 

g)         The Department will accept or reject the transition plan within 10 days after submission.  If the transition plan does not meet the minimum requirements in subsection (f) and is rejected, the Department will work with the facility, the transferee, and the transferor to bring the transition plan into compliance.  (Section 3-112(c) of the Act)

 

h)         If the Department finds that an entity failed to follow an accepted transition plan and ensure residents are provided adequate care during the change of ownership process, and finds actual harm to a resident, the Department will establish a high-risk designation pursuant to paragraph (9) of Section 3-305 of the Act.  The Department will issue a violation to the entity that failed to carry out their responsibility under the transition plan that resulted in the violation.  As described in this Section, the change of ownership process shall begin upon submission of the transition plan to 30 days after the transfer of the facility.  (Sections 3-112(c), 3-113(b), and 3-114 of the Act)

 

i)          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)

 

j)          If the applicant has not been previously licensed or if the facility is not in operation at the time application is made, the Department will issue only 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).

 

k)         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, shall 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 fully and completely inspect the establishment within appropriate time frames 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.

 

l)          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 will 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) Under no condition will more than two successive probationary licenses be issued.

 

m)        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.

 

n)         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 twenty-four consecutive months.

 

(Source:  Amended at 49 Ill. Reg. 6515, effective April 22, 2025)

 

Section 330.160  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 other licensure requirements, the license shall be renewed in accordance with Section 3-110 of the Act.  The renewal application shall not be approved unless the applicant has provided to the Department an accurate disclosure document in accordance with the Alzheimer's Special Care Disclosure Act [220 ILCS 4] and Section 330.163 of this Part, if applicable. (Section 3-115 of the Act)

 

(Source:  Amended at 24 Ill. Reg. 17304, effective November 1, 2000)

 

Section 330.163  Alzheimer's Special Care Disclosure

 

A facility that offers to provide care for persons with Alzheimer's disease through an Alzheimer's special care unit or center shall disclose to the Department or to a potential or actual client of the facility the following information in writing on request of the Department or client:

 

a)         The form of care or treatment that distinguishes the facility as suitable for persons with Alzheimer's disease;

 

b)         The philosophy of the facility concerning the care or treatmemt of persons with Alzheimer's disease;

 

c)         The facility's pre-admission, admission, and discharge procedures;

 

d)         The facility's assessment, care planning, and implementation guidelines in the care and treatment of persons with Alzheimer's disease;

 

e)         The facility's minimum and maximum staffing ratios, specifying the general licensed health care provider to client ratio and the trainee health care provider to client ratio;

 

f)         The facility's physical environment;

 

g)         Activities available to clients at the facility;

 

h)         The role of family members in the care of clients at the facility; and

 

i)          The costs of care and treatment under the program or at the center. (Section 15 of the Alzheimer's Special Care Disclosure Act)

 

(Source:  Added at 23 Ill. Reg. 1085, effective January 15, 1999)

 

Section 330.165  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, or to revoke the current license of a facility.

 

b)         A determination by the Director or his or her designee to take adverse licensure action against a facility shall 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 a facility shall include, but not be limited to, any of 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 the Act after the Department has sent to the facility 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 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; or

 

B)        Two or more misdemeanors involving moral turpitude. (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)         The facility is operating (or, for an initial applicant, intends to operate) with personnel who are insufficient in number or unqualified by training or experience to properly care for the number and type of residents in the facility.  Standards in this Part concerning personnel, including Sections 330.910, 330.920, and 330.930, will be considered in making this determination.  (Section 3-119(a)(3) of the Act)

 

5)         Financial or other resources are insufficient financial or other resources to operate the facility in accordance with the Act and this Part.  Financial information and changes in financial information provided by the facility under Section 330.120(f) 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 330.510.  (Section 3-119(a)(5) of the Act)

 

7)         The facility has committed two Type "AA" violations within a two-year period.  (Section 3-119(a)(6) of the Act)

 

8)         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 resident's written consent or the consent of his or her legal guardian.

 

C)        The facility has secured property, or a bequest of property, from a resident by undue influence.

 

9)         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.

 

10)       The facility has refused to allow an inspection or survey of the facility by agents of the Department .

 

c)         The Director or his or her designee shall 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 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.170  Denial of Initial License

 

a)         A determination by the Director or his or her 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 330.165 or the following criteria are met:

 

1)         Conviction of the applicant, or if the applicant is a firm, partnership or association, or any of its members or if a corporation, the conviction of the corporation or any of its officers and stockholders, or of the person designated to manage or supervise the facility  of any of the following crimes during the previous 5 years.  Such convictions shall be verified by a certified copy of the record of the court of conviction.

 

A)        A felony; or

 

B)        Two or more misdemeanors involving moral turpitude.  (Section 3-117(2) of the Act)

 

2)         Prior license revocation.  Both of the following conditions shall be met:

 

A)        Revocation of a facility license during the previous 5 years, if such prior license was issued to the individual applicant, a controlling owner or controlling combination of owners of the applicant; or any affiliate of the individual applicant or controlling owner of the applicant or affiliate of the applicant was a controlling owner of the prior license.  Operation for the purposes of this provision shall include individuals with responsibility for the overall management, direction, or supervision of the facility.

 

B)        The denial of an application for a license pursuant to this subsection (a)(2) must be supported by evidence that such prior revocation renders the applicant unqualified or incapable of meeting or maintaining a facility in accordance with the Act and this Part.  This determination will be based on the applicant's qualifications and ability to meet the criteria outlined in Section 330.165(b) as evidenced by the application and the applicant's prior history.  (Section 3-117(5) of the Act)

 

3)         Personnel insufficient in number or unqualified by training or experience to properly care for the proposed number and type of residents.  (Section 3-117(3) of the Act)

 

4)         Insufficient financial or other resources to operate and conduct the facility in accordance with this Part and with contractual obligations assumed by a recipient of a grant under the Equity in Long-Term Care Quality Act and the plan (if applicable) submitted by a grantee for continuing and increasing adherence to best practices in providing high-quality nursing home care.  (Section 3-117(4) of the Act)

 

5)         That the facility is not under the direct supervision of a full-time administrator, as defined by this Part, who is licensed, if required, under the Nursing Home Administrators Licensing and Disciplinary Act.  (Section 3-117(6) of the Act)

 

6)         That the facility is in receivership and the proposed licensee has not submitted a specific detailed plan to bring the facility into compliance with the requirements of the Act and this Part, and with federal certification requirements, if the facility is certified, and to keep the facility in such compliance.  (Section 3-117(7) 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 these rules under which the application is being denied.

 

2)         A notice of the opportunity for a hearing under Section 3-103 of the Act. If the applicant desires to contest the denial of a license, it shall provide written notice to the Department of a request for a hearing within 10 days after receipt of the notice of denial.  (Section 3-118 of the Act)

 

(Source:  Amended at 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.175  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 330.165(b) and in Section 3-119(a) of the Act.  Pursuant to Section 10-65 of the Illinois Administrative Procedure Act  [5 ILCS 100/10-65], 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 shall notify the facility.  The notice to the facility 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 the Act and this Part on which the application for renewal is being denied.

 

2)         A statement of the date on which the current license of the facility will expire as provided in subsection (c) of this Section and Section 3-119(d) of the Act.

 

3)         A description of the right of the applicant to appeal the denial of the application for renewal and the right to a hearing.  (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 current license of the facility shall be extended by the Department when it finds that such extension is necessary to permit orderly removal and relocation of residents.  (Section 3-119(d)(3) of the Act)

 

(Source:  Amended at 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.180  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 330.165(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 level A violation as provided in Section 330.282(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 shall notify the facility.  The notice to the facility shall be in writing and shall include:

 

1)         A clear and concise statement of the basis of the revocation.  The statement shall include a citation to the provisions of the Act and this Part on which the license is being revoked.

 

2)         A statement of the date on which the revocation will take effect as provided in subsection (c) of this Section 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 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 when it finds that such extension is necessary to permit orderly removal and relocation of residents.  (Section 3-119(d)(3) of the Act)

 

(Source:  Amended at 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.190  Experimental Program Conflicting With Requirements

 

a)         Any facility desiring to conduct an experimental program or do research which 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 which would violate residents' rights under the Act.  (A, B)

 

b)         The Department may grant to a facility special permission to provide day care when it has adequate facilities and staff to satisfactorily provide such services based on the requirements in Section 330.4510.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.200  Inspections, Surveys, Evaluations and Consultation

 

The terms survey, inspection and evaluation are synonymous.  These terms refer to the overall examination of compliance with the Act and this Part.

 

a)         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 such other properly identified persons, including local health department staff, as the Department may designate. 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. (Section 3-212(a) of the Act)  The licensee, or person representing the licensee in the facility, shall provide to the representative of the Department access and entry to the premises or facility for obtaining information required to carry out this Act and the rules promulgated under the Act.  In addition, representatives of the Department shall have access to and may reproduce or photocopy at the Department's 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)  A facility may charge the Department for photocopying at a rate determined by the facility not to exceed the rate in the Freedom of Information 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 (Section 3-318(a)(2) of the Act);

 

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 (Section 3-318(a)(3) of the Act);

 

3)         Intentionally prevent or interfere with the preservation of evidence pertaining to any violation of the Act or this Part (Section 3-318(a)(4) of the Act);

 

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)(5) 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 subsection 330.120(d) 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 will 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:

 

3)         penalties or other enforcement actions;

 

4)         the number and severity of complaints received about the facility;

 

5)         any allegations of resident abuse or neglect;

 

6)         weather conditions

 

7)         health emergencies; or

 

8)         other reasonable belief that deficiencies exist. (Section 3-212(b) of the Act)

 

e)         Upon completion of each inspection, survey and evaluation, the appropriate Department personnel who conducted the inspection, survey or evaluation shall submit a physical or electronic copy of their report to the licensee upon exiting the facility, and shall submit the actual report to the appropriate regional office of the Department.  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 ten days after receipt of the copy of the report.  (Section 3-212(c) of the Act)

 

f)         Consultation consists of providing advice or suggestions to the staff of a facility at their request relative to specific methods of the scope of regulation, method of compliance with the Act or rules, or general matters of resident care.

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.210  Filing an Annual Attested Financial Statement

 

a)         Filing Requirement

 

1)         Each licensee shall submit an annual attested financial statement to the Department.  This financial statement shall be filed in a prescribed format on forms supplied by the Department.  The forms will be developed in conjunction with the Illinois Department of Public Aid.  (Section 3-208 of the Act)

 

2)         The time period covered in the financial statement shall be a period determined by the Department for the initial filing, and shall thereafter coincide with the facility's fiscal year or the calendar year.

 

b)         The Department may require any facility to file an audited financial statement, if the Department determines that such a statement is needed. (Section 3-208 of the Act)

 

c)         Additional Filing Requirements

 

1)         The Department may require any or all facilities to submit attested or audited financial statements more frequently than annually, if the Department determines that more frequent financial statements are needed.

 

2)         The frequency and time period of such filings shall be as determined by the Department for each individual facility.  (Section 3-208 of the Act)

 

d)         Filing Deadline and Completeness

 

1)         The financial statement shall be filed with the Department within 90 days following the end of the designated reporting period.

 

2)         The financial statement will not be considered as having been filed unless all sections of the prescribed forms have been properly completed.  Those sections which do not apply to a particular facility shall be noted "not applicable" on the forms.

 

e)         The information required to be submitted in the financial statement will 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; such as administrative salaries, professional services, fees, subscriptions, promotional, insurance, travel, clerical, employee benefits, license fees, and inservice training and education.

 

D)        Ownership; 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 shop.

 

4)         Income information, including operating and nonoperating 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.

 

f)         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.

 

1)         A facility which is licensed for the first time (a newly constructed facility) must file a projection of capital costs.

 

2)         Each of the above must file a full cost report within nine months after acquisition (covering the first six months of operation.).  Each must also file a cost report within 90 days of the close of its first complete fiscal year.

 

g)         No public funds shall be expended for the maintenance of any resident in any facility which has failed to file this financial statement, and no public funds shall be paid to, or on behalf of, a facility which has failed to file the statement. (Section 3-208(b) of the Act)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.220  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.  Section 2-206 of the Act 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 which 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 has been 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 (42 USCA 301 et seq.);

 

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. (Section 2-205 of the Act)

 

e)         However, the disclosure of information described in subsection (c)(1) of this Section 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 titled Access to Records of the Department of Public Health (2 Ill. Adm. Code 1127).  The Department may, at its discretion, waive reproduction fees if the party requesting the material is involved in legal action with the Department.

 

(Source:  Amended at 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.230  Information to be Made Available to the Public by the Licensee

 

a)         Every facility shall conspicuously post or display in an area of it 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 number 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;

 

4)         A list of the material available for public inspection under Section 3-210 of the Act;

 

5)         Phone numbers and websites for rights protection services must be posted in common areas and at the main entrance and provided upon entry and at the request of resident's representatives; and

 

6)         The statement "The Illinois Long-Term Care Ombudsman Program is a free resident advocacy service available to the public.".

 

b)         The administrator shall post for all residents and at the main entrance the name, address, and telephone number of the appropriate State governmental office where complaints may be lodged in language the resident can understand, which must include notice of the grievance procedure of the facility or program as well as addresses and phone numbers for the Office of Health Care Regulation and the Long-Term Care Ombudsman Program and website showing the information of a facility's ownership.  The facility shall include a link to the Long-Term Care Ombudsman Program's website on the home page of the facility's website.  (Section 3-209(a) of the Act)

 

c)         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 5 years;

 

2)         A copy of every order pertaining to the facility issued by the Department or a court during the past 5 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 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 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.240  Municipal Licensing

 

a)         Municipalities which 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 (Ill. Rev. Stat. 1987, ch. 24, pars. 1-3-1 et seq.).

 

b)         Municipalities shall issue licenses so that the expiration dates are distributed throughout the calendar year.  The month the license expires shall coincide with the date of original licensure of the licensee.  During the 24 month period following the effective date of the Act, the municipality may issue renewal licenses for period of less than one year in order to distribute the expiration date of such licenses throughout the calendar year.

 

c)         The municipality shall notify the Department within ten days from 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 will 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 will 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 facility may not be licensed for a different classification by the Department than by the municipality.

 

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 which govern the regulation of the facility.  The Department may survey any former facility which once held a license to insure that the facility is not again operating without a license. Municipalities may charge a reasonable license or renewal fee for the regulation of facilities, which fees shall be in addition to the fees paid to the Department.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.250  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 that 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 (Section 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 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 that 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 41 Ill. Reg. 14826, effective November 15, 2017)

 

Section 330.260  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 which 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 which prevent full licensure and which 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 ten (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 such time as the applicant or licensee has had the opportunity to request a hearing pursuant to subsection (d) of this Section, 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) of this Section. 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 17 Ill. Reg. 15089, effective September 3, 1993)

 

Section 330.270  Monitor and Receivership

 

a)         The Department may place an employee or agent to serve as a monitor in a facility 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; or

 

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 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. (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 monitor's duties as evidenced in a personal interview of the candidate;

 

4)         not be related to the owners of the involved facility either 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 full-time work experience in the long-term care industry of the State of Illinois.

 

c)         The monitor shall be under the supervision of the Department; shall perform the duties of a monitor delineated in Section 3-502 of the Act; and shall accomplish the following actions:

 

1)         visit the facility as directed by the Department;

 

2)         review all records pertinent to the condition for such monitor's placement under subsection (a) of this Section;

 

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 strictly confidential and not subject to disclosure without written authorization from the Department or by court order subject to disclosure only in accordance with the provisions of the Freedom of Information Act, subject to the confidentiality requirements of the Act.

 

e)         The assignment as monitor may be terminated at any time by the Department.

 

f)         Through consultation with the long-term care industry associations, professional organizations, consumer groups and health-care management corporations, the Department shall maintain a list of receivers. Preference on the list shall be given to individuals possessing a valid Illinois Nursing Home Administrator's License, experience in financial and operations management of a long-term care facility and individuals with access to consultative experts with the aforementioned experience.  To be placed on the list, individuals must meet the following minimum requirements:

 

1)         be in good physical and mental 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 by 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 in the Illinois long-term care industry.

 

g)         Upon appointment of a receiver for a facility by a court, the Department shall inform the individual of all legal proceedings to date which concern the facility.

 

h)         The receiver may request that the Director of the Department 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 cost 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, his medical records and his belongings if he 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 the aforesaid powers and duties, the receiver shall be considered a public employee under the Local Governmental and Governmental Employees Tort Immunity Act [745 ILCS 10]. 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 19 Ill. Reg. 11567, effective July 29, 1995)

 

Section 330.271  Presentation of Findings

 

a)         If it is probable that findings will be presented that could be issued as violations of regulations which represent a direct threat to the health, safety or welfare of residents, surveyors shall notify the administrator or designee during the course of the survey of such possible findings.

 

b)         The Department shall 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 shall be presented during the exit conference.  If the investigation has not been completed at the time of the facility exit, the Department shall inform the facility administrator or designee that the investigation is not complete and that findings may 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 shall schedule a time and place for the exit conference to be held at the conclusion of the survey.

 

d)         At the exit conference, surveyors shall 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, in their discretion, modify or eliminate any or 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) of this Section, 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 A or repeat Type B violations, the Department shall so 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 5 (five) working days from receipt of the notice required by subsection (f) of this Section to submit its additional comments to the Department.  The Department shall consider such additional comments in determining the existence and level of violation of the Act and/or 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 such 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 and/or their guests create an environment that is not conducive to a meaningful exchange of information.

 

(Source:  Added at 17 Ill. Reg. 15089, effective September 3, 1993)

 

Section 330.272  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 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 will be considered findings or deficiencies.  (Section 3-212(c) of the Act)

 

b)         In making this determination, the Director 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 330.200(e). (Section 3-212(c) of the Act)

 

c)         In determining whether the findings warrant the issuance of a notice of violation, the Director will consider the following factors:

 

1)         The severity of the finding.  The Director will consider whether the finding constitutes a 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 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 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 will consider whether the same finding or a similar finding relating to the same condition or occurrence has been included in previous reports and whether the facility has allowed the condition or occurrence to continue or to recur.  (Section 3-212(c) of the Act)

 

d)         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 will issue an administrative warning.  Any administrative warning shall be served upon the facility in the same manner as the notice of violation under Section 3-301 of the Act.  A written plan of correction is required to be filed for an administrative warning issued for violations of Sections 3-401 through 3-413 of the Act or Section 330.4300. (Section 3-303.2(a) of the Act)

 

e)         If, however, the situation, condition or practice that resulted in the issuance of an administrative warning, with the exception of administrative warnings issued pursuant to Sections 3-401 through 3-413 of the Act and Section 330.4300, is not corrected by 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 subsection (b) of Section 3-303 of the Act and Section 330.278(b). (Section 3-303.2(b) of the Act)

 

f)         Violations shall be determined under this Section no later than 75 days after completion of each inspection, survey, and evaluation. (Section 3-212(c) of the Act)

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.274  Determination of the Level 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 type of the violation.  Each violation shall be determined to be either a Type "AA", Type "A", Type "B", or Type "C" violation based on the criteria in this Section.

 

b)         The following definitions of types of violations shall be used in determining the type 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 will result therefrom or 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 minimal physical or mental harm to a resident.  (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 therefrom.  (Section 1-132 of the Act)

 

c)         In determining the type of a violation, the Director 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 such 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 such notice.  Failure of the facility to notify residents of potentially harmful conditions or occurrences will be considered.  The adequacy of the method of such notification and the extent to which such 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 such harm.

 

B)        Whether available statistics and records from similar facilities indicate that direct and imminent danger to the resident or residents has resulted from similar conditions or occurrences and the frequency of such 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 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.276  Notice of Violation

 

a)         Each notice of violation shall be prepared 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 alleged by the Department to have been violated.  (Section 3-301 of the Act)

 

3)         A statement of the type of violation as determined pursuant to Section 330.274.

 

4)         Information regarding any action the Department may take under the Act, including the requirement of a facility plan of correction under Section 3-303 of the Act; placement of a facility on a list prepared under Section 3-304 of the Act; assessment of a penalty under Section 3-305 of the Act; issuance of a conditional license under Sections 3-311 through 3-317 of the Act; or license suspension or revocation under Section 3-119 of the Act.

 

5)         Information regarding the rights to a hearing under Section 3-703 of the Act.  (Section 3-301(a) of the Act)

 

6)         One of the following requirements for corrective action:

 

A)        For Type "AA" violations and Type "A violations, a statement that necessary corrective action to abate or eliminate the situation, condition or practice constituting a Type "AA" violation or a Type "A" violation shall be taken 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)  In setting this period, the Department will consider whether harm to residents of the facility is imminent, whether necessary precautions can be taken to project residents before the corrective action is completed, and whether delay would pose additional risks to the residents.

 

B)        For Type "B" violations, a request that the facility submit a plan of correction within ten days after receipt of the notice of violation pursuant to Section 3-303(b) of the Act and Section 330.278.  (Section 3-303(b) of the Act)

 

b)         Each notice of violation shall be sent to the facility and the licensee or served personally at the facility within ten days after the Director determines that issuance of a notice of violation is warranted under Section 300.272.  (Section 3-301(a) of the Act).

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.277  Administrative Warning

 

a)         If the Department finds a situation, condition, or practice which 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 or his or her designee determines that issuance of an administrative warning is warranted under Section 330.272.

 

d)         The facility is not required to submit a plan of correction in response to an administrative warning.

 

e)         If the Department finds, during the next on-site inspection which occurs no earlier  than 90 days from the issuance of the administrative warning, that the facility has not corrected the situation, condition, or practice which resulted in the issuance of the administrative warning, the Department shall notify the facility of the finding.  The facility shall then submit a written plan of correction as provided in Section 330.278.  The Department will consider the plan of correction and take any necessary action in accordance with Section 330.278.  (Section 3-303.2(b) of the Act)

 

(Source:  Amended at 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.278  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 330.277(d) 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 extent 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 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 330.120(d) 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 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 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.

 

3)         A specific date by which the corrective action will be completed.

 

f)         Submission of a plan of correction will 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 or eliminate, or correct the violation.

 

4)         The plan does not provide steps that will avoid future occurrences of the same and similar violations.

 

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 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.280  Reports of Correction

 

a)         In lieu of submission of 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 330.278 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 which 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 the facility has taken to avoid future occurrences of the same and similar violations;

 

3)         The specific date on which the corrective action was completed; and

 

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 will not be considered an admission by the facility that the violation has occurred.

 

d)         The Department will review and approve or disapprove the report of correction based on the criteria outlined in Section 330.278(e) 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 330.278.

 

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 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.282  Conditions for Assessment of Penalties

 

The Department will 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 up to $25,000 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. (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 which continues beyond the time specified in Section 3-303(a) of the Act, which is cited as a repeat violation, shall have its license revoked and shall be assessed a fine of 3 times the fine computed per resident per day under subsection (a) or (b).  (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.  (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 pursuant to 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 10 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 licensee who commits one or more Type "C" violations with a high risk designation shall be assessed a fine of up to $500 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), the Department will assess only one fine, which shall not exceed 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(7.5) of the Act)

 

h)         The minimum and maximum fines that may be assessed pursuant to Section 3-305 of the Act and this Section shall be twice those otherwise specified for any facility that willfully makes a misstatement of fact to the Department, or willfully fails to make a required notification to the Department, if that misstatement or failure delays the start of a surveyor or impedes a survey.  (Section 3-305(8) of the Act)

 

i)          High risk designation.  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, the Department may assess a fine of up to 2 times the maximum fine otherwise allowed.  (Section 3-305(9) 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 330.715(a)

 

2)         Section 330.715(b)

 

3)         Section 330.715(c)

 

4)         Section 330.725(a)

 

5)         Section 330.725(b)

 

6)         Section 330.725(c)

 

7)         Section 330.725(f)

 

8)         Section 330.725(j)

 

9)         Section 330.725(k)

 

10)       Section 330.725(l)

 

11)       Section 330.725(n)

 

12)       Section 330.725(o)

 

13)       Section 330.727(c)

 

14)       Section 330.727(d)

 

15)       Section 330.727(e)

 

16)       Section 330.780

 

17)       Section 330.785(b)

 

18)       Section 330.790

 

19)       Section 330.911

 

20)       Section 330.4240(a)

 

21)       Section 330.4240(d)

 

22)       Section 330.4240(e)

 

k)         If a licensee has paid a civil monetary penalty imposed pursuant to the Medicare and Medicaid Certification Program for the equivalent federal violation giving rise to a fine under Section 3-305 of the Act and this Section 330.282, or provides the Department with a copy of a letter to the Centers for Medicare and Medicaid Services (CMMS) of its binding intent to waive its rights to a federal hearing to contest a civil monetary penalty for the equivalent federal violation, the Department shall offset the fine by the amount of the civil monetary penalty.  The offset may not reduce the fine by more than 75% of the original fine, however.  (Section 3-305(10) of the Act)  The meaning of "equivalent federal violation" shall be determined by the Department.  Upon request by the Department, the facility shall provide proof to the Department of the federal civil monetary penalty when the payment is due. 

 

l)          When the Department finds that a provision of Article II 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, which 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 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)

 

m)        For the purpose of computing a penalty under subsections (c) through (f), the number of residents per day shall be based on the average number of residents in the facility during the 30 days preceding the discovery of the violation.  (Section 3-305(5) of the Act)

 

n)         For purposes of assessing fines under this Section, a repeat violation shall be a violation which has been cited during one inspection of the facility for which an accepted plan of correction was not complied with 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)

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.284  Calculation of Penalties (Repealed)

 

(Source:  Repealed at 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.286  Notice of Penalty Assessment; Response by Facility

 

a)         If the Director 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 330.282.

 

2)         The amount of any reduction or whether the penalty has been waived pursuant to Section 330.288.

 

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 that the facility has 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)

 

b)         A facility may contest an assessment of a penalty by sending a written request to the Department for hearing under Section 3-703 of the Act.  Upon receipt of the request the Department shall 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 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, pursuant to subsection (b) shall constitute a waiver by the facility of a right to hearing pursuant to Section 3-703 of the Act.

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.287  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 or his or her designee will then consider any such 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 or his or her designee 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 or his or her designee 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 or his or her designee 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 or his or her designee will also consider any evidence that the violations constitute a pattern of deliberate action by the facility.  Then extent of 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.  Those 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 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.288  Reduction or Waiver of Penalties

 

a)         Reductions for all types of violations subject to penalties.

 

1)         The Director consider the factors contained in Section 330.287 in determining whether to reduce the amount of the penalty to be assessed from the amount calculated pursuant to Section 330.282 and in determining the amount of such reduction.

 

2)         When the Director 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 "AA" or Type "A" violation to an amount less than $1000.

 

b)         Reductions and waivers for Type "B" violations.

 

1)         Penalties resulting from Type "B" violations may be reduced or waived only under one of the following conditions:

 

A)        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.

 

B)        The facility submits a plan of correction within ten days after the notice of violation is received, and once the plan is approved by the Department, the facility 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.

 

C)        The facility submits a plan of correction within ten days after the notice of violation is received, which provides for a correction time that is less than or equal to 30 days and the Department approves the plan.

 

D)        Correction of the violation requires substantial capital improvements or repairs in the physical plan of the facility, the facility submits a plan of correction for violations involving substantial capital improvements, which provides for correction within the initial 90-day limit provided under Section 3-303 of the Act, and the plan is approved by the Department.  (Section 3-308 of the Act)

 

2)         Under these conditions, the Director will consider the factors outlined in Section 330.287 in determining whether to reduce or waive the penalty and in setting the amount of any reduction.

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.290  Quarterly List of Violators (Repealed)

 

(Source:  Repealed at 24 Ill. Reg. 17304, effective November 1, 2000)

 

Section 330.300  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.  Approval will be granted only if the facility can demonstrate the program will not interfere in any way with the residents in the other parts of the facility.

 

b)         Any alcoholism treatment program in a facility shall meet the requirements of the Alcoholism and Substance Abuse Treatment and Intervention Licenses and the Substance Use Disorder Act.

 

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 cannot be used for long-term care residents, nor can beds designated for long-term care residents be used for residents undergoing treatment for alcoholism.

 

e)         The alcoholism treatment program staff shall not be utilized in performing 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.  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 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.310  Department May Survey Facilities Formerly Licensed

 

The Department may survey any former facility which once held a license to insure that the facility is not again operating without a license. (Section 3-107 of the Act)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.315  Supported Congregate Living Arrangement Demonstration (Repealed)

 

(Source:  Repealed at 49 Ill. Reg. 802, effective December 31, 2024)

 

Section 330.320  Waivers

 

a)         Upon application by a facility, the Director may grant or renew the waiver of the facility's compliance with the Act or this Part 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(a) 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(a) 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 this Part;

 

2)         the validity and effect upon patient health and safety of extending the waiver on the same basis;

 

3)         the effect upon the health and safety of residents;

 

4)         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);

 

5)         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

 

6)         the facility's attempts to comply with this Part.  (Section 3-303.1(a) of the Act)

 

d)         The Department will renew waivers relating to physical plant standards issued pursuant to the Act at the time of the indicated reviews, unless it can show why these 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 this Part without substantial increase in cost.  (Section 3-303.1(b) of the Act)

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.330  Definitions

 

The terms defined in this Section are terms that are used in one or more of the sets of licensing standards established by the Department to license various levels of long-term care.  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;

 

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 Nursing Home Care 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 330.1145 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 330.277 and Section 3-303.2 of the Act that indicates that a situation, condition, or practice in the facility violates the Act or the Department's rules, but is not 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 of 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 that 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.

 

Autism or 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 interaction, 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.  When 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, mental retardation, 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(a) of the Act)  For the purposes of this term and its use in Section 330.1145, "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.

 

Convenience − the use of any restraint by the facility to control resident behavior or maintain a resident, which 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.  This definition is limited to the definition of chemical restraint and Section 330.1145 of this Part.

 

Cruelty and Indifference to Welfare of the Resident − failure to provide a resident with the care and supervision he or she requires, or the infliction of mental or physical abuse.

 

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 [225 ILCS 25].

 

Department – the Department of Public Health.  (Section 1-109 of the Act)

 

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;

 

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 which 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; or

 

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; or

 

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, which included consultation from a dietitian; or

 

has successfully completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course; or

 

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.

 

Director − the Director of Public Health or designee. (Section 1-110 of the Act)

 

Director of Nursing Service − the full-time Professional Registered 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.

 

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 and are clinically documented in the resident's medical record. (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 Long-Term Care Facility − a private home, institution, building, residence, or any other place, whether operated for profit or not, or a county home for the infirm and chronically ill operated pursuant to Division 5-21 or 5-22 of the Counties Code, or any similar institution operated by a political subdivision of the State of Illinois, which provides, through its ownership or management, personal care, sheltered care or nursing for three or more persons, not related to the applicant or owner by blood or marriage.  It includes skilled nursing facilities and intermediate care facilities as those terms are defined in Title XVIII and Title XIX of the federal Social Security Act (42 U.S.C. 1395 et seq. and 1396 et seq.). It also includes homes, institutions, or other places operated by or under the authority of the Illinois Department of Veterans' Affairs.  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, such 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 "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;

 

A facility licensed under the ID/DD Community Care Act;

 

A facility licensed under the Specialized Mental Health Rehabilitation Act of 2013;

 

A facility licensed under the MC/DD Act; or

 

A medical foster home, as defined in 38 CFR 17.73, that is under the oversight of the United States Department of Veterans Affairs.  (Section 1-113 of the Act)

 

Facility, Sheltered Care − when used in this Part is synonymous with a sheltered care facility, which facility provides maintenance and personal care.

 

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.

 

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 the alleviation of a disability or 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, sheltered employment, protective services, counseling and other services.

 

"High Risk Designation – a violation, as described in Section 330.282(i), of a provision that has been identified by the Department in Section 330.282(j) 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:

 

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, 405.1, 407, or 407.1 of the Illinois Controlled Substances Act; and a felony offense described in the Methamphetamine Control and Community Protection Act; or

 

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 I of Section 10 of the Sex Offender Management Board Act; or  

 

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)

 

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 their 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 Practical Nurse − a person with a valid Illinois license to practice as a practical nurse.

 

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.

 

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 reports periodically to the Department on the operations of the facility.

 

Neglect − a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident. (Section 1-117 of the Act) This shall include any allegation in which:

 

the alleged failure causing injury or deterioration is ongoing or repetitious; or

 

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 − a registered 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" above, "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 their 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(a) 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 this Section, 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)

 

Psychiatric Services Rehabilitation Aide – an individual employed by a long-term care facility to provide, for mentally ill residents, at a minimum, crisis intervention, rehabilitation, and assistance with activities of daily living. (Section 1-120.7 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.

 

Reasonable Visiting Hour − any time between the hours of 10 a.m. and 8 p.m. daily. (Section 1-121 of the Act)

 

Registered 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, or manager, or supervisor of the facility is not reputable.

 

Resident − a person receiving personal or medical care, including but not limited to mental health treatment, psychiatric rehabilitation, physical rehabilitation, and assistance with activities of daily living, from a facility. (Section 1-122 of the Act)

 

Resident's Representative − a person other than the owner not related to the resident, or an agent or employee of a facility not related to the resident, designated in writing by a resident to be their representative, or the resident's guardian. (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.

 

Sheltered Care − maintenance and personal care. (Section 1-124 of the Act)

 

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.

 

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 330.140(a)(3) and 330.150(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 330.165(b)(1).

 

Supervision − authoritative guidance by a qualified person for the accomplishment of a function or activity within their 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.

 

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 which 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 (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 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.340  Incorporated and Referenced Materials

 

a)         The following standards and guidelines are incorporated in this Part:

 

1)         For existing facilities (see Subpart O), National Fire Protection Association (NFPA) 101 (2012):  Life Safety Code Chapter 19, applies to and is part of this Part, which may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA  01269.

 

A)        All appropriate references under NFPA 101 (2012), Chapter 2, Referenced Publications; and

 

B)        NFPA 101 A (2013), Guide on Alternative Approaches to Life Safety

 

2)         For new facilities (see Subpart M), NFPA 101 (2012):  Life Safety Code, Chapter 18 and all appropriate references under Chapter 2, Referenced Publications, applies to and is part of this Part, which may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA  01269:

 

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

 

3)         The following guidelines and toolkits of the Center for Infectious Diseases, Centers for Disease Control and Prevention, United States Public Health Service, Department of Health and Human Services may be obtained from the National Technical Information Services (NTIS), 5301 Shawnee Road, Alexandria, VA  22312, info@ntis.gov, or the following Internet addresses:

 

A)        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

 

B)        Guidelines for Preventing Healthcare-Associated Pneumonia, 2003 (March 26, 2004), available at:  https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm

 

C)        2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (September 20, 2024), available at:  https://www.cdc.gov/infection-control/media/pdfs/guideline-isolation-h.pdf?CDC_AAref_Val=https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf

 

D)        Infection Control in Healthcare Personnel, available in two parts:  Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services, available at:  https://www.cdc.gov/infection-control/media/pdfs/Guideline-Infection-Control-HCP-H.pdf (October 25, 2019) and Epidemiology and Control of Selected Infections Transmitted Among Healthcare Personnel and Patients, available at:  https://www.cdc.gov/infection-control/media/pdfs/Guideline-IC-HCP-H.pdf (March 28, 2024)

 

E)        The Core Elements of Antibiotic Stewardship for Nursing Homes (March 18, 2024), available at:  https://www.cdc.gov/antibiotic-use/media/pdfs/core-elements-antibiotic-stewardship-508.pdf?CDC_AAref_Val=https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-H.pdf

 

F)         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

 

G)        Nursing Home Antimicrobial Stewardship Guide, available at:  https://www.ahrq.gov/nhguide/index.html (March 2023)

 

H)        Toolkit 3.  Minimum Criteria for Common Infections Toolkit, available at:  https://www.ahrq.gov/nhguide/toolkits/determine-whether-to-treat/toolkit3-minimum-criteria.html (September 2017)

 

I)         Toolkit for Controlling Legionella in Common Sources of Exposure (January 13, 2021), available at:  https://www.cdc.gov/control-legionella/media/pdfs/Control-Toolkit-All-Modules.pdf

 

4)         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 330.4220.)

 

5)         American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE): ASHRAE Guideline 12-2020, "Managing the Risk of Legionellosis Associated with Building Water Systems" (March 30, 2021), which may be obtained from the American Society of Heating, Refrigerating, and Air Conditioning Engineers, Inc., 1791 Tullie Circle, N.E., Atlanta, GA  30329.

 

b)         All incorporations by reference of federal guidelines and the standards of nationally recognized organizations refer to the standards on the date specified and do not include any amendments or editions subsequent to the date specified.

 

c)         The following statutes, federal regulation, and State regulations are referenced in this Part:

 

1)         Federal statutes:

 

A)        Civil Rights Act of 1964 (42 U.S.C. 2000e et seq.)

 

B)        Social Security Act (42 U.S.C. 301 et seq., 1935 et seq. and 1936 et seq.)

 

C)        Controlled Substances Act (21 U.S.C. 802)

 

2)         Federal regulation: 38 CFR 17.73, Medical Foster Homes – General (July 1, 2023)

 

3)         State of Illinois statutes:

 

A)        Substance Use Disorder Act [20 ILCS 301]

 

B)        Child Care Act of 1969 [225 ILCS 10]

 

C)        Court of Claims Act [705 ILCS 505]

 

D)        Illinois Dental Practice Act [225 ILCS 25]

 

E)        Election Code [10 ILCS 5]

 

F)         Freedom of Information Act [5 ILCS 140]

 

G)        General Not For Profit Corporation Act of 1986 [805 ILCS 105]

 

H)        Hospital Licensing Act [210 ILCS 85]

 

I)         Illinois Health Facilities Planning Act [20 ILCS 3960]

 

J)         Illinois Municipal Code [65 ILCS 5]

 

K)        Life Care Facilities Act [210 ILCS 40]

 

L)        Local Governmental and Governmental Employees Tort Immunity Act [745 ILCS 10]

 

M)       Medical Practice Act of 1987 [225 ILCS 60]

 

N)        Mental Health and Developmental Disabilities Code [405 ILCS 5]

 

O)        Nurse Practice Act [225 ILCS 65]

 

P)         Nursing Home Administrators Licensing and Disciplinary Act [225 ILCS 70]

 

Q)        Nursing Home Care Act [210 ILCS 45]

 

R)        Illinois Occupational Therapy Practice Act [225 ILCS 75]

 

S)         Pharmacy Practice Act [225 ILCS 85]

 

T)         Illinois Physical Therapy Act [225 ILCS 90]

 

U)        Private Sewage Disposal Licensing Act [225 ILCS 225]

 

V)        Probate Act of 1975 [755 ILCS 5]

 

W)       Illinois Public Aid Code [305 ILCS 5]

 

X)        Illinois Administrative Procedure Act [5 ILCS 100]

 

Y)        Clinical Psychologist Licensing Act [225 ILCS 15]

 

Z)        Dietitian Nutritionist Practice Act [225 ILCS 30]

 

AA)     Health Care Worker Background Check Act [225 ILCS 46]

 

BB)     Clinical Social Work and Social Work Practice Act [225 ILCS 20]

 

CC)     Illinois Living Will Act [755 ILCS 35]

 

DD)     Illinois Power of Attorney Act [755 ILCS 45/Art. IV]

 

EE)      Health Care Surrogate Act [755 ILCS 40]

 

FF)      Health Care Right of Conscience Act [745 ILCS 70]

 

GG)     Abused and Neglected Long-Term Care Facility Residents Reporting Act [210 ILCS 30]

 

HH)     Supportive Residences Licensing Act [210 ILCS 65]

 

II)        MC/DD Act [210 ILCS 46]  

 

JJ)        Community Living Facilities Licensing Act [210 ILCS 35]

 

KK)     Community-Integrated Living Arrangements Licensure and Certification Act [210 ILCS 135]

 

LL)      Counties Code [55 ILCS 5]

 

MM)    Alzheimer's Disease and Related Dementias Special Care Disclosure Act [210 ILCS 4]

 

NN)     State Fire Marshal Act [20 ILCS 2905]

 

OO)     Illinois Act on the Aging [20 ILCS 105]

 

PP)      Illinois Speech-Language Pathology and Audiology Practice Act [225 ILCS 110]

 

QQ)     Assisted Living and Shared Housing Act [210 ILCS 9]

 

RR)     Alternative Health Care Delivery Act [210 ILCS 3]

 

SS)      Podiatric Medical Practice Act of 1987 [225 ILCS 100]

 

TT)      Illinois Optometric Practice Act of 1987 [225 ILCS 80]

 

UU)     Physician Assistant Practice Act of 1987 [225 ILCS 95]

 

VV)     Language Assistance Services Act [210 ILCS 87]

 

WW)   ID/DD Community Care Act [210 ILCS 47]

 

XX)     Authorized Electronic Monitoring in Long-Term Care Facilities Act [210 ILCS 32]

 

YY)     Illinois Emergency Management Agency Act [20 ILCS 3305]

 

ZZ)      Latex Glove Ban Act [410 ILCS 180]

 

4)         State of Illinois rules:  

 

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

 

B)        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)       Intermediate Care for the Developmentally Disabled Facilities Code (77 Ill. Adm. Code 350)

 

xiii)      Medically Complex for the Developmentally Disabled Facilities Code (77 Ill. Adm. Code 390)

 

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)    Authorized Electronic Monitoring in Long-Term Care Facilities Code (77 Ill. Adm. Code 389)

 

C)        Department of Human Services, Alcoholism and Substance Abuse Treatment and Intervention Licenses (77 Ill. Adm. Code 2060)

 

D)        Office of the State Fire Marshal, Fire Prevention and Safety (41 Ill. Adm. Code 100)

 

E)        Department on Aging, Community Care Program (89 Ill. Adm. Code 240)

 

(Source:  Amended at 49 Ill. Reg. 802, effective December 31, 2024)

 

Section 330.510  Administrator

 

a)         There shall be a responsible and qualified administrator full-time 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)         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 resident's 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.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.710  Resident Care Policies

 

a)         The facility shall have written policies and procedures governing all services provided by the facility.  The written policies and procedures shall be formulated with the involvement of the administrator.  The written policies shall be followed in operating the facility and shall be reviewed at least annually by the Administrator.  The policies shall comply with the Act and this Part.

 

b)         All of the information contained in the policies shall be available for review by the Department, residents, staff and the public.

 

c)         The written policies shall include, but are not limited to, the following provisions:

 

1)         Admission, transfer and discharge of residents, including categories of residents accepted and not accepted, residents that will be transferred or discharged, transfers within the facility from one room to another, and other types of transfers.

 

2)         Resident care services including physician services, emergency services, personal care services, activity services, dietary services and social services. 

 

3)         A policy to identify, assess, and develop strategies to control risk of injury to residents and nurses and other health care workers associated with the lifting, transferring, repositioning, or movement of a resident.  The policy shall establish a process that, at a minimum, includes all of the following:

 

A)        Analysis of the risk of injury to residents and nurses and other health care workers, taking into account the resident handling needs of the resident populations served by the facility and the physical environment in which the resident handling and movement occurs.

 

B)        Education and training of nurses and other direct resident care providers in the identification, assessment, and control of risks of injury to residents and nurses and other health care workers during resident handling and on safe lifting policies and techniques and current lifting equipment.

 

C)        Evaluation of alternative ways to reduce risks associated with resident handling, including evaluation of equipment and the environment.

 

D)        Restriction, to the extent feasible with existing equipment and aids, of manual resident handling or movement of all or most of a resident's weight, except for emergency, life-threatening, or otherwise exceptional circumstances.

 

E)        Procedures for a nurse to refuse to perform or be involved in resident handling or movement that the nurse, in good faith, believes will expose a resident or nurse or other health care worker to an unacceptable risk of injury.

 

F)         Development of strategies to control risk of injury to residents and nurses and other health care workers associated with the lifting, transferring, repositioning, or movement of a resident.

 

G)        Consideration of the feasibility of incorporating resident handling equipment or the physical space and construction design needed to incorporate that equipment when developing architectural plans for construction or remodeling of a facility or unit of a facility in which resident handling and movement occurs.

 

H)        Fostering and maintaining resident safety, dignity, self-determination, and choice.  (Section 3-206.05 of the Act)

 

d)         For the purposes of subsection (c)(3):

 

1)         "Health care worker" means an individual providing direct resident care services who may be required to lift, transfer, reposition, or move a resident.  (Section 3-206.05 of the Act)

 

2)         "Nurse" means an advanced practice registered nurse, a registered nurse, or a licensed practical nurse licensed under the Nurse Practice Act.  (Section 3-206.05 of the Act)

 

e)         The facility shall have a written agreement with one or more hospitals to provide diagnostic, emergency and acute care services. The Department will waive this requirement if the facility can document that it is unable to meet the requirement because of its remote location or refusal of local hospitals to enter an agreement. The services shall include:

 

1)         Emergency admissions;

 

2)         Admission of facility residents who are in need of hospital care;

 

3)         Diagnostic services; and

 

4)         Any other hospital-based services needed by the resident.

 

f)         An identification wristlet may be employed for any resident upon a physician's order, which shall document the need for the identification wristlet in the resident's clinical record.  A facility may require a resident residing in an Alzheimer's disease unit, as defined in Subpart U of 77 Ill. Adm. Code 300, with a history of wandering to wear an identification wristlet, unless the resident's guardian or power of attorney directs that the wristlet be removed.  All identification wristlets shall include, at a minimum, the resident's name and the name, telephone number, and address of the facility issuing the identification wristlet.  (Section 2-106a of the Act)

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.715  Request for Resident Criminal History Record Information

 

a)         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 18 or older seeking admission to the facility, unless a background check was initiated by a hospital pursuant to the Hospital Licensing Act.  Background checks 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)

 

b)         The facility shall check for the individual's name on the Illinois Sex Offender Registration website at www.isp.state.il.us and the Illinois Department of Corrections sex registrant search page at www.idoc.state.il.us to determine if the individual is listed as a registered sex offender.

 

c)         If the results of the background check are inconclusive, the facility shall initiate a fingerprint-based check, unless the fingerprint 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) The facility shall arrange for a fingerprint-based background check or request a waiver from the Department within 5 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. 

 

d)         A waiver issued pursuant to Section 2-201.5(b) of the Act 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)

 

e)         The facility shall provide for or arrange for any required fingerprint-based checks to be taken on the premises of the facility.  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 waiver issued pursuant to Section 2-201.5(b) of the Act.

 

f)         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/or while the Identified Offender Report and Recommendation is pending.

 

(Source:  Amended at 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.720  Admission and Discharge Policies

 

a)         All involuntary discharges and transfers shall be in accordance with Sections 3-401 through 3-423 of the Act. 

 

b)         No resident determined by professional evaluation to be in need of nursing care shall be admitted to or kept in a sheltered care facility.  Neither shall any such resident be kept in a distinct part designated and classified for sheltered care.

 

c)         Homes in Chicago licensed as Residential Care (Half-Way) Homes shall only accept and keep persons requiring residential care.  Residential care is defined as maintenance and oversight.  Oversight is defined as general watchfulness and appropriate action to meet the total needs of residents, exclusive of nursing or personal care, as defined in Chapter 136.1 of the "Municipal Code of the City of Chicago".  Oversight shall include, at a minimum, social, recreational, and employment opportunities for residents who, by reason of previous physical or mental disability, or in the opinion of a licensed physician, are in need of residential care.

 

d)         Each facility shall have a policy concerning the admission of persons needing prenatal or maternity care, and a policy concerning the keeping of such persons who become pregnant while they are residents of the facility.  If these policies permit such persons to be admitted to or kept in the facility, then the facility shall have a policy concerning the provision of adequate and appropriate prenatal and maternity care to such individuals from in-house or outside resources.

 

e)         No person shall be admitted to or kept in the facility:

 

1)         Who is at risk because the person is reasonably expected to self-inflict serious physical harm or to inflict serious physical harm on another person in the near future, as determined by professional evaluation;

 

2)         Who is destructive of property and that destruction jeopardizes the safety of her/himself or others;

 

3)         Who has serious mental or emotional problems based on medical diagnosis; or

 

4)         Who is an identified offender, unless the assessment requirements of Section 330.715 for new admissions and the requirements of Section 330.725 are met.

 

f)         Children under 18 years of age shall not be cared for in a facility for adults.

 

g)         A facility shall not refuse to discharge or transfer a resident when requested to do so by the resident himself or, if the resident is incompetent, by the resident's guardian.

 

h)         No resident shall be admitted with a communicable, contagious or infectious disease as set forth in Section 330.1130 of this Part.

 

i)          A facility shall not admit more residents than the number authorized by the license issued to it.

 

(Source:  Amended at 31 Ill. Reg. 6072, effective April 3, 2007)

 

Section 330.724  Criminal History Background Checks for Persons Who Were Residents on May 10, 2006 (Repealed)

 

(Source:  Repealed at 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.725  Identified Offenders

 

a)         The facility shall review the results of the criminal history background checks immediately upon receipt of these checks.

 

b)         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; while the results of a request for a waiver of a fingerprint-based check are pending; and/or while the Identified Offender Report and Recommendation is pending.

 

c)         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, 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 (c)(2), any criminal history record information contained in its files.

 

d)         The facility shall comply with all applicable provisions contained in the Uniform Conviction Information Act.

 

e)         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.  The fee shall be deposited into the State Police Services Fund.  The fee shall not exceed the actual cost of processing the inquiry. (Section 2-201.5(c) of the Act)

 

f)         If identified offenders 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, to verify compliance with the requirements of Public Act 94-163 and Public Act 94-752, or to verify compliance with applicable terms of probation, parole, 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 330.785 of this Part.

 

3)         Every licensed facility shall provide to every prospective and current resident and resident's guardian, and to every facility employee, a written notice, prescribed by the Department, advising the resident, guardian, or employee of his or her right to ask whether any residents of the facility are identified offenders. The facility shall confirm whether identified offenders are residing in the facility. 

 

A)        The notice shall also 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.idoc.state.il.us.  (Section 2-216 of the Act)

 

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 must also include the resident's criminal history record.

 

g)         Facilities shall maintain written documentation of compliance with Section 330.715 of this Part.

 

h)         Facilities shall annually complete all of the steps required in subsection (f) of this Section for identified offenders.  This requirement does not apply to residents who have not been discharged from the facility during the previous 12 months.

 

i)          For current residents who are identified offenders, the facility shall review the security measures listed in the Identified Offender Report and Recommendation provided by the Department of the State Police.

 

j)          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.

 

k)         The facility shall incorporate the Identified Offender Report and Recommendation into the identified offender's care plan.  (Section 2-201.6(f) of the Act)

 

l)          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(a) of the Act reveals that the identified offender poses a significant risk of harm to others within the facility, 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)

 

m)        The facility's reliance on the Identified Offender Report and Recommendation prepared pursuant to Section 2-201.6(a) 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.

 

n)         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.

 

o)         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 330.780 of this Part. 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 from misconduct by the identified offender, then the facility shall transfer or discharge the identified offender in accordance with Section 330.4300 of this Part.

 

p)         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.

 

q)         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:  Amended at 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.726  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, it shall commence involuntary transfer or discharge proceedings pursuant to Section 3-402 of the Act and Section 330.4300 of this Part. (Section 2-201.6(g) of the Act)

 

b)         All discharges and transfers shall be pursuant to Section 330.4300 of this Part.

 

c)         When a resident who is an identified offender is discharged, the discharging facility shall notify the Department.

 

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 330.725 of this Part and subsection (a) of this Section;

 

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 330.725(j).

 

(Source:  Amended at 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.727  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, it shall commence involuntary transfer or discharge proceedings pursuant to Section 3-402 of the Act and Section 330.4300 of this Part. (Section 2-201 of the Act)

 

b)         All discharges and transfers shall be pursuant to Section 330.4300 of this Part.

 

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.

 

d)         This notification shall include all of the documentation required under Section 330.725 of this Part and subsection (a) of this Section, and the transferring facility shall provide this information to the receiving facility to complete the discharge planning.

 

e)         If the following information 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 Illinois 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 of the Unified Code of Corrections)

 

f)         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 and/or regulated in their home state and would be authorized to receive this information if they were in Illinois.

 

(Source:  Amended at 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.730  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 contact.

 

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 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. 111 ½, 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. 15851, effective October 15, 1994)

 

Section 330.740  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 resident advisory 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 and the nonresident members shall be elected to the council by vote of the resident members of the council.

 

d)         In facilities of 50 or fewer beds, the council may consist of all of the residents of the facility, if the residents choose to operate this way.

 

e)         All 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 Section 330.740(a).

 

g)         All residents' advisory council meetings shall be open to participation by all residents and by 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 nonmembers 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 will be maintained in the office of the Administrator.  (Section 2-203(c) of the Act)

 

k)         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)

 

l)          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)

 

m)        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. 8828, effective June 6, 2007)

 

Section 330.750  General Policies

 

a)         The facility shall have daily visiting hours from 10 A.M. to 8 P.M. daily.

 

b)         There shall be no resident traffic through a resident's room by residents of the opposite sex to reach any other area of the building.

 

c)         Children, not employed in the facility, under 16 years of age related to employees, owners, or administrators 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.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.760  Personnel Policies

 

a)         Each facility shall develop and maintain written personnel policies that 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 330.765, 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 Health Care Worker Registry prior to hiring.

 

e)         All personnel shall have either training or experience, or both, in the job assigned to them.

 

f)         Orientation and In-Service Training

 

1)         All new employees 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 basic 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 shall complete an orientation program covering the facility's policies and procedures for resident care services before being assigned to provide direct care to residents.  This orientation program shall include information on the prevention and treatment of pressure injuries and the importance of nutrition in general health care.

 

2)         All employees 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 330.790, 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 pressure injuries.  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 or electronic records of program content for each session and of personnel attending each session shall be kept.

 

3)         All facilities shall provide training and education on the requirements of Section 2-106.1 of the Act and Section 330.1155 of this Part to all personnel involved in providing care to residents, and train and educate those personnel on the methods and procedures to effectively implement the facility's policies. Training and education provided under Section 2-106.1 of the Act and Section 330.1155 shall be documented in each personnel file.  (Section 2-106.1(b-15) of the Act)

 

g)         Employees shall be assigned duties that are directly related to their job functions only, as identified in their job descriptions.  Exceptions may be made in emergencies.

 

h)         Personnel policies shall include a plan to provide personnel coverage for regular staff when they are absent.

 

i)          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 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.761  Whistleblower Protection

 

a)         For the purposes of this Section, "retaliatory action" means the reprimand, discharge, suspension, demotion, denial of promotion or transfer, or change in the terms and conditions of employment of any employee of a facility that is taken in retaliation for the employee's involvement in a protected activity as set forth in Section 3-810 of the Act and this Section 330.761.  (Section 3-810(a) of the Act)

 

b)         A facility shall not take any retaliatory action against an employee of the facility, including a nursing home administrator, because the employee does any of the following:

 

1)         Discloses or threatens to disclose to a supervisor or to a public body an activity, inaction, policy, or practice implemented by a facility that the employee reasonably believes is in violation of a law, rule, or regulation.

 

2)         Provides information to or testifies before any public body conducting an investigation, hearing, or inquiry into any violation of a law, rule, or regulation by a nursing home administrator.

 

3)         Assists or participates in a proceeding to enforce the provisions of the Act and this Part.  (Section 3-810(b) of the Act)

 

c)         A violation of the Act and this Section may be established only upon a finding that the employee of the facility engaged in conduct described in subsection (b) of Section 3-810 of the Act and this Section 330.761 and this conduct was a contributing factor in the retaliatory action alleged by the employee.  There is no violation of this Section, however, if the facility demonstrates by clear and convincing evidence that it would have taken the same unfavorable personnel action in the absence of that conduct.  (Section 3-810(c) of the Act)

 

d)         The employee of the facility may be awarded all remedies necessary to make the employee whole and to prevent future violations of this Section.  Remedies imposed by the court may include, but are not limited to, all of the following:

 

1)         Reinstatement of the employee to either the same position held before the retaliatory action or to an equivalent position;

 

2)         Two times the amount of back pay;

 

3)         Interest on the back pay;

 

4)         Reinstatement of full fringe benefits and seniority rights; and

 

5)         Payment of reasonable costs and attorney's fees.  (Section 3-810(d) of the Act)

 

(Source:  Added at 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.765  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 suspectibility 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 330.1135.  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. 6562, effective April 17, 1989)

 

Section 330.770  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 in 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 330.Table A), 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 330.2620(d), 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 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 the local emergency management agency, the facility shall participate in emergency planning activities.

 

(Source:  Amended at 37 Ill. Reg. 2315, effective February 4, 2013)

 

Section 330.780  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 a reportable incident or accident results in the death of a resident, the facility shall, after contacting local law enforcement pursuant to Section 330.785, notify the Regional Office by phone only. For the purposes of this Section, "notify the Regional Office by phone only" means talk with a Department representative who confirms over the phone that the requirement to notify the Regional Office by phone has been met.  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 37 Ill. Reg. 2315, effective February 4, 2013)

 

Section 330.785  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 77 Ill. Adm. Code 300.330.

 

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 procedure;

 

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. 4859, effective April 1, 2002)

 

Section 330.790  Infection Control

 

a)         Policies and procedures for investigating, controlling, and preventing infections in the facility shall be established and followed.  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.  Activities shall be monitored to ensure that these policies and procedures are followed. 

 

b)         A group, e.g., an infection control committee, quality assurance committee, or other facility entity, shall periodically review the results of investigations and activities to control infections.

 

c)         Depending on the services provided by the facility, each facility shall adhere to the following guidelines of the Center for Infectious Diseases, Centers for Disease Control and Prevention, United States Public Health Service, Department of Health and Human Services, as applicable (see Section 330.340):

 

1)         Guideline for Hand Hygiene in Health-Care Settings

 

2)         Guidelines for Preventing Healthcare-Associated Pneumonia

 

3)         2007 Guideline for Isolation Precautions:  Preventing Transmission of Infectious Agents in Healthcare Settings

 

4)         Infection Control in Healthcare Personnel

 

5)         The Core Elements of Antibiotic Stewardship for Nursing Homes

 

6)         The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A: Policy and Practice Actions to Improve Antibiotic Use

 

7)         Nursing Home Antimicrobial Stewardship Guide

 

8)         Toolkit 3.  Minimum Criteria for Common Infections Toolkit

 

9)         Toolkit for Controlling Legionella in Common Sources of Exposure

 

d)         The facility shall establish an infection prevention and control program (IPCP) that shall include, at a minimum, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.792  Testing for Legionella Bacteria

 

a)         A facility shall develop a policy for testing its water supply for Legionella bacteria.  The policy shall include the frequency with which testing is conducted.  The policy and the results of any tests and corrective actions taken shall be made available to the Department upon request.  (Section 3-206.06 of the Act) 

 

b)         The policy shall be based on the ASHRAE Guideline "Managing the Risk of Legionellosis Associated with Building Water Systems" and the Centers for Disease Control and Prevention's "Toolkit for Controlling Legionella in Common Sources of Exposure".  The policy shall include, at a minimum:

 

1)         A procedure to conduct a facility risk assessment to identify potential Legionella and other waterborne pathogens in the facility water system;

 

2)         A water management program that identifies specific testing protocols and acceptable ranges for control measures; and

 

3)         A system to document the results of testing and corrective actions taken.

 

(Source:  Added at 46 Ill. Reg. 10485, effective June 2, 2022)

 

Section 330.795  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 940).

 

(Source:  Added at 29 Ill. Reg. 12891, effective August 2, 2005)

 

Section 330.796  Electronic Monitoring

 

A facility shall comply with Section 2-115 and subsections 3-318(a)(8) and (9) of the Act, with the Authorized Electronic Monitoring in Long-Term Care Facilities Act, and with the Authorized Electronic Monitoring in Long-Term Care Facilities Code.

 

(Source:  Added at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.910  Personnel

 

a)         A facility shall not employ an individual as a nursing assistant, habilitation aide, home health aide, psychiatric services rehabilitation aide, or child care aide, 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 inquired of 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.   (Section 3-206.01 of the Act)

 

b)         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.  At a minimum, at least one staff member shall be awake, dressed, and on duty at all times.

 

c)         The facility shall provide an administrator as set forth in Subpart B.

 

d)         The facility shall provide activity personnel as set forth in Section 330.1310(b).

 

e)         The facility shall provide dietary personnel as set forth in Sections 330.1910 and 330.1920.

 

f)         Facilities that care for intellectually disabled or discharged psychiatric residents shall be required to employ a social worker.  The social worker shall devote at least 40 hours per week in a facility that cares for 75 or more residents.  Facilities that care for fewer than 75 residents shall have a social worker who may be assigned other duties or shared with other facilities.

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.911  Health Care Worker Background Check

 

A facility shall comply with the Health Care Worker Background Check Act [225 ILCS 46] and the Health Care Worker Background Check Code (77 Ill. Adm. Code 955).

 

(Source:  Amended at 29 Ill. Reg. 12891, effective August 2, 2005)

 

Section 330.913  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 of the Civil Administrative Code of Illinois, 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:  Former Section 330.913 repealed at 15 Ill. Reg. 516, effective January 1, 1991; new Section 330.913 added at 48 Ill. Reg. 13812, effective August 28, 2024)

 

Section 330.916  Student Interns (Repealed)

 

(Source:  Repealed at 17 Ill. Reg. 19258, effective October 26, 1993)

 

Section 330.920  Consultation Services

 

a)         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.

 

b)         The facility shall have a written agreement for activity program consultation if required under Section 330.1310(c).

 

c)         The facility shall obtain consultation, as needed, from a dietician if therapeutic diets are prescribed (see Section 330.1940(e)).

 

d)         If the facility does not employ a registered professional nurse, the facility shall arrange for consultation from a registered nurse.  The consultant shall assist with developing policies, methods and procedures relating to the medical program, medication, in-service on these medications and in-service training on all aspects of personal care.

 

(Source:  Amended at 26 Ill. Reg. 10559, effective July 1, 2002)

 

Section 330.930  Personnel Policies

 

The personnel policies required in Section 330.760, Section 330.761, and other personnel policies established by the facility shall be followed in the operation of the facility.

 

(Source:  Amended at 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.940  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. 7397, effective May 3, 2024)

 

Section 330.1110  Medical Care Policies

 

a)         The facility shall have a written program of medical services approved in writing by the advisory physician 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.

 

b)         The services of a physician licensed to practice medicine in Illinois shall be available to every resident of the facility.

 

c)         All residents, or their guardians, shall be permitted their choice of a physician.

 

d)         All residents shall be seen by their physician as often as necessary to assure adequate health care.

 

e)         Each resident admitted shall have a complete physical examination, within five days prior to admission, or within 72 hours after admission to the facility.  This examination shall include documentation of the presence or the absence of tuberculosis infection by tuberculin skin test in accordance with Section 330.1135 and an evaluation of the resident's condition and recommendations for their care including personal care needs and permission for participation in the activity program.  (See Section 330.1310(c).)

 

f)         The facility shall notify the physician of any accident, injury, or unusual change in a resident's condition.

 

g)         At the time of an accident, immediate treatment shall be provided by personnel trained in medically approved first aid procedures.

 

h)         A facility shall not refer a resident or the family of a resident to a home health agency, home nursing agency, or home services agency unless the agency is licensed under the Home Health, Home Services, and Home Nursing Agency Licensing Act.  A facility shall request a copy of an 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)

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.1120  Personal Care

 

a)         Each resident shall have proper daily personal attention and care including skin, nails, hair, and oral hygiene, in addition to treatment ordered by the physician.  (B)

 

b)         Each resident shall have at least one complete bath and hair wash weekly and as many additional baths and hair washes as necessary for satisfactory personal hygiene.  (B)

 

c)         Each resident shall have clean suitable clothing in order to be comfortable, sanitary, free of odors, and decent in appearance.

 

d)         Each resident shall have clean bed linens at least once weekly and more often if necessary.

 

e)         Each resident shall have sufficient clothing, in good condition, to be properly dressed each day.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.1125  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 any life-sustaining treatment.  Every facility shall establish a policy concerning the implementation 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 judgement 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 made 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 modification 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. 16180, effective January 1, 1994)

 

Section 330.1130  Communicable Disease Policies

 

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

 

b)         The facility shall not knowingly admit a person with a communicable, contagious, or infectious disease, as defined in the Control of Communicable Diseases Code.  A resident who is suspected of or diagnosed as having any such 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 and Section 330.720 of this Part.  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:  Amended at 29 Ill. Reg. 12891, effective August 2, 2005)

 

Section 330.1135  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. 8064, effective July 15, 1999)

 

Section 330.1140 Care and Treatment of Sexual Assault Survivors

 

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

 

1)         Ambulance Provider – an individual or entity that owns and operates a business or service using ambulances or emergency medical services vehicles to transport emergency patients.

 

2)         Sexual Assault – an act of nonconsensual sexual conduct or sexual penetration, as defined in Section 12-12 of the Criminal Code of 1961, including, without limitation, acts prohibited under Sections 12-13 through 12-16 of the Criminal Code of 1961.

 

b)         The facility shall adhere to the following protocol for the care and treatment of residents who are suspected of having been sexually assaulted in a long term care facility or elsewhere (Section 3-808 of the Act):

 

1)         Notify local law enforcement pursuant to the requirements of Section 330.785;

 

2)         Call an ambulance provider if medical care is needed;

 

3)         Move the survivor, as quickly as reasonably possible, to a closed environment to ensure privacy while waiting for emergency or law enforcement personnel to arrive. The facility shall ensure the welfare and privacy of the survivor, including the use of incident code to avoid embarrassment; and

 

4)         Offer to call a friend or family member and a sexual assault crisis advocate, when available, to accompany the survivor.

 

c)         The facility shall take all reasonable steps to preserve evidence of the alleged sexual assault, and not to launder or dispose of the resident's clothing or bed linens until local law enforcement can determine whether they have evidentiary value, including encouraging the survivor not to change clothes or bathe, if he or she has not done so since the sexual assault.

 

d)         The facility shall notify the Department and draft a descriptive summary of the alleged sexual assault pursuant to the requirements of Section 330.780.

 

(Source:  Old Section repealed at 20 Ill. Reg. 12160, effective September 10, 1996; new Section added at 35 Ill. Reg. 11513, effective June 29, 2011)

 

Section 330.1145  Restraints

 

a)         The facility shall have written policies controlling the use of physical 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 restraint, such as 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 physical 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.  The policies shall be followed in the operation of the facility and shall comply with the Act and this Part.

 

b)         No physical restraints with locks shall be used.

 

c)         Physical restraints shall only be used in an emergency as specified in Section 330.1150.

 

d)         Neither restraints nor confinements shall be employed for the purpose of punishment or for the convenience of any facility personnel.  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)

 

e)         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)

 

f)         The use of chemical restraints is prohibited.

 

g)         A physical restraint may be used only with the informed consent of the resident, the resident's guardian, or other authorized representative.  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)

 

h)         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.

 

1)         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.

 

2)         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.

 

i)          Whenever a period of use of a restraint is initiated, the resident shall be advised of their right to have a person or organization of their choosing, including the Guardianship and Advocacy Commission, notified of the use of the restraint. A recipient who is under guardianship may request that a person or organization of their choosing be notified of the restraint, whether or not the guardian approves the notice. If the resident so chooses, the facility shall make the notification within 24 hours, including any information about the period of time that the 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.

 

j)          Whenever a physical restraint is used on a resident whose primary mode of communication is sign language, the resident shall be permitted to have their 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)

 

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

 

l)          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.

 

m)        A resident placed in a restraint must be checked at least every 15 minutes by staff trained in the use of restraints and a record of these checks and usage of restraints must be kept.  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.

 

n)         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.

 

o)         In no event may restraint continue for longer than 2 hours unless within that time period a nurse with supervisory responsibilities, advanced practice psychiatric nurse, or a physician confirms, in writing, following a personal examination of the resident, that the restraint does not pose an undue risk to the resident's health in light of the resident's physical or medical condition.  The order shall state the events leading up to the need for restraint and the purpose for which restraint is employed.  The order shall also state the length of time restraint is to be employed and the clinical justification for the length of time.  No order for restraint shall be valid for more than 16 hours. [405 ILCS 5/2-108(a)].

 

p)         No form of seclusion shall be permitted.

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.1150  Emergency Use of Physical Restraints  

 

a)         If a resident needs emergency care, physical restraints may be used for brief periods to permit treatment to proceed unless the facility has notice that the resident has previously made a valid refusal of 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 proved 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 eight 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 staff person at all times until either the resident has been examined by a physician or the physical restraint is removed.  The resident's needs for toileting, ambulation, hydration, nutrition, repositioning, and skin care must be met while the temporary restraint is being used.

 

d)         Authorizations to use or extend the use of 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.

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.1155  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 330.330.  (Section 2-106.1(b-3) 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 surrogate decision maker, after the resident, or the resident's surrogate decision maker, 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, a registered nurse, or a licensed nurse, as defined in the Nurse Practice Act.  (Section 2-106.1(d) of the 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.  (Section 2-106.1(b-3) of the Act)

 

11)         "Surrogate decision maker" – an individual representing the resident's interests in regard to consent to receive psychotropic medications, as permitted by Section 2-106.1(b-3) of the Act and this Section. (Section 2-106.1(b-3)

 

b)         State laws, regulations, and policies related to psychotropic medication are intended to ensure psychotropic medications are used only when the medication is appropriated to treat a resident's specific, diagnosed, and documented condition and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication.  (Section 2-106.1(b) of the Act)

 

c)         Psychotropic medication shall only be given in both emergency and nonemergency situations if the diagnosis of the resident supports the benefit of the medication and clinical documentation in the resident's medical record supports the benefit of the medication over the contraindications related to other prescribed medications.  (Section 2-106.1(b-3) of the Act)

 

d)         A resident shall not be given unnecessary drugs.  An unnecessary drug is any drug 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; or

 

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

 

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

 

e)         Except in the case of an emergency, psychotropic medication shall not be administered without the informed consent of the resident or the resident's surrogate decision maker.  (Section 2-106.1(b) of the Act) Additional informed consent is not required for changes in the prescription so long as those changes are described in the original written informed consent form, as required by subsection (h)(12)(A).  The informed consent may provide for a medication administration program of sequentially increased doses or a combination of medications to establish the lowest effective dose that will achieve the desired therapeutic outcome, pursuant to subsection (h)(12)(A).  The most common side effects of the medications shall be described.  In an emergency, a facility shall:

 

1)         Document the alleged emergency in detail, including the facts surrounding the mediation's need, pursuant to the requirements of Section 330.1720; and

 

2)         Present this documentation to the resident and the resident's representative or other surrogate decision maker no later than 24 hours after the administration of emergency psychotropic medication.  (Section 2-106.1(b-3) of the Act

 

f)         Residents shall not be given antipsychotic drugs unless antipsychotic drug therapy is ordered by a physician or an authorized prescribing professional, as documented in the resident's comprehensive assessment, to treat a specific 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 E.

 

g)         Residents who use antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue these drugs in accordance with Appendix E.  In compliance with subsection 2-106.1(b-3) of the Act and this Section, the facility shall obtain informed consent for each dose reduction.

 

h)         Protocol for Securing Informed Consent for Psychotropic Medication

 

1)         Except in the case of an emergency as described in subsection (e), a facility shall obtain voluntary informed consent, in writing, from a resident or the resident's surrogate decision maker before administering or dispensing a psychotropic medication to that resident.  When informed consent is not required for a change in dosage as described in subsection (h)(12)(A), the facility shall note in the resident's file that the resident was informed of the dosage change prior to the administration of the medication or that verbal, written, or electronic notice has been communicated to the resident's surrogate decision maker that a change in dosage has occurred.  (Section 2-106.1(b-5) of the Act)

 

2)         No resident shall be administered psychotropic medication prior to a discussion between the resident or the resident's surrogate decision maker, or both, and the resident's physician or a physician the resident was referred to, a registered pharmacist, or a licensed nurse about the possible risks and benefits of a recommended medication, and the use of standardized consent forms designated by the Department.  (Section 2-106.1(b-3) of the Act)

 

3)         Prior to initiating any detailed discussion designed to secure informed consent, a licensed health care professional shall inform the resident or the resident's surrogate decision maker that 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 surrogate decision maker before the resident may be given the medication.

 

4)         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.

 

5)         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 surrogate decision maker, or both, and the resident's physician, or a physician the resident was referred to, or a registered pharmacist, or an advanced practice or registered professional nurse. 

 

6)         In addition to the oral discussion, the resident or the resident's surrogate decision maker shall be given the information in subsection (h)(4) in writing, in a form designated or developed by the Department.  Each form shall be written in plain language understandable to the resident or the resident's surrogate decision maker, be able to be downloaded from the Department's official website or another website designated by the Department, shall include information specific to the psychotropic medication for which consent is being sought, and shall be used for every resident for whom psychotropic drugs are prescribed.  (Section 2-106.1(b-3) of the Act) 

 

7)         If the written information is in a language not understood by the resident or the resident's surrogate decision maker, the facility, in compliance with the Language Assistance Services Act and the Language Assistance Services Code, shall provide, at no cost to the resident or the resident's surrogate decision maker, an interpreter capable of communicating with the resident or the resident's surrogate decision maker and the authorized prescribing professional conducting the discussion. 

 

8)         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 surrogate decision maker 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.  If the resident has dementia and the facility is unable to contact the resident's surrogate decision maker, the facility shall not administer psychotropic medication to the resident except in an emergency as provided by subsection (e).

 

9)         Informed consent shall be sought first from a resident, then from a surrogate decision maker, in the following order of priority:

 

A)        The resident's guardian of the person if one has been named by a court of competent jurisdiction.

 

B)        In the absence of a court-ordered guardian, informed consent shall be sought from a health care agent under the Illinois Power of Attorney Act who has authority to give consent.

 

C)        If neither a court-ordered guardian of the person, nor a health care agent under the Power of Attorney Act, is available, and the attending physician determines that the resident lacks capacity to make decisions, informed consent shall be sought from the resident's attorney-in-fact designated under the Mental Health Treatment Preference Declaration Act, if applicable, or the resident's representative.  (Section 2-106.1(b-3) of the Act)

 

10)        Regardless of the availability of a surrogate decision maker, the resident may be notified and present at any discussion required by this Section.  Upon request, the resident, or the resident's surrogate decision maker, 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. 

 

11)        The facility shall inform the resident, surrogate decision maker, or both of the existence of a copy of:

 

A)        The resident's care plan;

 

B)        The facility policies and procedures adopted in compliance with Section 2-106.1(b-15) of the Act, and this Section; and

 

C)        A notification that the most recent of the resident's care plans and the facility's policies are available to the resident or surrogate decision maker upon request.

 

12)        The maximum possible period for informed consent shall be until:

 

A)        A change in the prescription occurs, either as to type of psychotropic medication or an increase or decrease in dosage, dosage range, or titration schedule of the prescribed medication that was not included in the original informed consent; or

 

B)        A resident's care plan changes in a way that affects the prescription or dosage of the psychotropic medication.  (Section 2-106.1(b-3) of the Act)

 

13)        A resident or their surrogate decision maker 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 their surrogate decision maker by a licensed medical professional, and the reason for exceeding the recommended daily dosage is justified by the prescribing professional 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.

 

14)        Pursuant to Section 2-104(c) of the Act, the resident or the resident's surrogate decision maker shall be informed, at the time of the discussion required by subsection (h)(1), that their informed consent may be withdrawn at any time, and that, even with informed consent, the resident may refuse to take the medication. 

 

15)        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 Section 2-106.1(b-3) 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 surrogate decision maker shall be placed in the resident's record.

 

16)        No facility shall deny continued residency to a person on the basis of the person's or resident's, or the person's or resident's surrogate decision maker's, refusal of the administration of psychotropic medication, unless the facility can demonstrate that the resident's refusal would place the health and safety of the resident, the facility staff, other residents, or visitors at risk.  A facility that alleges that the resident's refusal to consent to the administration of psychotropic medication will place the health and safety of the resident, the facility staff, other residents, or visitors at risk shall:

 

A)        Document the alleged risk in detail, along with a description of all nonpharmacological or alternative care options attempted and why they were unsuccessful;

 

B)        Present this documentation to the resident or the resident's surrogate decision maker, to the Department, and to the Office of the State Long Term Care Ombudsman; and

 

C)        Inform the resident or their surrogate decision maker of their right to appeal an involuntary transfer or discharge to the Department as provided in the Act and this Part.  (Section 2-106.1(b-10) of the Act)

 

i)          All facilities shall implement written policies and procedures for compliance with Section 2-106.1 of the Act and this Section.  A facility's failure to make available to the Department the documentation required under this subsection is sufficient to demonstrate its intent to not comply with Section 2-106.1 of the Act and this Section and shall be grounds for review by the Department.  (Section 2-106.1(b-15) of the Act)

 

j)          Upon the receipt of a report of any violation of Section 2-106.1 of the Act and this Section, the Department will investigate and, upon finding sufficient evidence of a violation of Section 2-106.1 of the Act and this Section, may proceed with disciplinary action against the licensee of the facility. In any administrative disciplinary action under this subsection, the Department will have the discretion to determine the gravity of the violation and, taking into account mitigating and aggravating circumstances and facts, may adjust the disciplinary action accordingly.  (Section 2-106.1(b-20) of the Act)

 

k)         A violation of informed consent that, for an individual resident, lasts for 7 days or more under this Section is, at a minimum, a Type "B" violation. A second violation of informed consent within a year from a previous violation in the same facility regardless of the duration of the second violation is, at a minimum, a Type "B" violation.  (Section 2-106.1(b-25) of the Act)

 

l)          Any violation of Section 2-106.1 of the Act and this Section by a facility may be enforced by an action brought by the Department in the name of the People of Illinois for injunctive relief, civil penalties, or both injunctive relief and civil penalties. The Department may initiate the action upon its own complaint or the complaint of any other interested party.  (Section 2-106.1(b-30) of the Act)

 

m)        Any resident who has been administered a psychotropic medication in violation of Section 2-106.1 of the Act and this Section may bring an action for injunctive relief, civil damages, and costs and attorney's fees against any facility responsible for the violation.  (Section 2-106.1(b-35) of the Act)

 

n)         An action under this Section shall be filed within two years after either the date of discovery of the violation that gave rise to the claim or the last date of an instance of a noncompliant administration of psychotropic medication to the resident, whichever is later.  (Section 2-106.1(b-40) of the Act)

 

o)         A facility subject to action under Section 2-106.1 of the Act and this Section shall be liable for damages of up to $500 for each day, after discovery of a violation, that the facility violates the requirements of Section 2-106.1 of the Act and this Section.  (Section 2-106.1(b-45) of the Act)

 

p)         The rights provided for in Section 2-106.1 of the Act and this Section are cumulative to existing resident rights. No part of this Section shall be interpreted as abridging, abrogating, or otherwise diminishing existing resident rights or causes of action at law or equity.  (Section 2-106.1(b-55) of the Act)

 

q)         In addition to the penalties described in this Section and any other penalty prescribed by law, a facility that is found to have violated Section 2-106.1 of the Act and this Section shall thereafter be required to 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 Section 2-106.1 of the Act and this Section.  (Section 2-106.1(b-3) of the Act)

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.1160  Vaccinations

 

a)         A facility shall annually administer or arrange for administration of 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.  Influenza vaccinations for all residents age 65 and over shall be completed by November 30 of each year or as soon as practicable if vaccine supplies are not available before November 1.  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.  (Section 2-213(a) of the Act)

 

b)         A facility shall document in the resident's medical record that an annual vaccination against influenza was administered, arranged, refused or medically contraindicated.  (Section 2-213(a) of the Act)

 

c)         A facility shall administer 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.  (Section 2-213(b) of the Act)

 

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

 

e)         A facility shall distribute educational information provided by the Department on all vaccines recommended by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, including, but not limited to the risks associated with shingles and how to protect oneself against the varicella-zoster virus. The facility shall provide the information to each resident who requests the information and each newly admitted resident.  The facility may distribute the information to residents electronically.  (Section 2-213(e) of the Act)

 

f)         A facility shall document in the resident's medical record that he or she was verbally screened for risk factors associated with hepatitis B, hepatitis C, and HIV, and whether or not the resident was immunized against hepatitis B.  (Section 2-213(c) of the Act)

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.1310  Activity Program

 

a)         The facility shall provide an ongoing program of activities to meet the interests and preferences and the physical, mental and psychosocial well-being of each resident, in accordance with the resident's comprehensive assessment.  The activities shall be coordinated with other services and programs to make use of both community and facility resources and to benefit the residents.

 

b)         Activity personnel shall be provided to meet the needs of the residents and the program.  Activity staff time each week shall total not less than 45 minutes multiplied by the number of residents in the facility. This time shall be spent in providing activity programming as well as planning and directing the program.  The time spent in the performance of other duties not related to the activity program shall not be counted as part of the required activity staff time.

 

1)         In a facility whose residents participate in regularly scheduled therapeutic programs outside the facility, such as school, employment or sheltered workshop, the minimum hours per week of activity staff time may be reduced.  The reduction shall be calculated by multiplying the number of residents in the facility who participate in such programs by the percentage of the day that these residents spend in such programs.

 

2)         Activity personnel working under the direction of the activity director shall have a minimum of 10 hours of in-service training per calendar or employment year, directly related to recreation/activities.  In-service training may be provided by qualified facility staff and/or consultants, or may be obtained from college or university courses, seminars and/or workshops, educational offerings through professional organizations, similar educational offerings or any combination thereof.

 

c)         Activity Director and Consultation

 

1)         A trained staff person shall be designated as activity director and shall be responsible for planning and directing the activities program.  This person shall be regularly scheduled to be on duty in the facility at least four days per week.

 

2)         If the activity director is not a Certified Therapeutic Recreation Specialist (CTRS), Occupational Therapist Registered and Licensed (OTR/L), or a Licensed Social Worker (LSW) or Licensed Clinical Social Worker (LCSW) who has specialized course work in social group work, the facility shall have a written agreement with a person from one of those disciplines to provide consultation to the activity director and/or activity department at least monthly, to ensure that the activity programming meets the needs of the residents.

 

3)         Any person designated as an activity director hired after December 24, 1987 shall have a high school diploma or equivalent.

 

4)         Except for individuals qualified as a CTRS, OTR/L, LSW or LCSW as listed in subsection (c)(2) of this Section, any person hired as an activity director after November 1, 2000 shall have taken a 36-hour basic orientation course or shall register to take a 36-hour basic orientation course within 90 days after employment and shall complete the course within 180 days after employment.  This course shall be recognized by an accredited college or university or a nationally recognized continuing education sponsor following the guidelines of the International Association for Continuing Education and Training and include at least the following: resident rights; activity care planning for quality of life, human wellness and self-esteem; etiology and symptomatology of persons who are aged, developmentally disabled or mentally ill; therapeutic approaches; philosophy and design of activity programs; activity program resources; program evaluation; practitioner behavior and ethics; resident assessment and supportive documentation; standards and regulations concerning activity programs; management and administration.  Individuals who have previously taken a 36-hour basic orientation course, a 42-hour basic activity course or a 90-hour basic education course shall be considered to have met this requirement.

 

5)         The activity director shall have a minimum of ten hours of continuing education per year pertaining to activities programming.

 

6)         Consultation shall be required only quarterly when the activity director meets or exceeds the following criteria:

 

A)        High school diploma or equivalent, five years of full-time or 10,000 hours of part-time experience in activities (three years of that experience as an activity director), and completion of a basic orientation course of at least 36 hours; or

 

B)        A two-year associate's degree, three years of experience as an activity director, and completion of a basic orientation course of at least 36 hours; or

 

C)        A four-year degree, one year full-time experience as an activity director, and completion of a basic orientation course of at least 36 hours.

 

d)         Written permission, with any contraindications stated, shall be given by the resident's physician if the resident participates in the activity program.  Standing orders will be acceptable with individual contraindications noted.

 

e)         Activity program staff shall participate in the assessment of each resident, which shall include the following:

 

1)         Background information, including education level, cultural/social issues, and spiritual needs;

 

2)         Current functional status, including communication status, physical functioning, cognitive abilities, and behavioral issues; and

 

3)         Leisure functioning, including attitude toward leisure, awareness of leisure resources, knowledge of activity skills, and social interaction skills and activity interests, both current and past.

 

f)         The activity staff shall participate in the development of an individualized plan of care addressing needs and interests of the residents, including activity/recreational goals and/or interventions.

 

g)         The facility shall provide a specific, planned program of individual(including self-initiated) and group activities that are aimed at improving, maintaining, or minimizing decline in the resident's functional status, and at promoting well-being.  The program shall be designed in accordance with the individual resident's needs, based on past and present lifestyle, cultural/ethnic background, interests, capabilities, and tolerance. Activities shall be daily and shall reflect the schedules, choices, and rights of the residents (e.g., morning, afternoon, evenings and weekends).  The residents shall be given opportunities to contribute to planning, preparing, conducting, concluding and evaluating the activity program.

 

h)         The activity program shall be multifaceted and shall reflect each individual resident's needs and be adapted to the resident's capabilities.  The activity program philosophy shall encompass programs that provide stimulation or solace; promote physical, cognitive and/or emotional health; enhance, to the extent practicable, each resident's physical and mental status; and promote each resident's self-respect by providing, for example, activities that support self-expression and choice.  Specific types of activities may include:

 

1)         Physical activity (e.g., exercise, fitness, adapted sports);

 

2)         Cognitive stimulation/intellectual/educational activity (e.g., discussion groups, reminiscence, guest speakers, film, trivia, quizzes, table games, puzzles, writing, spelling, newsletter);

 

3)         Spiritual/religious activity (e.g., religious services, spiritual study groups, visits from spiritual support groups);

 

4)         Service activity (e.g., volunteer work for the facility, other individuals and/or the community);

 

5)         Sensory stimulation (e.g., tactile, olfactory, auditory, visual and gustatory);

 

6)         Community involvement (e.g., community groups coming into the facility for intergenerational programs, special entertainment and volunteer visits; excursions outside the facility to museums, sporting events, entertainment, parks);

 

7)         Expressive and creative arts/crafts (adapted to the resident's capabilities), music, movement/dance, horticulture, pet-facilitated therapy, drama, literary programs, art, cooking;

 

8)         Family involvement (e.g., correspondence, family parties, holiday celebrations, family volunteers); and

 

9)         Social activity (e.g., parties and seasonal activities).

 

i)          If residents participate in regularly scheduled therapeutic programs outside the facility (e.g., school, employment, or sheltered workshop), the residents' needs for activities while they are in the facility shall be met.

 

j)          Residents' participation in and response to the activity program shall be documented at least quarterly and included in the clinical record.  The facility shall maintain current records of resident participation in the activity program.

 

(Source:  Amended at 24 Ill. Reg. 17304, effective November 1, 2000)

 

Section 330.1320  Work Programs

 

Work programs for residents in facilities may be allowed if they are oriented toward resident adjustment and therapeutic benefits.

 

a)         Permission for such programming shall be secured from the Department. The program shall be presented in writing indicating such things as objectives, possible work assignment, duties, policies governing the program, agency involvement (where appropriate), and supervision.

 

b)         Residents involved in such programs shall meet all requirements of the Department for persons functioning in these positions.

 

c)         Residents shall not be used to replace employed staff.  (B)

 

d)         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.  (See Section 330.1710(f)(1).)

 

e)         All such programs shall be in full compliance with all applicable regulations of both the State and Federal Departments of Labor.  Any program found by the Department not to be in compliance with State and Federal Departments of Labor regulations shall be terminated immediately.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.1330  Written Policies for Restorative Services

 

There shall be written policies, which are followed in the operation of the facility covering all restorative services offered by the facility to achieve and maintain the highest possible degree of function, self-care and independence.  These shall be developed as set forth in Section 330.710 (a) through (c).  (B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.1340  Volunteer Program

 

a)         If the facility has a volunteer or auxiliary program, a facility staff person shall direct the program.  Community groups such as Boy and Girl Scouts, church groups and civic organizations that may occasionally present programs, activities, or entertainment in the facility shall not be considered volunteers for the purposes of this Section.

 

b)         Volunteers shall complete a standard orientation program, in accordance with their facility responsibilities and with the facility's policies and procedures governing the volunteer program.  The orientation shall include, but not be limited to:

 

1)         Residents' rights;

 

2)         Confidentiality;

 

3)         Disaster preparedness (i.e., fire, tornado);

 

4)         Emergency response procedures;

 

5)         Safety procedures/precautions;

 

6)         Infection control; and

 

7)         Body mechanics.

 

c)         Volunteers shall respect all aspects of confidentiality.

 

d)         Volunteers shall be informed of and shall implement medical and physical precautions related to the residents with whom they work.

 

e)         Volunteers shall not take the place of qualified staff (e.g., activity professionals, nursing assistants, or case workers).

 

(Source:  Added at 24 Ill. Reg. 17304, effective November 1, 2000)

 

Section 330.1510  Medication Policies

 

a)         Every facility shall adopt written policies and procedures for assisting residents in obtaining individually prescribed medication for self-administration and for disposing of medications prescribed by the attending physicians.  These policies and procedures shall be consistent with the Act and this Part and shall be followed by the facility.

 

1)         Medication policies and procedures shall be developed with consultation from an Illinois registered professional nurse and a registered pharmacist.  These policies and procedures shall be part of the written program of care and services. 

 

2)         All medications taken by residents shall be ordered by the licensed prescriber directly from a pharmacy.  If the facility has a licensed nurse who supervises the medication regimen of the residents, the nurse may transmit the licensed prescriber's orders to the pharmacy.

 

3)         If facility policy permits residents to be totally responsible for their own medication, with written permission from the attending physician, the resident and attending physician shall be given written statements concerning what the responsibilities of the facility, the resident and the physician are if the resident, or any other person, suffers harm as a result of the resident's handling his or her own medications.

 

4)         If the facility elects to administer medications to some residents for control purposes, the medications shall be administered by personnel who are licensed to administer medications, in accordance with their respective licensing requirements.  Medications shall not be recorded as having been administered prior to their actual administration to the resident.

 

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)         Drug and Pharmacy Restrictions

 

1)         No facility shall stock drugs.

 

2)         No facility shall operate a pharmacy.

 

d)        All medications on individual prescription or from the licensed prescriber's personal supply shall be labeled as set forth in Section 330.1530(f).  A licensed prescriber who dispenses medication 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].  

 

1)         All other medications shall be authorized by a licensed prescriber for individual resident use, and shall be clearly identified with the resident's name. 

 

2)         Attending physicians shall review the medication regimen of each resident at least every six months.  This review shall be documented in the resident's record.

 

e)         Medication Records

 

1)         All medications used by residents shall be recorded by facility staff at time of use.  (See Section 330.1710.)

 

2)         A medication record shall be kept for those residents for whom the attending physician has given permission to keep their medication in their room and to be fully responsible for taking the medications in the correct dosage and at the proper times.

 

f)         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 the applicable provisions of NFPA 99 and the NFPA Life Safety Code (see Section 330.340).

 

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.

 

g)           All medications having an expiration date that has passed, and all medications of residents who have died shall be disposed of in accordance with the written policies and procedures established by the facility in accordance with Section 330.1510.  Medications shall be transferred with a resident, upon 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.  Disposition shall be noted in the resident's record.

 

(Source:  Amended at 27 Ill. Reg. 5886, effective April 01, 2003)

 

Section 330.1520  Administration of Medication

 

a)         All medications taken by residents shall be self-administered, unless administered 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.

 

b)         No person shall be admitted to a facility who is not capable of taking his or her own medications and any needed biologicals, as approved in writing by the resident's personal physician. Facility staff may remind residents when to take medications and watch to ensure that they follow the directions on the container. 

 

c)         Assistance in Self-Administration of Medications

 

1)         Facility staff may assist a resident in the self-administration of medications by taking the medication from the locked area where it is stored and handing it to the resident.  If the resident is physically unable to open the container, a staff member may open the container for the resident.

 

2)         Facility staff may also assist physically impaired residents, such as those who have arthritis, cerebral palsy, or Parkinson's disease, in the removal of the medication from the container and in assisting the resident in consuming or applying the medication when requested to do so by the resident.  (For example, a staff member may place a dose of medicine in a container and place the container to the mouth of a resident who would not be able to do so himself without spilling it.) 

 

(Source:  Amended at 27 Ill. Reg. 5886, effective April 01, 2003)

 

Section 330.1530  Labeling and Storage of Medications

 

a)         All medications shall be stored in a locked area at all times.  Areas shall be well lighted and of sufficient size to permit storage without crowding.  This area may be a drawer, cabinet, closet, or room.  In those facilities where a licensed nurse dispenses medication to residents, medications may be stored in a locked mobile medication cart, which is made immobile when not in use by the nurse to dispense medication. 

 

b)         The key to the medicine area shall be the responsibility of, and in the possession of, the staff persons responsible for overseeing the self-administration of medications by residents. 

 

1)         The medicine area shall not be used for any other purpose.  It shall not be located in residents' rooms, bathrooms, or the kitchen.  However, for those persons whom the attending physician has given written permission to handle their own medication, medications may be stored in a locked drawer or cabinet in the resident's room.

 

2)         Residents whom the attending physician has given permission to be totally responsible for their own medication shall maintain possession of the key, or combination of the lock, to their own medication storage area.  A duplicate key, or a copy of the combination, shall be kept by the facility in a secure place for emergency use.

 

c)         Medications for external use shall be kept in a separate location in the medicine area or in a separate locked area. 

 

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

 

e)         Biologicals or medications requiring refrigeration shall be kept in a separate, securely fastened and locked container in a refrigerator, or in a locked refrigerator.

 

f)         The label of each individual 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 of issue; expiration date of all time-dated drugs; name, address, and telephone number of pharmacy issuing the drug; and the initials of the pharmacist filling the prescription.  If the individual 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)         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. 

 

h)           The medications of each resident shall be kept and stored in their originally received containers.  Medications shall not be transferred between containers. 

 

(Source:  Amended at 27 Ill. Reg. 5886, effective April 01, 2003)

 

Section 330.1710  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 treatments 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 and plans of treatment 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 treatments 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 rehabilitation 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 which contains the date and time each medication is taken, name of drug, dosage, and by whom administered.  A medication administration record is not required for residents who have been approved by their physician to be fully responsible for their own medications under Section 330.1510(d)(2).

 

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 of decubitus ulcers, weight monitoring to determine a resident's weight loss or gain, blood pressure monitoring, and fluid intake and output.

 

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

 

j)          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 330.1740 of this Part.

 

k)         Discharge information shall be completed 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.

 

(Source:  Amended at 23 Ill. Reg. 8064, effective July 15, 1999)

 

Section 330.1720  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)         Marital Status, and the name of spouse (if there is one),

 

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

 

4)         Date of current admission to the facility,

 

5)         State or country of birth,

 

6)         Home address,

 

7)         Religious affiliation (if any),

 

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

 

9)         Name and telephone number of the resident's personal physician,

 

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

 

11)         Race and origin,

 

12)         Most recent occupation,

 

13)         Whether the resident or the resident's spouse is a veteran,

 

14)         Father's name and mother's maiden name,

 

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

 

16)         The diagnosis applicable at the time of admission.

 

b)         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)         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 restoration potential.  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 treatments, diet, activities and special procedures or orders required for the safety and well-being of the resident.  The physician's order sheet shall also include a record of the medications prescribed for the resident by the physician, and a statement that the resident is capable of self-administering these medications.

 

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

 

A)        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 and work programs shall be recorded as they are noted.  If no significant observations or developments are noted for three months, an entry shall be made in the record of that fact.

 

4)         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.

 

5)         The results of the physical examination conducted pursuant to Section 330.1110(d) of this Part.

 

6)         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.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.1730  Records Pertaining to Residents' 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. 6562, effective April 17, 1989)

 

Section 330.1740  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. 6562, effective April 17, 1989)

 

Section 330.1750  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 information regarding the physician's notification and response regarding any serious accident or injury, or significant change in condition, as required by Section 330.1110(e) of this Part.

 

b)         The resident's record shall identify the reasons for any order and use of safety devices or restraints, as required by Section 330.1140(d) 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 330.1310(d) of this Part.

 

d)         The records of residents participating in work programs shall document the appropriateness of the program for the resident and the resident's response to the program, as described in Section 330.1320(d) of this Part.

 

e)         Documentation of the review of the medication regimen by the attending physician shall be entered in the resident's record, as required by Section 330.1510(c)(2) of this Part.

 

f)         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 330.1940 of this Part.

 

g)         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 330.4210(b) of this Part.

 

h)         The facility shall comply with Section 330.4210(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.

 

i)          The facility shall permit each resident, resident's parents, guardian or representative to inspect and copy the resident's medical records as provided by Section 330.4220(g) of this Part.

 

j)          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 Section 330.4300(d) and (g) of this Part.

 

k)         Summaries of discussions and explanations of any planned involuntary transfers or discharges shall be included in the medical record of the resident that is to be involuntarily transferred or discharged, as described in Section 330.4300(j) of this Part.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.1760  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 330.210 of this Part.

 

b)         The minutes of resident advisory council meetings required by Section 330.740(j) of this Part.

 

c)         The records of in-service training required by Section 330.760(b)(2) of this Part.

 

d)         Copies of reports of serious incidents or accidents involving residents required by Section 330.780 of this Part.

 

e)         The reports of findings and recommendations from consultants required in Section 330.1770(a) of this Part.

 

f)         Copies of the quarterly reports for all employees that are filed for Social Security and Unemployment Compensation as required by Section 330.1770(d) of this Part.

 

(Source:  Amended  at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.1770  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 date 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 Unemployment 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 330.210 of this Part.

 

2)         Records and daily time schedules shall be kept on each employee as set forth in Section 330.760(a) and (b) of this Part.

 

3)         Menu and food purchase records shall be maintained as set forth in Section 330.1980(d) and (f) of this Part.

 

4)         The facility shall maintain a file of all reports of serious incidents or accidents involving residents as required by Section 330.780 of this Part.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.1910  Director of Food Services

 

a)         Each facility shall have a full-time person, suited by training and experience, who has been designated by the administrator to be responsible for the total food service operation of the facility.  This person shall be on duty a minimum of 40 hours each week.  (B)

 

b)         The head cook may be designated to fill this position as long as it does not interfere with the responsibilities of either position.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.1920  Dietary Staff in Addition to Director of Food Services

 

There shall be a sufficient number of food service personnel employed and on duty to meet the dietary needs of all persons eating meals in the facility.  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. 6562, effective April 17, 1989)

 

Section 330.1930  Hygiene of Dietary Staff

 

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

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.1940  Diet Orders

 

a)         A current diet manual (printed or electronic) shall be available and in use (printed or electronic).  A manual shall be available to the food and nutrition services department in addition to the nursing department for use by physicians or dietitians when writing diet orders.

 

b)         Physicians shall write a diet order for each resident indicating whether the resident is to have a general or a therapeutic diet.  The attending physician may delegate writing a diet order to the dietitian.

 

1)         The resident's diet order shall be included in the medical record.

 

2)         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 or dietitian.  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 the food service department, name of physician or dietitian 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.

 

e)         The facility shall provide supervision for preparing and serving the therapeutic diets, obtaining consultation as needed from a dietitian.

 

f)         A therapeutic diet means a diet ordered by the physician or dietitian as part of a 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).

 

g)         The kinds and variation of 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, 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 by a physician or dietitian every 48 hours.  Medical soft diets, sometimes known as transitional diets, shall be reviewed by a physician or dietitian 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 by a physician or dietitian as needed, or at least every three months.

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.1950  Meal Planning

 

Each resident shall be served food to meet the resident's needs and to meet physician's orders. The facility shall use this Section to plan menus and purchase food in accordance with the following Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences.

 

a)         Milk and Milk Products Group:  16 ounces or more of Grade A whole or low fat pasteurized milk where milk is used for fluid consumption.  Calcium equivalents for eight ounces of milk:

 

1)         1½ ounces natural cheese,

 

2)         Two ounces processed cheese,

 

3)         One cup yogurt or one cup frozen yogurt,

 

4)         One cup cottage cheese, or

 

5)         1½ cups ice cream or ice milk.

 

b)         Meat Group:  A total of 6 ounces (by weight) of good quality protein to provide 38 to 42 grams of protein daily.  To ensure variety, food items repeated within the same day shall not be counted as meeting a required serving.  The following are examples of one serving:

 

1)         Three ounces (excluding bone, fat and breading) of any cooked meat such as whole or ground beef, veal, pork or lamb; poultry; organ meats such as liver, heart, kidney; prepared luncheon meats.

 

2)         Three ounces (excluding skin and breading) of cooked fish or shell fish or ½ cup canned fish.

 

3)         Three ounces of natural or processed cheese or 3/4 cup cottage cheese.

 

4)         Three eggs (minimum weight 21 ounces per dozen, considered a medium egg).  Note:  If one egg is served at a meal, a protein food of good quality may be reduced from six to five ounces for the remaining meals.  If two eggs are served at a meal, a minimum of two ounces of good quality protein shall be served at each of the remaining meals.

 

5)         1½ cups cooked dried peas or beans, six tablespoons of peanut butter, or one cup nuts, not more than twice a week and provided that eggs, milk or lean meat is served at the same meal.

 

6)         Three ounces of soy protein containing not less than 21 grams of protein or in combination with other sources of quality protein to equal 21 grams of protein, provided that it is acceptable to the resident population.

 

7)         Combinations of all above examples are acceptable, provided that the minimum of six ounces of a good quality protein food is served daily and provided that the combinations do not conflict with eye appeal or palatability.

 

8)         The content of meat alternative products shall be listed on the menu.

 

c)         Vegetable and Fruit Group:  Five or more servings of fruits or vegetables.

 

1)         A serving consists of:

 

A)        ½ cup chopped, raw, cooked, canned or frozen fruit or vegetables;

 

B)        ¾ cup fruit or vegetable juice; or

 

C)        One cup raw leafy vegetable.

 

2)         The five or more servings shall consist of:

 

A)        Sources of Vitamin C

 

i)          One serving of a good source of vitamin C (containing at least 60 mg of vitamin C); or

 

ii)         Two servings of a fair source of vitamin C.  This may be more than one food item and shall contain a total of at least 65 mg of vitamin C.

 

B)        One serving of a good source of vitamin A at least three times a week supplying at least 1000 micrograms retinol equivalent (RE) of vitamin A.

 

c)         Other fruits and vegetables, including potatoes, that may be served in ⅓ cup or larger portions.

 

3)         To ensure variety, food items repeated within the same day shall not be counted as meeting a required serving.

 

d)         Bread, Cereal, Rice and Pasta Group:  Six or more servings of whole grain, enriched or restored products.  One serving equals:

 

1)         One slice of bread,

 

2)         ½ cup of cooked cereal, rice, pasta, noodles, or grain product,

 

3)         ¾ cup of dry, ready-to-eat cereal,

 

4)         ½ hamburger or hotdog bun, bagel or English muffin,

 

5)         One 4-inch diameter pancake,

 

6)         One tortilla,

 

7)         Three to four plain crackers (small),

 

8)         ½ croissant (large), doughnut or danish (medium),

 

9)         1/16 cake,

 

10)       Two cookies, or

 

11)       1/12 pie (2-crust, 8").

 

e)         Butter or Margarine:  To be used as a spread and in cooking.

 

f)         Other foods shall be served to round out meals, satisfy individual appetites, improve flavor, and meet the individual's nutritional and caloric needs.

 

g)         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), 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 another 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.

 

D)        Snack:

 

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

 

(Source:  Amended at 23 Ill. Reg. 8064, effective July 15, 1999)

 

Section 330.1960  Therapeutic Diets (Repealed)

 

(Source:  Repealed at 23 Ill. Reg. 8064, effective July 15, 1999)

 

Section 330.1970  Scheduling of 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.  The 14 hour span shall not apply to facilities using the "four or five meal-a-day" plan, provided the evening meal is substantial and includes, but is not limited to, a good quality protein, bread or bread substitute, a dessert and a nourishing beverage.

 

b)         Bedtime snacks of nourishing quality shall be offered.   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, or as otherwise indicated in the resident's plan of care.

 

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

 

(Source:  Amended at 16 Ill. Reg. 14370, effective September 3, 1992)

 

Section 330.1980  Menus and Food Records

 

a)         Menus, including menus for "sack" lunches and between meal or bedtime snacks, 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 for not less than  30 days.

 

(Source:  Amended at 23 Ill. Reg. 8064, effective July 15, 1999)

 

Section 330.1990  Food Preparation and Service

 

a)         Foods 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.  (B)

 

c)         All residents shall be served in a dining room or multipurpose room except for an individual with a temporary illness or for other valid reasons.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.2000  Food Handling Sanitation

 

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

 

(Source:  Amended at 49 Ill. Reg. 802, effective December 31, 2024)

 

Section 330.2010  Kitchen Equipment, Utensils, and Supplies

 

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.

 

(Source:  Amended at 14 Ill. Reg. 14928, effective October 1, 1990)

 

Section 330.2210  Maintenance

 

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

 

1)         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 coverings, such as tile or linoleum; loose handrails or railings; loose or broken window panes, and any other similar hazards.  (B)

 

2)         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)

 

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

 

4)         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).

 

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

 

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

 

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

 

8)         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)

 

b)         Plumbing Maintenance

 

1)         Each facility shall maintain all plumbing fixtures and piping in good repair and properly functioning.

 

2)         Each facility shall protect the potable water supply from contamination by providing and properly installing adequate, backflow protection devices or providing adequate air gaps on all fixtures that may be subject to backflow or back siphonage.

 

(Source:  Amended at 14 Ill. Reg. 14928, effective October 1, 1990)

 

Section 330.2220  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, as nonslip as possible, and free from tripping hazards including throw or scatter rugs.

 

3)         Control odors within the housekeeping staff's area 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. 6562, effective April 17, 1989)

 

Section 330.2230  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.  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 laundering and transporting soiled linens.  If an in-house laundry service is provided, then the following conditions shall exist:

 

1)         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.

 

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

 

3)         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.

 

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

 

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

 

6)         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, such supplies and equipment 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 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. 14928, effective October 1, 1990)

 

Section 330.2410  Furnishings

 

a)         Bed Requirements

 

1)         Each resident shall be provided with a bed that is at least 36 inches wide, has a headboard, is of sturdy construction, and is in good repair.  Cots, rollaway, double, or folding beds shall not be used.

 

2)         Double beds may be used for married couples, if they desire this arrangement, if approved in writing by the Department.

 

3)         Each bed shall be provided with a clean, firm, comfortable mattress and box springs of appropriate size for the bed.

 

4)         Each bed shall be provided with a minimum of one clean, comfortable pillow.

 

b)         Each bedroom shall have window shades, or equivalent, that are in good repair.

 

c)         A satisfactory reading lamp, or equivalent, shall be provided for each bed.

 

d)         Each bedroom shall be provided with a mirror, unless there is a mirror in an adjoining bathroom.  Each lavatory shall be provided with a mirror.

 

e)         Each living room provided for residents' use shall have an adequate number of reading lamps, tables, and chairs or settees.  These furnishings shall be well constructed and of satisfactory design for the residents.

 

f)         Dining room furnishings shall be provided for each resident that are well constructed, comfortable, in good repair, and of satisfactory design for the residents.  The facility shall provide a sufficient number of tables of a type that can accommodate residents who require the use of a wheelchair.

 

g)         Office spaces 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.

 

h)         For each bed the facility shall provide:

 

1)         A minimum of two adequately sized dresser drawers.

 

2)         A comfortable chair.

 

3)         An individual towel rack.

 

4)         A satisfactory reading light over, or at the side of, the bed.

 

5)         Adequate closet, locker, or wardrobe space for hanging clothing within the room.

 

6)         A satisfactory bedside cabinet.

 

i)          A facility shall permit a resident to bring their own furnishings so long as those furnishings do not impede access into or out of the resident's room.

 

j)          A facility shall make reasonable efforts to have activated at all times the closed captioning feature on a television in a common area provided for use by the general public or in a resident's room, or enable the closed captioning feature when requested to do so by a member of the general public or a resident, if the television includes a closed captioning feature.  As used in this subsection (i), "closed captioning" means a text display of spoken words presented on a television that allows a deaf or hard of hearing viewer to follow the dialogue and the action of a program simultaneously.

 

1)         It is not a violation of this subsection if the closed captioning feature is deactivated by a member of the facility's staff after the feature is enabled in a common area or in a resident's room unless the deactivation of the closed captioning feature is knowing or intentional.  It is not a violation of this subsection if the closed captioning feature is deactivated by a member of the general public, a resident, or a member of the facility's staff at the request of a resident of the facility.  Facilities shall ensure that staff are trained on the requirements of this subsection (i) and that staff, prior to deactivating a television's closed captioning feature, confirm with others within the television viewing area of the intention to deactivate the closed captioning feature.  If residents are not in agreement on deactivating the closed captioning feature, then the closed captioning feature shall not be deactivated.

 

2)         If a facility does not have a television in a common area that includes a closed captioning feature, then the facility shall ensure that all televisions subsequently obtained for common areas include a closed captioning feature.  This subsection does not affect any other provision of law relating to disability discrimination or providing reasonable accommodations or diminish the rights of a person with a disability under any other law.  Nothing in this subsection shall apply to televisions that are privately owned by a resident or third party and not owned by the facility.  (Section 3-801.2 of the Act)

 

3)         A facility shall post information regarding the availability of closed captioning on televisions in the facility and shall provide residents with information on how to activate the closed caption feature.

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.2420  Equipment and Supplies

 

a)         The facility shall have a supply of thermometers, emesis basins, ice bags, hot water bottles or equivalent, bedpans, urinals, and sets of enema equipment sufficient to meet the needs of its residents.

 

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

 

c)         A sufficient supply of linen and bedding in good condition to provide proper care and comfort to the residents shall be maintained.  The linen supply shall include, but not be limited, to the following:

 

1)         Sheets, four per bed.

 

2)         Pillowcases, three per bed.

 

3)         Bed blankets, two per bed.

 

4)         Bedspreads, two per bed.

 

5)         Washcloths and hand towels, as needed.

 

6)         Bath towels, three per bed.

 

7)         Patient hospital gowns as needed.

 

8)         Pillows, one per bed plus a ten percent reserve.

 

d)         A first-aid kit or emergency box shall be maintained in every facility. The first aid kit or emergency box shall contain bandages, sterile gauze dressings, bandage scissors, tape, sling, burn ointment, and any other equipment deemed necessary by the advisory physician or the medical advisory committee.

 

e)         Activity program supplies shall be provided to maintain an ongoing program to meet the varied interests and needs of the residents.  These supplies shall include, but are not limited to, games, crafts supplies, current magazines, books, radio, television, and a device for playing music, which shall include but is not limited to a record player or CD player.

 

f)         Dishes and kitchen equipment shall be provided as set forth in Sections 330.2000 and 330.2010.

 

g)         Cleaning equipment and supplies shall be provided as set forth in Sections 330.2210 through 330.2220.

 

h)         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. 802, effective December 31, 2024)

 

Section 330.2610  Codes

 

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

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.2620  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 "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. 6562, effective April 17, 1989)

 

Section 330.2630  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 "Private Sewage Disposal Code" (77 Ill. Adm. Code 905).  (B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.2640  Plumbing

 

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

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.2810  Applicable Requirements (Repealed)

 

(Source:  Repealed at 8 Ill. Reg. 24241, effective November 28, 1984)

 

Section 330.2820  Applicability of These Standards

 

a)         This Subpart M shall apply to all new construction. This includes all new buildings; and all additions, and alterations to existing buildings.

 

b)         Alterations that do not bring the building in compliance with the standards in this Subpart M may be approved by the Department in licensed facilities if it can be demonstrated to the satisfaction of the Department that the alterations will provide equivalent facilities, or safety to the residents and will not increase bed capacity.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.2830  Submission of a Program Narrative

 

A written description of the program shall be submitted for review with, or prior to, submission of the preliminary drawings and outline specifications.  Drawings will not be reviewed until this written description is submitted.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.2840  New Constructions, Additions, Conversions, and Alterations

 

a)         When construction is contemplated for new buildings, additions, conversions, or alterations to existing buildings, coming within the scope of these standards, preliminary drawings and outline specifications shall be submitted to the Department for review and approval prior to starting final working drawings and specifications.  Such approval will be based upon compliance with Section 330.2850 of this Subpart.

 

b)         A review of preliminary drawings and outline specifications will be made only after the pre-application information forms have been submitted to the Department.  (See Section 330.120(a).)

 

c)         The final working drawings and specifications for all trades shall be submitted to the Department for review and approval prior to releasing them to bidders.  Such approval will be based upon compliance with Section 330.2850 of this Subpart.

 

d)         The Department shall be notified of the award of contracts.

 

e)         Any contract modifications which affect or change the function, design, or purpose of a facility shall be submitted to the Department for approval prior to authorizing the modifications.  (B)

 

f)         The Department shall be notified when construction has been completed and prior to any area of the building being occupied by residents.  (B)

 

g)         Minor alterations or remodeling changes which do not affect the structural integrity of the building, change functional operation, affect fire safety, add facilities over those for which the facility is licensed and classified, need not be submitted for approval.

 

h)         No system of water supply, sewerage, plumbing, garbage or refuse disposal shall be installed, nor any such existing system materially altered or extended until complete plans and specifications for the installation, alteration, or extension have been submitted to the Department, reviewed and approved.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.2850  Preparation and Submission of Drawings and Specifications

 

a)         The preparation and submission of drawings and specifications shall be executed by or be under the immediate supervision of an architect registered in the State of Illinois, unless this requirement is waived by the Department.

 

b)         All drawings and specifications shall identify clearly the facility as to its name, proposed level of services and location.

 

c)         All drawings and specifications shall contain the architect's name and address.  The first sheet of the drawings and the cover of the specifications shall have his Illinois registration seal and the date.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.2860  First Stage Drawings

 

a)         Development of the preliminary sketch plans shall indicate in detail the assignment of all spaces, including size of areas and rooms, and shall outline the fixed and movable equipment and furniture.

 

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

 

c)         The total floor area shall be computed and shown on the drawings.

 

d)         The drawings shall include:

 

1)         A plan of each floor including the basement or ground floor.

 

2)         Roof plan.

 

3)         Elevations of all facades.

 

4)         A plot plan showing roads, parking areas, sidewalks, existing structures, location of easements, setbacks, utilities, manholes and inverts.

 

5)         Sections through the building.

 

6)         Existing work must be completely shown on submission for additions, conversions or alterations.

 

e)         Outline specifications shall provide a general description of the construction including interior finishes; acoustical material; its extent and type; extent of the floor covering, air conditioning, heating and ventilating systems, and their controls, general description of the electrical service; and the type of elevators.

 

f)         The following information shall be submitted on or with the preliminary drawings and outline specifications:

 

1)         Name of proposed facility.

 

2)         Address of proposed facility.

 

3)         Name of owner.

 

4)         Level of care to be provided.

 

5)         Number of residents by floor, and total number.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.2870  Second Stage Drawings

 

All working drawings shall be well prepared so that clean and distinct prints may be obtained, accurately dimensioned, and include all necessary explanatory notes, schedules, and legends.  Working drawings shall be complete and adequate for contract and construction purposes.  Separate drawings shall be prepared for each of the following sections of work; Architectural, Structural, Mechanical, and Electrical.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.2880  Architectural Drawings

 

The architectural drawings shall include:

 

a)         Site plan showing all new 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 seeded.  All structures and improvements which are to be removed under the construction contract shall be shown.

 

b)         Plan of each floor and roof.

 

c)         Elevations of each facade.

 

d)         Sections through building.

 

e)         Required scale and full size details.

 

f)         Elevator and dumbwaiter details and dimensions, size of car platform, travel, pit and machine room.

 

g)         Kitchen, laundry and clean and soiled utility room shall show location, size and required connections of all fixed and movable equipment.

 

h)         Schedule of doors and finishes.

 

i)          Location of all fixed equipment and major items of movable equipment.  Equipment not in contract shall be so indicated.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.2890  Structural Drawings

 

a)         The structural Drawings shall include:

 

1)         Plans of foundations, floors, roofs, and all intermediate levels shall show a complete design with sizes, sections, and the relative location of the various members.  Schedule of beams, girders, and columns.

 

2)         Floor levels, column centers, and offsets shall be dimensioned.

 

3)         Special openings and pipe sleeves shall be dimensioned or otherwise noted for easy reference.

 

4)         Details of all special connections, assemblies, and expansion joints shall be given.

 

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

 

b)         For special structures, a stress sheet shall be incorporated in the drawings showing:

 

1)         Outline of structure.

 

2)         All load assumptions used.

 

3)         Stresses and bending moments separately for each kind of loading.

 

4)         Maximum stresses and bending moment for which each member is designed.

 

5)         Horizontal and vertical reactions at column bases.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3000  Mechanical Drawings

 

Mechanical drawings shall include:

 

a)         These drawings with specifications shall show the complete heating, steam piping, ventilation and air conditioning systems; plumbing, drainage and stand pipe systems; laundry and kitchen ventilation.

 

b)         Heating, steam piping, air conditioning and ventilation including:

 

1)         Radiators and steam heated equipment, such as sterilizers, warmers, and steam tables.

 

2)         Heating and steam mains and branches with pipe sizes.

 

3)         Diagram of heating and steam risers with pipe sizes.

 

4)         Sizes, types and heating surfaces of boilers; furnace with stokers and oil burners, if any.

 

5)         Pumps, tanks, boiler breeching, piping and boiler room accessories.

 

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

 

7)         Supply and exhaust ventilating systems with necessary duct work and piping.

 

8)         Air quantities for all room supply and exhaust ventilating duct openings.

 

c)         Plumbing, drainage, and stand pipe systems including:

 

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

 

2)         Location and size of soil, waste, and vent stacks with connections to house drains, clean outs, fixtures, and equipment.

 

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

 

4)         Riser diagram to show all plumbing stacks with vents, water risers, and fixture connections.

 

5)         Gas, oxygen, and special connections.

 

6)         Stand pipe and sprinkler systems.

 

7)         Plumbing fixtures and fixtures which require water and drain connections.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3010  Electrical Drawings

 

Electrical drawings shall include:

 

a)         All electrically operated systems and equipment.

 

b)         Electrical service entrance with service switches, service feeders to the public service feeders, and characteristics of the light and power current.  Transformers and their connections shall be shown.

 

c)         Plan and diagram showing main switchboard, power panels, light panels, and equipment.  Feeder and conduit sizes shall be shown with schedule of feeder breakers or switches.

 

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

 

e)         Telephone layout showing service entrance, switchboard, strip boxes, outlets, and branch conduit as approved by the telephone company.  Provide separate room and conduits for racks and automatic switching equipment as required by the telephone company.

 

f)         Fire alarm system with stations, signal systems, detectors, control board, and wiring diagrams.

 

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

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3020  Additions to Existing Structures

 

Procedures and requirements for working drawings and specifications shall be followed as set forth in Sections 330.2880 through 330.3030; and in addition, the following information shall be submitted:

 

a)         Type of activities within the existing building and distribution of existing beds

 

b)         Type of construction of existing building and number of stories.

 

c)         Plans and details showing attachment of new construction to the existing structure and mechanical systems.

 

d)         Exits including details and distances when related to the addition.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3030  Specifications

 

Specifications shall supplement the drawings to fully describe, except where fully indicated and described on the drawings, the materials, workmanship, the kind, sizes, capacities, finishes, and other characteristics of all materials, products, articles, and devices and shall include:

 

a)         Cover or title sheet.

 

b)         Index.

 

c)         Instructions to bidders.

 

d)         Bid form.

 

e)         Form of agreement.

 

f)         General conditions.

 

g)         Special conditions.

 

h)         Performance and payment bond forms.

 

i)          Sections describing materials and workmanship in detail for each class of work.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3040  Building Codes (Repealed)

 

(Source:  Repealed at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.3050  Site

 

Every building shall:

 

a)         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 and hazardous smoke and fumes; not in a deteriorated, unpleasant, or potentially hazardous urban area; and not near uncontrolled sources of insect and rodent breeding.

 

b)         Be located so that the building or buildings can comply with any 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.

 

c)         Comply with all applicable zoning ordinances.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3060  General Building Requirements

 

Every building shall:

 

a)         Be structurally sound, in good repair, and attractive inside and outside.  (B)

 

b)         Have a minimum of one adequately sized elevator in all buildings of two or more stories in height.  Additional elevators as determined by the Department shall be provided based upon the population and condition of the residents.  The basement shall be considered as one story if it is used by residents.  (B)

 

c)         Have stairways with a minimum head room of seven feet, a minimum width of three feet eight inches on required exit stairs, when serving resident areas, and three feet for all others.  If handrails project more than three and one-half inches, the width shall be measured between the handrails.  Have treads of not less than 11 inches, and risers of not more than seven and one-half inches.  Stairways with triangular or winding treads or single risers are not acceptable.  (B)

 

d)         Have sturdy handrails on both sides of each stairway whether inside or outside of the building.  Handrails shall be one and one-half inches in diameter at least and one and one-half inches clear of the wall.  (B)

 

e)         Have a ceiling height of eight feet or more throughout all rooms occupied or used by the residents.  (B)

 

f)         Have main entrance and exit doors swinging outward with a minimum clear width of three feet, eight inches.  Provide panic hardware and door closers.  (B)

 

g)         Have each exterior door equipped with a signal that will alert personnel in the area if a resident leaves the building.  An exterior door that is supervised during certain periods during the day or night 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)

 

h)         Have all doors and windows in good repair so that they fit snugly and are weathertight, yet will open and close easily.

 

i)          Have all outside doors, other than at required exits, and nonstationary windows equipped with tight fitting full length 16 mesh screens. Screen doors shall be equipped with self-closing devices.

 

j)          Have all floors free from cracks and finished so that they can be easily, properly, and efficiently cleaned.  Floors in bathrooms, kitchens, and utility rooms shall be covered wall to wall with inlaid linoleum, terrazzo, ceramic tile, or an equivalent material.  (B)

 

k)         Have all walls and ceilings of sound construction and covered with plaster or an equivalent, free from cracks, holes, or heavily textured surfaces.

 

l)          Be constructed and maintained so as to prevent the entrance and harborage of rats, mice, flies, and other insects.

 

m)        Be provided with sufficient and satisfactory artificial lighting wherever required throughout the building and grounds.

 

n)         All doorways used by residents shall be flush with the floor.

 

o)         Be served by reliable telephone service.  (B)

 

p)         Provide a medicine cabinet and sink with hot and cold running water. (See Section 330.1530(a).)

 

q)         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.

 

r)          Install partitions, screens, shields, or other means to protect residents from thermal hazards such as radiators, hot water or steam pipes, baseboard heaters, therapy equipment, or other surfaces accessible to residents which may exceed a temperature of 140 degrees Fahrenheit.  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.

 

(Source:  Amended at 14 Ill. Reg. 14928, effective October 1, 1990)

 

Section 330.3070  Administration

 

Every building shall:

 

a)         Provide sufficient administrative office space for clerical, financial, and managerial functions.

 

b)         Provide satisfactory space which can be used for privacy in interviewing applicants and for discussion with relatives.

 

c)         Provide satisfactory space or an office for the administrator.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3080  Corridors

 

Every building shall meet the following requirements:

 

a)         All corridors used by residents shall have a minimum unobstructed width of six feet and lighted properly at night and all other times when necessary.  If handrails project more than three and one-half inches, the width shall be measured between handrails.  (B)

 

b)         Corridors used by residents shall be enclosed and have a minimum ceiling height of seven feet eight inches.  (B)

 

c)         Corridors and passages used by residents shall have sturdy handrails one and one-half inches in diameter and be at least one and one-half inches clear of the wall.  (B)

 

d)         Enclosed corridors shall be properly heated.

 

e)         Corridors shall not be used to supply air to or exhaust air from any room, except that exhaust air from corridors may be used to ventilate rooms such as bathrooms, toilet rooms, or janitor's closets which open directly on corridors.

 

f)         For exit corridors, see Section 330.3380.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3090  Bath and Toilet Rooms

 

Every building shall meet the following requirements:

 

a)         Provide a minimum of one water closet, one lavatory, and one bathtub or shower for each sex on each floor occupied by residents.

 

b)         Provide fixtures in the following minimum numbers.  The maximum capacity of resident beds on each floor shall be used in determining the number of fixtures required, irrespective of the fact that some of the beds may not be occupied.

 

c)         One lavatory and one water closet for each ten resident beds on each floor.

 

d)         One bathtub or shower for each 15 resident beds on each floor.

 

e)         All bath and toilet rooms shall be easily accessible, conveniently located, and well lighted.  They shall be ventilated to the outside atmosphere by an exhaust fan with six air changes an hour.  Group bath and toilet facilities shall be partitioned for complete privacy.

 

f)         Resident toilet rooms shall open directly to corridors or into resident bedrooms.  When the toilet rooms open into resident bedrooms, the door must swing into the resident's bedroom.  All doors in the toilet rooms used by residents shall have a minimum door width of three feet.  (B)

 

g)         Bathroom fixtures shall be of substantial construction and designed so that they may be easily and properly cleaned.  All bathtubs, showers, and water closets shall be provided with satisfactory and properly placed handgrips or grab bars.

 

h)         Each bath and toilet room shall be well lighted, have a light switch just inside the door, be provided with a well-lighted mirror for each lavatory. 

 

i)          Provide at least one bathroom or enclosure of not less than eight feet six inches by eight feet six inches with an acceptable system for bathing persons with physical disabilities.  If a shower is installed in lieu 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 approximately four and one-half feet above the floor 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.

 

1)         All other showers shall have a minimum dimension of three feet by three feet and need not have a water inlet as specified above.

 

2)         Shower stalls shall have a low or no curb at the entrance opening.

 

j)          If toilets provided adjacent to residents' bedrooms are not large enough to permit use by wheelchair residents, at least one toilet room or enclosure in the facility five feet by six feet shall be provided.  Provide a lavatory usable by wheelchair residents for this toilet.

 

k)         No toilet or bathroom doors shall be hardwared to allow a resident to become locked in the room.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3100  Living, Dining, Activity Rooms

 

Every building shall have living, dining, and activity rooms which meet the following requirements:

 

a)         Provide at least one comfortably furnished living room and dining room for use of residents.  In multiple story buildings, living rooms will be provided on each floor.  The activity room may be combined with the living or dining room.  Under no circumstances shall this room or rooms be used as a bedroom.

 

b)         The room shall have a combined area of not less than 25 square feet per resident bed.

 

c)         The dining room or area shall have at least ten square feet per resident bed.

 

d)         Room shall be well lighted and ventilated and easily accessible to all residents.

 

e)         Be an outside room.  Additional interior rooms may be used for television, craft, or similar activities.

 

f)         Be so located that the room is not an entrance vestibule from the out-of-doors, nor an obstruction to traffic in and out of the facility.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3110  Bedrooms

 

Every building shall meet the following requirements:

 

a)         Resident bedrooms in all facilities shall be a minimum of ten feet between walls or a wall and any built-in furniture or storage space.  Each such bedroom shall have an entrance directly off a corridor with an entrance door not less than three feet wide that swings into the room.

 

b)         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.

 

c)         Each multiple bedroom used for residents shall have at least 80 square feet of usable floor area for each resident, not including any space taken for closets, wardrobes, bathrooms, and clearly definable entryway areas.  Beds shall be at least three feet apart, and no more than three deep from an outside wall.

 

d)         Maximum capacity of a bedroom shall be four residents.

 

e)         Each bedroom shall be at or above grade level.

 

f)         Each room used as a resident bedroom shall have at least one outside window, and a total window area to the outside equal to at least one-tenth the floor area of the room.  Windows shall open and close easily.

 

g)         Each bedroom shall have adequate and satisfactory artificial light and be equipped with at least three duplex electric convenience outlets.  Electric cords shall not be strung from a ceiling fixture.  There shall be an electric switch near the door to control at least one light in the room.

 

h)         Provide a closet or wardrobe of at least two feet square for each resident.

 

i)          Bedroom doors shall have no hardware that will allow the resident to lock himself in the room.  The door may be keyed on the corridor side to prevent others from entering the room.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3120  Special Care Room

 

Every building shall meet the following requirements:

 

a)         Provide for each 50 beds or less, a single bedroom to isolate a resident who becomes ill enough to require special care.  It shall be located for proper and efficient supervision of the resident.  (B)

 

b)         Provide this room with a toilet, lavatory, and all other necessary facilities to meet the resident's needs.

 

c)         This room shall have at least 100 square feet of usable floor area, not including any space taken up by closets and wardrobes.  It shall be a minimum of ten feet from wall to wall or a wall and any built-in furniture or storage space.

 

d)         The room may be included in the authorized maximum bed capacity for the facility.  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 he 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.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3130  Kitchen

 

Every building shall meet the following requirements:

 

a)         The kitchen shall have an area of at least 200 square feet.

 

b)         Provide a kitchen properly located for efficient food service, and large enough to accommodate the equipment and personnel needed to prepare and serve the number of meals required.  The kitchen area, not including food storage area, shall be approximately ten square feet for each resident bed whether the beds are in the same building or not.  The approximate ten square feet per resident bed may be reduced for facilities with 40 or more beds.  Any deviation must receive prior approval from the Department.  (B)

 

c)         Provide a kitchen with institutional type equipment for convenience in operation, for healthful working conditions, for good sanitation, and for control of heat, noise, and odors.  (B)

 

d)         Equipment shall be in compliance with the adopted Standards, Basic or Special Criteria of the National Sanitation Foundation Testing Laboratory, or equivalent.  (B)

 

e)         Provide appropriate equipment for the preparation and serving of meals, for the refrigeration of perishable foods, and for washing and sanitizing dishes and utensils.  (B)

 

f)         The kitchen shall be provided with at least one handwashing facility separate from food preparation and pan-washing equipment and include hot and cold water, soap, and individual towels.

 

g)         Finish the walls and ceilings of all food handling rooms with washable, light colored surfaces.

 

h)         Effectively screen all openings to the outer air during insect season.  Screen doors to the outside shall open outward and be equipped with self-closing devices or an approved alternate method.

 

i)          Provide an adequate supply of hot and cold running water under pressure to rooms in which food is prepared or dishes washed.

 

j)          Provide satisfactory facilities for washing and sanitizing dishes and cooking utensils.  The kitchen shall be equipped with a three compartment sink for washing pots and pans.  One compartment shall contain no less than 14 inches depth of water at 170 degrees Fahrenheit.  In addition to the sink, a commercial type dishwasher is recommended.  (B)

 

k)         The kitchen shall be so located that it will not be used as a passageway by residents nor nonfood handling staff.

 

l)          The dishwashing area should be so located that soiled dishes will not pass through the food preparation area.  Provide ventilation that will produce negative pressure.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3140  Laundry

 

Every building shall:

 

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

 

b)         Provide satisfactory storage and separate counting rooms for soiled and clean linens.

 

c)         Have the laundry room, storage and counting rooms located in areas not used by residents nor for food storage, preparation or serving, and so that soiled linens are not carried through a food handling area to reach them.

 

d)         Provide proper mechanical ventilation.

 

e)         If a washer and dryer are provided for personal use by residents, they shall be located in an area separate from the laundry.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3150  Housekeeping, Service, and Storage

 

Every building shall:

 

a)         On each floor, provide janitor closets with sink or floor receptor and space for cleaning supplies, linen closets, and general storerooms.

 

b)         Provide sufficient storage space for the personal possessions of residents, staff, and activity materials.

 

c)         Provide sufficient storage for bulk and refrigerated food.  (B)

 

d)         Provide sufficient storage for wheelchairs, walkers, and similar equipment temporarily not being used.

 

e)         Have a medicine storage cabinet or room conveniently located and capable of being locked.  (B)

 

f)         Have no storage space that constitutes a fire or accident hazard.  (A, B)

 

g)         Provide a total area of approximately ten square feet per resident for the storage areas designated in this Section.  This does not include closets or wardrobes in resident's rooms.  About one-fourth of the total area shall be for bulk and daily food storage located in a room convenient to the kitchen.

 

h)         Provide separate clean and soiled linen rooms.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3160  Plumbing

 

a)         Every building shall meet the following plumbing requirements:

 

1)         Comply with the Department's rules entitled "Illinois Plumbing Code" (77 Ill. Adm. Code 890).  (A, B)

 

2)         All plumbing shall be of adequate size and so installed that fixtures receive water under good pressure and are satisfactorily drained.

 

3)         All plumbing fixtures having connections to the building water supply shall be connected or equipped so as to prevent any back flow of contaminated material to the water supply piping.  (A, B)

 

4)         Individual sewer connections shall be such that backflow cannot occur from the building sewer to the fixture.  (A, B)

 

5)         No physical connection shall be permitted between a safe and an unsafe water supply.  (A, B)

 

b)         The following standards shall be used as a guide to determine satisfactory compliance of individual fixtures:

 

1)         Lavatory faucets shall discharge at least one inch above the top rim of the lavatory bowl.  (B)

 

2)         Bathtub, sink, laundry, and tub faucets shall discharge at least two inches above the top rim of the sink.  (B)

 

3)         Flush tank type toilets shall be equipped with approved antisiphon ball cocks, so installed that the effective air openings of the vacuum breaker is at least one inch above the top of the overflow tube in the toilet flush tank.  (B)

 

4)         Flushometer type toilets shall be equipped with approved vacuum breakers, installed on the discharge side of the flush valve, and at least four inches above the top of the toilet bowl.  (B)

 

5)         Dishwashing machines, laundry machines, urinals, and drinking fountains shall be so installed as to provide backflow protection.  (B)

 

6)         All fixtures having, or capable of receiving, a hose shall have a vacuum breaker located at least six inches above the highest head that normally may be placed on the unit.  The height of the antisiphon unit should be sufficient to prevent any pressure on the unit, other than atmospheric pressure, when the control valve is closed.  (B)

 

7)         Potable water shall be protected from cross connections to sewage piping systems, boilers, and other sources of contaminated water.  (B)

 

8)         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.

 

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

 

10)         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,)

 

(Source:  Amended at 14 Ill. Reg. 14928, effective October 1, 1990)

 

Section 330.3170  Heating and Cooling

 

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 330.770(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 330.770(j).

 

(Source:  Amended at 35 Ill. Reg. 3415, effective February 14, 2011)

 

Section 330.3180  Electrical

 

a)         All electric wiring and equipment shall comply with the latest revisions of the National Electric Code.  (A, B)

 

b)         Each facility shall provide sufficient and satisfactory artificial lighting and power to meet all the requirements and demands of the building.

 

c)         Emergency Electrical Service

 

1)         An emergency electrical service, which may be battery operated if effective for four or more hours, shall provide service as follows:  (B)

 

A)        Illumination for means of egress.

 

B)        Illumination of exit signs and exit directional signs.

 

C)        Fire alarm system.

 

D)        Telephone service.

 

2)         The emergency electrical service shall be in accordance with the National Fire Protection Association Codes.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3310  Applicable Requirements (Repealed)

 

(Source:  Repealed at 8 Ill. Reg. 24241, effective November 28, 1984)

 

Section 330.3320  Applicability of These Standards

 

a)         This Subpart N applies to all new construction. This includes all new buildings; and all additions, and alterations to existing buildings.  Building codes cited under Section 330.3040 apply.

 

b)         Institutional occupancy (a), Health Care Facilities, of the Life Safety Code shall apply throughout unless specifically stated otherwise.  (A, B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3330  Fire Protection

 

a)         In addition to this Subpart N, the provisions of  Fire Prevention and Safety (41 Ill. Adm. Code 100), Office of the State Fire Marshal, shall apply.  (A, B)

 

b)         Upon request by the Department, the Division of Fire Prevention of the Office of the State Fire Marshal shall make inspection for fire safety and compliance with these standards.  It shall call to the attention of the Department any violations of these standards which pertain to fire protection.  The Division of Fire Prevention shall be privileged to make as many subsequent visits as deemed necessary for assurance of compliance.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3340  Fire Department Service and Water Supply

 

All buildings shall meet the following requirements:

 

a)         Be located not more than three miles from a satisfactory fire station operated by a paid or volunteer organized fire department.  A greater distance may be allowed if the building is protected by an approved automatic sprinkler system with flow alarm.  (B)

 

b)         Be served by a water supply that will supply a sufficient volume of water to fight a fire, and, if involved, the Division of Fire Prevention of the Office of the State Fire Marshal, and satisfactory and accessible for fire department use.  (B)

 

c)         Have at least one 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 an acceptable equivalent.  Additional hydrants may be required if needed to properly protect the residents from fire hazards.  Evaluation of the above shall involve consideration of deliverable satisfactory water pressure.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3350  General Building Requirements

 

a)         Facilities of only one story in height shall be constructed of fire resistive construction, protected noncombustible construction, protected ordinary construction, protected wood frame construction, heavy timber construction, or unprotected noncombustible construction.  All facilities except those of fire resistive construction or protected noncombustible construction shall be equipped throughout with an automatic extinguishing system.  (A, B)

 

b)         Facilities of more than one story in height shall be constructed of fire resistive construction, except facilities of not more than three stories in height may be constructed of protected noncombustible construction if equipped throughout with an automatic extinguishing system.  (A, B)

 

c)         A story is that portion of a building between the upper surface of any floor and the upper surface of the floor next above, except that the topmost story shall be that portion of a building between the upper surface of the topmost floor and the upper surface of the roof above.

 

d)         A basement is any story or floor level below the main or street floor.  Where, due to grade differences, there are two levels each qualifying as a street floor, a basement is any floor level below the lower of the two street floors.  Basements shall not be counted in determining the height of a building in stories.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3360  Exit Facilities and Subdivision of Floor Areas

 

Every building shall meet the following requirements:

 

a)         An exit shall be a way of departure from the interior of the building to the open air outside at the ground level.  It may comprise vertical and horizontal means of travel such as doorways, corridors, passageways, stairways, and ramps, including all elements necessary for emergency escape from the building.  An exit begins at any doorway or other point of access to an exit from which residents may proceed to the exterior of the building with reasonable safety.

 

b)         At least two exits, remote from each other, shall be provided for each floor or fire section of the building used by residents.  At least one of the exits from each floor or fire section shall be an exit door, stairway, or smokeproof tower.  (A, B)

 

c)         All other exits shall be either of the above type or a horizontal or ramp type.  (B)

 

d)         Travel distance

 

1)         Travel distance between any room door intended as exit access and an exit shall not exceed 100 feet.

 

2)         Travel distance between any point in a room and an exit shall not exceed 150 feet.

 

3)         Travel distance between any point in an institutional sleeping room or suite and an exit access door of that room or suite shall not exceed 50 feet.

 

4)         Minimum travel distances specified in subsections (d)(1) and (d)(2) of this Section may be increased by 50 feet in buildings completely equipped with automatic fire extinguishing systems.  (A, B)

 

e)         Exits shall be arranged so there are no pockets or dead-ends exceeding 30 feet.  (A, B)

 

f)         All main exits shall lead directly to the outside.  Any corridor or passageway a part of the exit route shall be enclosed as required for stairways.  (A, B)

 

g)         Decorative materials applied to walls or ceilings in means of egress and any room shall have a flame spread rating not to exceed 25 except in individual rooms of not over four persons in capacity which may have a rating of not more than 75.  (A, B)

 

h)         Decorative materials applied to wall or ceiling surfaces of corridors more than 48 inches above the floor shall not ignite nor flame when inserted for five minutes in a furnace heated to 1200 degrees Fahrenheit.  (A, B)

 

i)          Floor coverings shall have a smoke developed rating not to exceed 450 as an average of the flaming and nonflaming values as determined by the test procedures outlined in Appendix II NBS Technical Notes 708.  (A, B)

 

j)          Each floor shall be divided into at least two fire sections by a one hour fire rated smokestop partition, located to provide ample space on each side for the total number of residents on the floor.  Additional partitions may be necessary for the safety of the residents.  (A, B)

 

k)         Openings in smokestop partition shall be protected by a pair of approved doors with a fire resistive rating of at least three-fourths of an hour, shall be self-closing, and shall be closed at all times unless they have magnetic hold devices connected to the fire detection or sprinkler system.  The doors shall swing in a direction opposite from the other and shall be three feet eight inches in clear width.  (A, B)

 

l)          Corridor length between smokestop partitions, horizontal exits, or from either to the end of the corridor on any institutional sleeping floor shall not exceed 150 feet.  (A, B)

 

m)        Corridor partition walls shall be continuous from the floor slab to the underside of the floor or roof slab above, through any concealed spaces such as those above the suspended ceilings and through interstitial structural and mechanical spaces.  (A, B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3370  Stairways, Vertical Openings, and Doorways

 

Every building shall meet the following requirements:

 

a)         Stairways shall be enclosed and all openings to them shall be equipped with self-closing doors having a minimum of three feet, eight inches in clear width.  Each door shall swing in the direction of exit travel and be equipped with a view panel of clear wired glass, and shall be incapable of being locked from the inside of the stairwell.  (A, B)

 

b)         All vertical openings or shafts (elevators, dumbwaiters, laundry chutes, and stairways) shall be enclosed with material having not less than a two hour fire resistive rating.  All doors opening into such vertical openings shall be noncombustible with at least a one and one-half hour "B" labeled door.  (A, B)

 

c)         Vertical openings and shafts shall be located in rooms of not less than one hour fire resistive construction.  The doors shall be three-fourths hour rated solid core wood doors or an equivalent.  (A, B)

 

d)         All required exit doors shall swing outward, be equipped with panic hardware, and be free of any obstruction, chain, locking or holding device.  Each exit door and each door in an exit passageway shall be at least three feet, eight inches in clear width.  If the doors have no latching mechanism, panic hardware may not be required.  (A, B)

 

e)         Any hazardous area shall be enclosed with construction having at least a one hour fire resistance rating or be provided with automatic fire protection.  If the hazard is severe it shall have both.  Doors shall be kept closed when not in use.  (A, B)

 

f)         Any door that is part of a fire wall separating sections of a building, or two abutting buildings, shall be appropriate for the fire resistance rating of the separation.  (A, B)

 

g)         Doors to residents' rooms shall be of solid core wood construction of at least one and three-fourths inches thickness or equivalent, and shall be at least three feet wide and swing into the room.  (A, B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3380  Corridors

 

Every building shall meet the following requirements:

 

a)         All corridors required for exit access shall have a minimum unobstructed width of six feet.  They shall be equipped on both sides with sturdy handrails, one and one-half inches clear of the wall.  (A, B)

 

b)         Exit corridors shall be one hour fire resistance rated construction.  (A, B)

 

c)         All wood doors shall be one and three-fourths inch wood, solid core or equivalent.  Glass lights shall be wire glass, limited to 720 square inches in size.  Louvers in doors shall not be permitted.  (A, B)

 

d)         Fixed wired glass vision panels may be placed in corridor walls, provided they do not exceed 1,296 square inches in size having a maximum dimension of four feet, six inches and are installed in approved steel frames.  Fixed wired glass vision panels may be installed in wood doors, provided they do not exceed 720 square inches in size and are installed in approved steel frames.  (A, B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3390  Exit Lights and Directional Signs

 

Every building shall meet the following requirements:

 

a)         Exit and directional signs shall comply with the rules for Fire Prevention and Safety of the Office of the State Fire Marshal (41 Ill. Adm. Code 100).  (B)

 

b)         Every required exit shall have an exit sign readily visible, and additional directional signs shall be located as required to clearly identify the direction of travel to reach the nearest exit.  (B)

 

c)         All signs shall be properly illuminated at all times.  (B)

 

d)         All signs shall be on an emergency electrical system.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3400  Hazardous Areas and Combustible Storage

 

Every building shall meet the following requirements:

 

a)         All installations of fuel oil, gas, or liquefied petroleum gas heating equipment or appliances shall conform with the latest revision of the American Gas Association Standards and the National Fire Protection Association pamphlets.  (A, B)

 

b)         The room in which the heating equipment is located shall be adequately vented to the outside atmosphere to properly support combustion.  Doors shall swing into the room.  (A, B)

 

c)         All exposed heating ducts in the basement and the smoke pipe or breeching shall be located a safe distance from all combustible material.  If they are not a safe distance, the combustible material must be covered properly with a satisfactory fire resistive material.  (A, B)

 

d)         All paints, oils, and flammable materials shall be stored in a fire resistive room in approved metal containers or cabinets or outside the building.  (A, B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3410  Fire Alarm and Detection System

 

a)         There shall be an approved fire detection and alarm system throughout the facility.  (A, B)

 

b)         The fire alarm system shall be manually and automatically operated, electrically supervised, and be equipped with automatic detectors.  Pre-signal systems are not permitted.  (A, B)

 

c)         The system shall automatically transmit the alarm to any available municipal fire department by direct private lines or through an approved central station.  (A, B)

 

d)         The fire alarm system shall be tested at least weekly.  (A, B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3420  Fire Extinguishers, Electric Wiring, and Miscellaneous

 

a)         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.  (A, B)

 

b)         No fuse or circuit breaker shall be used which would permit a circuit to be overloaded.  (A, B)

 

c)         Drop or extension cords shall not be hung or otherwise supported by a metal support.  (A, B)

 

d)         The building shall be in good condition and repair, especially the roof, chimney, and foundation, so that adequate protection is provided against fire hazards.  (A, B)

 

e)         Approved metal containers with proper covers shall be provided for daily storage of rubbish.  (A, B)

 

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

 

g)         Comply with any reasonable additional fire protection measures recommended by the Department over and above the requirements in this Subpart, if conditions in and around the building, including its location, indicate that such additional protection is needed.  (A, B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3430  Use of Fire Extinguishers, Evacuation Plan, and Fire Drills

 

a)         All personnel employed on the premises shall be properly instructed in the use of fire extinguishers.  (B)

 

b)         A written plan of evacuation shall be prepared, posted, and made familiar to all personnel employed on the premises.  (B)

 

c)         There shall be a minimum of six fire drills conducted annually (two on each shift) at irregular intervals.  The local fire authorities should be requested to assist periodically in these drills.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3610  Site

 

Every existing facility shall comply with any applicable local zoning ordinance.  (A, B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3620  General Building Requirements

 

Every existing facility shall:

 

a)         Be structurally sound, in good repair, and attractive inside and out.  (B)

 

b)         Have stairs, whether inside or outside of the building, provided with sturdy handrails.  Stairways over three feet wide shall have handrails on each side.  (B)

 

c)         Be served by reliable telephone service.

 

d)         Be served by reliable electrical service.  The Department may require a standby electric generator on the premises to provide an emergency supply of electricity to maintain essential services when it has evidence that there have been frequent and prolonged interruptions of service that have resulted in a threat to the residents' health and welfare.  (B)

 

e)         Be constructed and maintained so as to prevent the entrance and harborage of rats, mice, flies, and other insects.

 

f)         Have all outside doors, other than required exits, and nonstationary windows equipped with tight-fitting, full-length 16-mesh screens.  Screen doors shall be equipped with self-closing devices.

 

g)         Have each exterior door equipped with a signal that will alert personnel in the area if a resident leaves the building.  Any exterior door that is supervised during certain periods during the day or night 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)

 

h)         Be provided with sufficient and satisfactory artificial lighting wherever required throughout the building and grounds.

 

i)          Have smooth floors which are free from cracks and finished so that they can be easily and properly cleaned.  Floors in bathrooms, kitchens, and utility rooms shall be covered wall to wall with terrazzo, inlaid linoleum, tile or approved equivalent.  (B)

 

j)          Have all walls and ceilings of sound construction, covered with plaster or approved equivalent, in good repair, and free from cracks or holes for easy and proper cleaning.

 

k)         Have all windows in good repair so that they fit snugly, yet will open and close easily.

 

l)          Have safety devices provided across low windows, on open porches, at changes in floor level, and at other danger areas inside or outside the building, when there is a danger present to residents.  (B)

 

m)        Have no other business conducted in the building 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.

 

n)         Have any thresholds for doorways used by residents flush with the floor.

 

o)         Have a ceiling height of eight feet or more throughout all rooms occupied or used by residents.

 

p)         Provide a medicine cabinet. (See Section 330.1520.)

 

q)         Install partitions, screens, shields, or other means to protect residents from thermal hazards such as radiators, hot water or steam pipes, baseboard heaters, therapy equipment, or other surfaces accessible to residents which may exceed a temperature of 140 degrees Fahrenheit.  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.

 

(Source:  Amended at 16 Ill. Reg. 14370, effective September 3, 1992)

 

Section 330.3630  Administration

 

Every existing facility shall provide sufficient administrative office space for clerical, financial, and managerial functions.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3640  Corridors

 

Every existing facility shall have:

 

a)         All corridors and passages used by residents at least three feet wide and properly lighted at night and at other times when necessary.  If handrails project more than three and one-half inches, the width shall be measured between the handrails.  (B)

 

b)         No nonambulatory residents in a bedroom unless it can be reached by passing through a passage or corridor which is at least four feet wide and is properly lighted at night and at other times when necessary.  (B)

 

c)         All corridors and passages used by residents provided with sturdy handrails on each side.  (B)

 

d)         All corridors enclosed from weather and properly heated.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3650  Bath and Toilet Rooms

 

a)         Every existing facility shall be provided with a minimum of one water closet, one lavatory, and one bathtub or shower on each floor occupied by residents.

 

b)         Every existing facility shall have bathroom fixtures provided in the following minimum numbers:

 

1)         One lavatory and one water closet for each ten resident beds on each floor.

 

2)         One bathtub or shower for each 15 resident beds on each floor.  The number of resident beds shall be used in determining the number of bathroom fixtures required, irrespective of the fact that some of the beds may not be occupied, or may be occupied by bedfast residents.

 

c)         Every existing facility shall have no toilet room, other than for employees, open directly into a kitchen, pantry, food preparation or food storage room.

 

d)         Every existing facility shall have bathroom fixtures of substantial construction, in good repair and design, so that they may be satisfactorily cleaned.  All toilets, showers, and bathtubs shall be provided with satisfactory handgrips to assist residents in using them.

 

e)         Every existing facility shall have each toilet and bathroom adequately lighted, have a light switch just inside or outside the door, and be provided with a well-lighted mirror for each lavatory.

 

f)         Every existing facility shall have all bath and toilet rooms conveniently located and ventilated to the outside atmosphere either by a window or an exhaust fan.  No such room shall open directly into a kitchen, dining room, pantry, food preparation or food storage room.  Neither shall it be so located that a resident must pass through any such area to reach it.

 

g)         Every existing facility shall have all toilet and bathrooms with no hardware that will allow a resident to lock himself in the room.  (B)

 

h)         Every existing facility shall have partial partitions or cubical curtains to afford privacy for each toilet and bath fixture when there are more than one of each type fixture in a room.

 

i)          Every existing facility shall have toilet enclosures.

 

j)          Any shower stalls shall be a minimum of three feet wide by three feet deep.  Satisfactory and properly placed handgrips shall be provided in the shower stall.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3660  Living, Dining, and Activity Rooms

 

a)         Every existing facility shall:

 

1)         Provide accessible and satisfactory areas for living, dining, and activities to meet the needs of the residents.  These rooms shall:

 

2)         Be well lighted and ventilated, and easily accessible to all residents.

 

3)         Be an outside room.  Additional interior rooms may be used for television, crafts, or similar activities.

 

4)         Provide adequate floor area to satisfactorily serve the residents in the facility.

 

5)         Be so located that the room is not an entrance vestibule from the out-of-doors, nor an obstruction to traffic in and out of the facility.

 

b)         Every existing facility shall have at least one comfortably furnished living room on each floor.  These living rooms shall, in multiple story buildings, be provided on each floor unless a variance to this requirement is approved in writing by the Department.  Under no circumstances shall the living room be used as a bedroom.  The minimum floor space for a living room shall be 80 square feet.  The dining room shall be sufficient in area to properly and comfortably seat the residents.  The combined living room, dining room, and activity area shall be approximately 15 square feet per resident bed.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3670  Bedrooms

 

a)         Every existing facility shall meet the following requirements for bedrooms:

 

1)         Each single bedroom for a resident shall have at least 60 square feet of floor area not including any space taken up by closets.  Facilities established after January 1, 1958, shall provide 70 square feet for a single room.

 

2)         Each multiple bedroom used for residents shall have at least 60 square feet of floor area, not including any space taken up by closets, for each resident's bed.  There shall be a three foot minimum distance between beds.

 

b)         All bedrooms shall meet the following requirements:

 

1)         No more than four residents shall share a bedroom, regardless of its size.

 

2)         Each bedroom shall be provided with a door and have the furniture in the room so arranged, even if it reduces the bed capacity of the room, so that the bed, bedside stand, and chair for each resident will be reasonably well arranged.  Beds shall not be located near radiators, registers, nor sources of drafts.

 

3)         No room which opens into the kitchen shall be used as a resident bedroom.

 

4)         No rooms shall be used as resident bedrooms which necessitate passing through a kitchen to reach any other part of the facility.

 

5)         Occupancy of bedrooms shall be such that residents of one sex will not pass through a bedroom for the opposite sex to reach any part of the facility.

 

6)         Each bedroom shall have adequate and satisfactory artificial light and be equipped with at least one duplex electric convenience outlet.  Electric cords shall not be strung from a ceiling fixture.  There shall be an electric switch near the door in each bedroom to control at least one light in the room.  (B)

 

7)         Each bedroom shall be an outside room and have window glass area equal to at least ten percent of the usable floor area.  This window area shall provide an amount of light equivalent to that provided by an unobstructed window.

 

8)         Rooms with a floor more than three feet below the adjacent ground level shall not be used for resident bedrooms.

 

9)         Bedroom doors shall have no hardware that will allow the resident to lock himself in the room.  The door may be keyed on the corridor side to prevent others from entering the room.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3680  Special Care Room

 

Every existing facility shall provide a vacant bedroom, or one that can be vacated, for use as a bedroom to temporarily isolate a resident who becomes ill.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3690  Kitchen

 

Every existing facility shall:

 

a)         Provide a kitchen properly located for efficient food service, and large enough to accommodate the equipment and personnel needed to prepare and properly serve the number of meals required, all in accordance with the Department's rules entitled "Food Service Sanitation" (77 Ill. Adm. Code 750).  Adequacy of the kitchen facilities will be determined by the Department if it is sufficient to meet the needs of the residents based on professional evaluation.  (B)

 

b)         Provide a subkitchen with satisfactory facilities for serving meals properly from thermo containers; for storing staple foods and nutrients; and for properly washing and sanitizing dishes if the prepared meals are transported to the facility from a central kitchen in another building.

 

c)         Have the walls and ceilings of all food handling rooms finished with smooth, washable, light colored surfaces.

 

d)         Have all openings to the outer air effectively screened during fly season, and have screen doors either open outward, equipped with self-closing devices, or a satisfactory alternate method.

 

e)         Have adequate artificial light provided on all work surfaces in rooms in which food is prepared and dishes are washed.  Artificial light shall be used except when equivalent natural light is present.

 

f)         Have food servicing rooms adequately ventilated so as to be reasonably free from disagreeable odors and moisture.

 

g)         Have an adequate supply of hot and cold running water under pressure, easily available to rooms in which food is prepared and dishes are washed.

 

h)         Have future installations of equipment of an institutional type in compliance with the adopted standards of the National Sanitation Foundation Testing Laboratory (including basic or special criteria), or equivalent.  (B)

 

i)          Have the kitchen so located that no resident must pass through it to reach the bathroom, his bedroom, the living room, or out-of-doors.

 

(Source:  Amended at 14 Ill. Reg. 14928, effective October 1, 1990)

 

Section 330.3700  Laundry Room

 

Every existing facility shall:

 

a)         Provide a laundry room equipped with adequate facilities for satisfactorily doing all laundering, unless a commercial laundry service is used.

 

b)         Provide satisfactory storage and counting areas for soiled and clean linens.  These may be in the same room if well defined and adequate separation can be provided.  Mechanical ventilation shall provide sufficient air flowing from the clean area to the soiled, with proper exhaust.

 

c)         Not be located in a room used by residents, or for food storage, preparation or serving.  It shall be so located that soiled linens are not carried through a food handling area to reach it.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3710  Housekeeping and Service Rooms and Storage Space

 

Every existing facility shall:

 

a)         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.

 

b)         Provide adequate storage space for excess personal possessions of residents and staff, 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.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3720  Plumbing and Heating

 

a)         Every existing facility shall comply with the Department's rules titled Illinois Plumbing Code.

 

b)         All plumbing installations and fixtures on the premises shall be of such a type and design that danger of contaminated water entering the drinking water piping by backflow or backsiphonage is eliminated.  The following standards shall be used as a guide to determine satisfactory compliance of individual fixtures: 

 

1)         Lavatory faucets shall discharge at least one inch above the top rim of the lavatory bowl;

 

2)         Faucets for bathtubs, sinks, and laundry tubs shall discharge at least two inches above the top rim of the fixture;

 

3)         Flush tank type toilets shall be equipped with approved antisiphon ball cocks, installed so that the effective air opening of the vacuum breaker is at least one inch above the top of the overflow tube in the toilet flush tank;

 

4)         Flushometer type toilets shall be equipped with approved vacuum breakers installed on the discharge side of the flush valve and at least four inches above the top of the toilet bowl;

 

5)         Dishwashing machines, laundry machines, urinals, and drinking fountains shall be installed so as to provide backflow protection;

 

6)         All fixtures having, or capable of receiving, a hose shall have a vacuum breaker located at least six inches above the highest head that normally may be placed on the unit.  The height of the antisiphon unit should be sufficient to prevent any pressure on the unit, other than atmospheric pressure, when the control valve is closed;

 

7)         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;

 

8)         Hot water available to residents at shower, bathing and hand-washing facilities shall not exceed 110 degrees Fahrenheit; and

 

9)         Protective measures, including, 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 ensure that the temperature of hot water available to residents at shower, bathing and hand-washing facilities shall not exceed 110 degrees Fahrenheit.

 

c)         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)

 

1)         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 330.770(j).

 

2)         The facility shall be equipped with a central heating plant and have a radiator, convector, or register in each room used by residents or staff.

 

3)         The mechanical system shall be capable of maintaining a temperature of at least 75 degrees Fahrenheit, pursuant to the requirements of Section 330.770(j) at all times.

 

4)         Alternative types of heating systems, such as ground water source heat pumps, may be accepted, provided that they meet or exceed the minimum requirements of this subsection (c).

 

(Source:  Amended at 35 Ill. Reg. 3415, effective February 14, 2011)

 

Section 330.3730  Electrical

 

Every existing facility shall meet the following electrical requirements:

 

a)         All electrical wiring and equipment shall comply with NFPA 70 effective at the time of approval by this Department of either the architectural plans or the building.

 

b)         All facilities shall provide sufficient and satisfactory artificial lighting and power to meet all the requirements and demands of the building.

 

c)         See Section 330.3960(a) for exit lights and subsections 330.3990 (g), (h) and (i) for emergency lighting.

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.3910  Fire Protection

 

a)         In addition to these standards, the provisions of Fire Prevention and Safety (41 Ill. Adm. Code 100) of the Office of the State Fire Marshal shall apply to all existing facilities.  (A, B)

 

b)         Upon request by the Department, the Office of the State Fire Marshal shall make inspections for fire safety and compliance with these standards.  It shall call to the attention of the Department any violations of these standards which pertain to fire protection.  The Office of the State Fire Marshal shall be privileged to make as many subsequent visits as deemed necessary for assurance of compliance.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3920  Fire Department Service and Water Supply

 

Every existing facility shall:

 

a)         Be served by a paid or voluntary organized fire department.  (A, B)

 

b)         Have an adequate water supply that is satisfactory and accessible for fire department use.  Facilities not served by a satisfactory supply must provide such supply.  (B)

 

c)         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 an acceptable equivalent.  Additional hydrants may be required if needed to properly protect the residents from fire hazards.  (B)

 

d)         Be located within two miles of, and served by, a satisfactory fire department.  (B)

 

e)         Not increase bed capacity if located more than two miles from a satisfactory fire department unless a satisfactory sprinkler system is installed.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3930  Occupancy and Fire Areas

 

Every existing facility shall meet the following requirements:

 

a)         Buildings with "nonfire resistive" type construction shall not house any residents above the second floor.  The third and fourth floors of facilities, including Residential Care (Half-Way) Homes that were in operation in the City of Chicago and subject to the local licensing ordinance for such homes in December 1968 may be approved for alert ambulatory residents if the facility is protected by an approved automatic sprinkler system or approved automatic fire detection and alarm system directly connected to the nearest available fire department in addition to the other usual fire protection measures.  (A, B)

 

b)         A basement shall not be counted as a floor unless the floor above is more than eight feet, six inches above the ground level at any adjacent point of the building.  Service and entrance area ways encompassing not more than 25 percent of the perimeter of the building may be disregarded.

 

c)         Attic and roof spaces, when designed for occupancy or used for storage, shall be considered as an additional story in a building.

 

d)         Any facility which is especially susceptible to rapid spread of fire by reason of combustible construction, unenclosed vertical openings, or other inflammable conditions, shall be protected by an approved automatic fire detection and alarm system with direct connection to the fire department or an approved automatic sprinkler system with a flow alarm.  (A)

 

e)         All sheltered care facilities that are not of fire restrictive or protected noncombustible type construction, shall be protected by an approved automatic sprinkler system with flow alarm.  (A)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3940  Exit Facilities and Subdivision of Floor Areas

 

Every existing facility shall meet the following requirements:

 

a)         Each floor used for the housing of residents shall have at least two approved exits which are well separated and provided in the most accessible locations.  (A, B)

 

b)         All future fire escapes shall be of fire resistive construction.  (B)

 

c)         All corridors and passageways to be used as a means of horizontal exit shall be at least three feet wide.  (B)

 

d)         Wherever an existing or future stairway, balcony landing, platform, slide escape, or runway of a fire escape stairway is located ten feet or less from a window or doorway, such window or door shall be provided with wired glass.  (B)

 

e)         All exits, passageways, and exits through rooms shall be kept free of any item that would obstruct the exit route.  (B)

 

f)         All corridors and passages to be used as a means of horizontal exit, or part of a means of exit, shall not lead through any room or space used for a purpose that may obstruct free passage.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3950  Stairways, Vertical Openings, and Doorways

 

Every existing facility shall meet the following requirements:

 

a)         All stairways shall be enclosed and protected with smokestop partitions and doors at each floor level.  All doors that are a part of this protection shall swing in the direction of the exit from the building, be provided with view panels of clear wired glass, and have door closers.  These doors shall be closed at all times when not in use.  (A, B)

 

b)         All vertical openings or shafts (including elevators, dumbwaiters, laundry chutes, and stairways) shall be completely lined with metal or equivalent fire resistive material.  Openings into shafts shall be protected with self-closing fire resistive doors.  A sprinkler head or detection device is recommended in each shaft.  (A, B)

 

c)         All required exterior exit doors shall swing outward, be equipped with panic hardware, and be free of any obstruction.  No chain locking, or holding device shall be permitted on any door equipped with panic hardware other than the latching mechanism of the panic hardware itself.  If the doors have no latching mechanism, panic hardware may not be required.  (A, B)

 

d)         Interior kitchen doors shall be covered with fire resistive material on the kitchen side with a view panel of clear, wired glass.  All such doors shall swing into the kitchen and shall be kept closed at all times when not in use unless otherwise approved by the Department.  Such approval will be granted only when such variance will not create a hazard to the health, welfare, or safety of residents.  (B)

 

e)         All doors from the basement which lead into the interior of the building shall be self-closing, be covered with fire resistive material on the basement side, and have a view panel of clear wired glass.  These doors shall be closed at all times when not in use.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3960  Exit and Fire Escape Lights and Directional Signs

 

Every existing facility shall meet the following requirements:

 

a)         Standard illuminated exit lights on a separate electric circuit shall be provided at all exits on each floor.  The signs shall bear the word "EXIT" in conspicuous lettering on a contrasting background to comply with local ordinances or practice.  These lights shall be kept lighted at all times.  (A, B)

 

b)         A fire escape sign shall be placed over the inside of each door to the fire escape.  The sign shall bear the words "FIRE ESCAPE" in conspicuous lettering on a contrasting background to comply with local ordinances or practice.  These lights should be lighted at all times.  (A, B)

 

c)         White lights shall be provided on the outside of the building over each door to the fire escape.  These lights shall be kept on a separate circuit and shall be kept lighted at all times unless they are on a timer or solar device.  (A, B)

 

d)         Directional signs of similar construction as above shall be provided throughout the building and its corridors as needed or required to show the direction to exits.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3970  Hazardous Areas and Combustible Storage

 

Every existing facility shall meet the following requirements:

 

a)         A central heating plant (including any coal storage) shall be located in a separate room.  The room, including the ceiling and any doors, shall be constructed of, or satisfactorily protected by, approved fire resistive material providing a fire resistance rating of at least one hour.  All doors to the room shall be protected with asbestos and metal on the furnace room side (or equivalent protection), swing into the room, and be self-closing.  The rooms shall be adequately vented to the outside atmosphere to properly support combustion in the furnace.  (Alternate modern types of heating systems are prohibited unless approved by the Department.)

 

b)         The entire basement ceiling in non-fire resistive buildings shall be protected with one-hour rated materials if it is not practical to provide a separate room for the heating plant.

 

c)         All exposed heating ducts in the basement and the smoke pipe or breeching shall be located a safe distance from all combustible material.  If they are not a safe distance, the combustible material shall be properly covered with a satisfactory resistive material.

 

d)         All installations of fuel oil, gas, or liquefied petroleum gas heating equipment and appliances shall conform to the following NFPA standards:

 

1)         NFPA 31.

 

2)         NFPA 54.

 

3)         NFPA 58.

 

e)         Auxiliary gas or electric space heaters of an approved closed type may be installed in areas requiring more heat than is produced by the central heating system.  Heaters in corridors shall be ceiling hung or wall recessed units.

 

f)         Floor type heaters or furnaces are not permitted.

 

g)         All paints, oils, and flammable materials shall be stored in a fire resistive room in approved metal containers and metal cabinets, or stored outside the building.

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.3980  Fire Alarm and Detection System

 

Existing facility shall meet the following requirements:

 

a)         An approved standard fire detection and alarm system shall be provided.  The rules for Fire Prevention and Safety of the Office of the State Fire Marshal (41 Ill. Adm. Code 100), effective at the time of construction  or acceptance of the building by this Department, shall apply in determining satisfactory compliance with this item.  (A, B)

 

b)         The fire alarm system shall be manually and automatically operated and equipped with detectors.  (A, B)

 

c)         Every facility shall have hazardous areas and rooms protected by an approved automatic detector system.  (A, B)

 

d)         The system shall automatically transmit the alarm to any available municipal fire department by direct private line or through an approved central station.  (A, B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.3990  Fire Extinguishers, Electric Wiring, and Miscellaneous

 

Every existing facility shall meet the following requirements:

 

a)         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.  (A, B)

 

b)         All electrical wiring and equipment shall comply with the latest revisions of the National Electric Code effective at the time of construction or acceptance of the building by this Department.  (A, B)

 

c)         No fuse or circuit breaker shall be used which would permit a circuit to be overloaded.  (A, B)

 

d)         Drop or extension cords shall not be hung or otherwise supported by a metal support.  (A, B)

 

e)         The building shall be in good condition and repair, especially the roof, chimney, and foundation, so that adequate protection is provided against fire hazards.  (A, B)

 

f)         All wood partitions located in the basement shall be protected with fire resistive material.  (A, B)

 

g)         Emergency sources of lighting shall be provided for use in case of electrical power failure.

 

h)         Acceptable methods of providing emergency lighting are:

 

1)         Emergency generator.

 

2)         Two service lines, each from a separate substation.

 

3)         Wet cell batteries in series.

 

4)         Self-charging, wall-mounted light units.

 

i)          Kerosene, gasoline, alcohol, or carbide lamps shall not be permitted on the premises.  (A, B)

 

j)          Approved metal containers with covers shall be provided for daily storage of ashes and rubbish.  (A, B)

 

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

 

l)          The Department reserves the right to require any reasonable additional fire protection measures deemed necessary for the safety of the residents.  Additional fire protection measures shall include, but are not limited to the institution of a fire watch installation of a sprinkler system and installation of smoke detectors.

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.4000  Use of Fire Extinguishers, Evacuation Plan, and Fire Drills

 

a)         All personnel employed on the premises shall be properly instructed in the use of fire extinguishers.  (B)

 

b)         A written plan of evacuation shall be prepared, posted, and made familiar to all personnel employed on the premises.  (B)

 

c)         Fire drills, involving all shifts, shall be conducted at sufficient intervals so that personnel on each shift participate in such a drill at least every six months.  The local fire authorities should be requested to assist periodically in these drills.  (B)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.4210  General

 

a)         No resident shall be deprived of any rights, benefits, or privileges guaranteed by State or federal law based on their status as a resident of a facility. 

 

1)         Residents shall have the right to be treated with courtesy and respect by employees or persons providing medical services or care and shall have their human and civil rights maintained in all aspects of medical care as defined in the State Operations Manual for Long-Term Care Facilities.

 

2)         Residents shall have their basic human needs, including but not limited to water, food, medication, toileting, and personal hygiene, accommodated in a timely manner, as defined by the person and agreed upon by the interdisciplinary team.

 

A)        A facility shall treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of the resident's quality of life, recognizing each resident's individuality.

 

B)        A facility shall protect and promote the rights of the resident.

 

C)        Residents have the right to reside in and receive services in the facility with reasonable accommodation of their needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

 

3)         Residents have the right to maintain their autonomy as much as possible. (Section 2-101 of the Act)

 

b)         A resident shall be permitted to retain and use or wear their personal property in their 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 storage space for the personal property of the resident.  (Section 2-103 of the Act)

 

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 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.  If a resident chooses to perform labor or services, the resident must be compensated at or above the prevailing wage rate.  (Section 2-113 of the Act)

 

1)         The resident has a right to choose or refuse to perform services for the facility and the facility shall not require a resident to perform services for the facility. 

 

2)         The resident may perform services for the facility if he or she chooses when:

 

A)        The facility has documented the resident's need or desire for work in the plan of care;

 

B)        The plan specifies the nature of the services performed and whether the services are voluntary or paid;

 

C)        Compensation for paid services is at or above prevailing rates; and

 

D)        The resident agrees to the work arrangement described it the plan of care.

 

l)          A resident shall be permitted the free exercise of religion. Upon a resident's request, and if necessary at their expense, the 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)         A facility shall immediately notify the resident's next of kin, representative and physician of the resident's death or when the resident's death appears to be imminent.  (Section 2-208 of the Act)

 

o)         The facility shall also immediately notify the resident's family, guardian, representative, conservator and any private or public agency financially responsible for the resident's care whenever unusual circumstances such as accidents, sudden illness, disease, unexplained absences, extraordinary resident charges, billings, or related administrative matters arise.

 

p)         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)

 

(Source:  Amended at 48 Ill. Reg. 7397, effective May 3, 2024)

 

Section 330.4220  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, should indicate any risk factors that may require special management, such as cardiovascular disease, maternal age  more than 35 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 4 weeks for the first 28 weeks of pregnancy, every 2-3 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, urinalysis for albumin and glucose.  Hemoglobin or hematocrit level shall be measured again early in the third trimester. Glucose screening is recommended for women who are 30 years of age or older;

 

I)         Evaluation and monitoring of nutritional status and habits;

 

J)         Education for health promotion and maintenance;

 

K)        Counseling concerning exercise and childbirth education programs;

 

L)        Postpartum review and evaluation 4-8 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, shall be performed 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)

 

j)          Every resident, resident's guardian, or parent if the resident is a minor shall be permitted to inspect and copy all of 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. 3415, effective February 14, 2011)

 

Section 330.4230  Restraints (Repealed)

 

(Source:  Repealed at 22 Ill. Reg. 16594, effective September 18, 1998)

 

Section 330.4240  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 of 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 the 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. 516, effective January 1, 1991)

 

Section 330.4250  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 Section 330.4250(f) of this Section, 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 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.  (Section 2-110(b) of the Act) (B)

 

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. 6562, effective April 17, 1989)

 

Section 330.4260  Resident's Funds

 

a)         A resident shall be permitted to manage his own financial affairs unless he or his guardian or if the resident is a minor, his parent, authorizes the administrator of the facility in writing to manage such resident's financial affairs under subsections (b) through (o) of this Section. (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 at Section 303 of Title III of the Medicare Catastrophic Coverage Act of 1988 (P.L. 100-360), 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 resident's 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 Insurance 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.  Alternatives that meet the requirements of this Section and were in place prior to October 1, 1994, must be submitted to the Department for review and approval within 120 days after October 1, 1994.

 

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 noninterest 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) of this Section, 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 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, his parent, to handle it differently.  (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 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)

 

o)         The facility shall 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.  Where such funds are withdrawn from the resident's personal account by any person other than the resident, the facility shall require such person to whom funds constituting any part of a resident's personal needs allowance are released to execute an affidavit that such funds shall be used exclusively for the benefit of the resident. (Section 2-201(9)(b) of the Act) "Personal needs allowance," for the purposes of this subsection, refers to the monthly allowance allotted by the Illinois Department of Public Aid to public aid recipients.

 

(Source:  Amended at 18 Ill. Reg. 15851, effective October 15, 1994)

 

Section 330.4270  Residents' Advisory Council

 

Each resident shall have the right to participate in a residents' advisory council as indicated in Section 330.740 (a) through (l).

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.4280  Contract With Facility

 

Each resident shall have the right to contract with the facility as indicated in Section 330.730 (a) through (s).

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.4290  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 I of Article II of the Act are violated. (Section 3-602 of the Act)

 

d)         A resident may maintain an action under this 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 these rules, 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 not 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. 6562, effective April 17, 1989)

 

Section 330.4300  Transfer or Discharge

 

a)         A resident may be discharged from a facility after the resident gives the administrator, a physician, or a nurse of the facility written notice of their 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 their guardian or if the resident is a minor, the resident's 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) of this Section.

 

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; or

 

D)        for either late payment or nonpayment for the resident's stay, except as prohibited by Titles 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, a 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) of this Section, 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.  Such payment shall terminate the transfer or discharge proceedings.  This subsection (c) does not apply to those residents whose care is provided under the Illinois Public Aid Code. (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 under Article V of the Illinois Public Aid Code.  (Section 3-401.1(a) of the Act) For the purposes of Section 3-401.1 of the Act, a recipient or applicant shall be considered a resident in the facility during any hospital stay totaling 10 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 10-day period.

 

B)        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 care in the facility without Medical Assistance only if:

 

i)          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 their care in the facility without Medical Assistance;

 

ii)         The resident (unless the resident is 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; and

 

iii)        In circumstances where the Medicare coverage is ending prior to the full 100-day benefit period, the facility provides notice to the resident and to the resident's representative that the resident's Medicare coverage will likely end in 5 days.  This notification shall specify that the resident shall not be required to move under this Section until these 5 days are up.  In cases where the facility is notified in a shorter time frame than 5 days by a managed care organization or the time frame is shorter than 5 days due to inaccurate reporting by an outside entity, the facility shall provide a minimum of 2 days' notification.  (Section 3-401.1 (a-5) of the Act)

 

C)        A facility which violates subsection (c)(2)(A) or (B) of 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)

 

d)         Involuntary transfer or discharge of a resident from a facility shall be preceded by the discussion required under subsection (j) of this Section 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. The State Long Term Care Ombudsman shall be notified at the time of the emergency transfer or discharge; (Section 3-402(a) of the Act)

 

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 and the State Long Term Care Ombudsman shall be notified prior to any such involuntary transfer or discharge.  The Department will immediately offer transfer, or discharge and relocation assistance to residents transferred or discharged under this subsection (d), and the Department may place relocation teams as provided in Section 3-419 of the Act; or (Section 3-402(b) of the Act)

 

3)         When an identified offender is within the provisional admission period defined in Section 1-120.3 of the Act and Section 330.330 of this Part.  If the Identified Offender Report and Recommendation prepared under Section 2-201.6 of the Act shows that the identified offender poses a serious threat or danger to the physical safety of other residents, the facility staff, or facility visitors in the admitting facility, and the facility determines that it is unable to provide a safe environment for the other residents, the facility staff, or facility visitors, the facility shall transfer or discharge the identified offender within 3 days after its receipt of the Identified Offender Report and Recommendation.  (Section 3-402(c) of the Act)

 

e)         For transfer or discharge made under subsection (d), the notice of transfer or discharge shall be made as soon as practicable before the transfer or discharge. The notice required by subsection (d) of this Section 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 or the State Long Term Care Ombudsman at the telephone numbers 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) of this Section and Section 3-403 of the Act 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) of this Section develops in the interim.  (Section 3-404 of the Act)

 

g)         A copy of the notice required by subsection (d) of this Section and Section 3-402 of the Act shall be placed in the resident's clinical record and a copy shall be transmitted to the Department, the State Long Term Care Ombudsman, 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 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, the resident's 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) of this Section 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) of this Section, the resident shall not be required to leave the facility before the 34^th day following receipt of the notice required under subsection (d) of this Section, 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) of this Section 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 Title XIX recipients affected by subsection (c) of this Section.  (Section 3-414 of the Act)

 

q)         The Department will transfer or discharge any resident from any facility required to be licensed under the Act and this Part 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) of this Section, the Department will 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 will offer transfer or discharge and relocation assistance to residents transferred or discharged under subsection (c) through (q) of this Section, 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 will 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 such place.  No resident shall be forced to remain in a temporary or permanent placement.  When 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.  When the Department provides information on available alternative placements in community-based settings for individuals being discharged or transferred from facilities licensed under the Act, the information must include a comprehensive list of a range of appropriate, client-oriented services and the name of and contact information for the ADA coordinator in the relocation locale.  The comprehensive list must include the name and contact information for each agency or organization providing those services and a summary of the services provided by each agency or organization.  A hotline or similar crisis telephone number must also be provided to individuals relocating into the community.  (Section 3-417 of the Act)

 

t)          The Department will 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 will 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 subsection (q) through (t) of this Section the Department will:

 

1)         Provide written notice to the facility prior to the transfer or discharge.  The notice will state the basis for the order of transfer or discharge and will 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) of this Section.  If a facility desires to contest a nonemergency transfer or discharge, prior to transfer or discharge it shall, within four working days after receipt of the notice, send a written request for an informal conference to the Department.  The Department will, within four 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 will affirm, modify or overrule its previous decision.  Except in an emergency, transfer or discharge will 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 will state the reason for which transfer or discharge is ordered and will inform the resident of the resident's right to challenge the transfer or discharge under subsection (x) of this Section.  The Department will 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) of this Section, the Department will notify the facility and any resident to be removed that an emergency has been found to exist and removal has been ordered, and will involve the residents in removal planning if possible.  With the consent of the resident or the resident's representative, the facility must inform the resident's designated care coordination unit, as defined in 89 Ill. Adm. Code 240.260, of the resident's pending discharge and must provide the resident or the resident's representative with the case coordination unit's telephone number and other contact information.  Following emergency removal, the Department will 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) of this Section. (Section 3-421 of the Act)

 

x)         Within ten 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 will hold the hearing within 30 days after receipt of the request.  The hearing will 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 will assist the resident in returning to the facility if assistance is requested. (Section 3-422 of the Act)

 

y)         The administrator of a facility licensed under the Act shall give 60 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 the office of the State Long-Term Care Ombudsman, 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.  If the Department suspends, revokes, or denies renewal of the facility's license, then notice shall be given no later than the date specified by the Department.  Notice shall state the proposed date of closing and the reason for closing.  The facility shall submit a closure plan to the Department for approval which shall address the process for the safe and orderly transfer of residents. The approved plan shall be included in the notice.  The facility shall offer to assist the resident in securing an alternative placement and shall advise the resident on available alternatives.  When 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.  A facility closing in its entirety shall not admit any new residents on or after the date written notice is submitted to the Department under the Act and this Part.  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 will place a relocation team in the facility as provided under subsection (u) of this Section.  (Section 3-423 of the Act)

 

(Source:  Amended at 49 Ill. Reg. 6515, effective April 22, 2025)

 

Section 330.4310  Complaint Procedures

 

a)         A resident shall be permitted to present grievances on behalf of themself or others to the administrator, the Long-Term Care Facility Advisory Board, the residents' advisory council, State governmental agencies or other persons of the resident's choice, free from restraint, interference, coercion, or discrimination and without threat of discharge or reprisal in any form or manner whatsoever.  Every facility licensed under the Act shall have a written internal grievance procedure that, at a minimum:

 

1)         sets forth the process to be followed;

 

2)         specifies time limits, including time limits for facility response;

 

3)         informs residents of their right to have the assistance of an advocate;

 

4)         provides for a timely response within 25 days by an impartial and nonaffiliated third party, including, but not limited to, the Long-Term Care Ombudsman, if the grievance is not otherwise resolved by the facility;

 

5)         requires the facility to follow applicable State and federal requirements for responding to and reporting any grievance alleging potential abuse, neglect, misappropriation of resident property, or exploitation; and

 

6)         requires the facility to keep a copy of all grievances, responses, and outcomes for three years and provide the information to the Department upon request.  (Section 2-112 of the Act)

 

b)         The administrator shall provide all residents or their representatives upon admission and at request with the name, address, and telephone number of the appropriate State governmental office where complaints may be lodged in language the resident can understand, which must include notice of the grievance procedure of the facility or program and addresses and phone numbers for the Office of Health Care Regulation and the Long-Term Care Ombudsman Program. (Section 2-112 of the Act)  Facilities shall:

 

1)         Provide all residents with a list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups including, but not limited to the State Long-Term Care Ombudsman Program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community, and the Medicaid Fraud Control Unit; and

 

2)         Post a statement that the resident may file a complaint with the Department concerning any suspected violation of State or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.

 

3)         Information provided to residents shall be in a format and a language (including Braille) that is clear and understandable to the resident or their representative.

 

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 which indicate that a resident's life or safety is in imminent danger shall be investigated with 24 hours after receipt of the complaint.  All other complaints shall 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 shall be investigated within appropriate time frames 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 330.276 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 after any Department employee enters a facility to begin an on-site inspection 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 may include comments or documentation provided by either the complainant or the licensee pertaining to the complaint.  The Department will also notify the facility of these findings within 10 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; the 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) of this Section.  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) of this Section 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) of this Section.  Upon receipt of the request the Department will conduct a hearing as provided under subsection (k) of this Section.  (Section 3-702(g) of the Act)

 

k)         Any person requesting a hearing to contest a decision rendered in a particular case may have the decision reviewed in accordance with Sections 3-703 through 3-712 of the Act.  (Section 3-703)

 

l)          When the Department finds that a provision of Article II of the Act, Rights and Responsibilities, 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.  (Section 3-305(6) of the Act)

 

(Source:  Amended at 49 Ill. Reg. 802, effective December 31, 2024)

 

Section 330.4320  Confidentiality

 

a)         The Department, the facility and all other public or private agencies 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 rule 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 which identifies a resident.  (B) (Section 2-206(b) of the Act)

 

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)

 

Section 330.4330  Facility Implementation

 

a)         The facility shall establish written policies and procedures to implement the responsibilities and rights provided in Article II of the Act.  The policies shall include the procedure for the investigation and resolution of resident complaints under the Act.  The policies shall be clear and unambiguous and shall be available for inspection by any person. A summary of the policies and procedures, printed in not less than 12 point type, shall be distributed to each resident and representative. (Section 2-210 of the Act)

 

b)         The facility shall provide copies of these policies and procedures upon request to next of kin, sponsoring agencies, representative payees and the public.

 

c)         Each resident and resident's guardian or other person acting for the resident shall be given a written explanation prepared by the Office of the State Long-term Care Ombudsman of all the rights enumerated in Part I of Article II of the Act and in Part 4 of Article III. For residents of facilities participating in Title 18 or 19 of the Social Security Act, the explanation shall include an explanation of residents' rights enumerated in the Act.  The explanation shall be given at the time of admission to a facility or as soon thereafter as the condition of this resident permits, but in no event later than 48 hours after admission, and again at least annually thereafter. At the time of implementation of the Act each resident shall be given a written summary of all the rights enumerated in Part I of Article II of the Act.  If a resident is unable to read such written explanation, it shall be read to the resident in a language the resident understands.  In the case of a minor or a person having a guardian, or other person acting for him, both the resident and the parent, guardian or other person acting for the resident shall be fully informed of these rights. (Section 2-211 of the Act)

 

d)         The resident, resident's representative, guardian, or parent of a minor resident shall acknowledge in writing the receipt from the facility of a copy of all resident rights set forth in Article II of the Act and a copy of all facility policies implementing such rights.

 

e)         The facility shall ensure that its staff is familiar with and observes the rights and responsibilities enumerated in the Act and this Part. (Section 2-212 of the Act) (B)

 

(Source:  Amended at 17 Ill. Reg. 19258, effective October 26, 1993)

 

Section 330.4340  Social Isolation

 

a)         For the purposes of this Section:

 

1)         "Assistive and supportive technology and devices" means computers, video conferencing equipment, distance-based communication technology, or other technological equipment, accessories, or electronic licenses as may be necessary to ensure that residents are able to engage in face-to-face, verbal-based, or auditory-based contact, communication, religious activity, or recreational activity with other facility residents and with family members, friends, loved ones, caregivers, and other external support systems, through electronic means, in accordance with the provisions of the Act and subsections (d)(2) and (3).

 

2)         "Religious and recreational activities" includes any religious, social, or recreational activity that is consistent with a resident's preferences and choosing, regardless of whether the activity is coordinated, offered, provided, or sponsored by facility staff or by an outside activities provider.

 

3)         "Resident's representative" has the same meaning as provided in Section 1-123 of the Act and Section 330.330. 

 

4)         "Social isolation" means a state of isolation wherein a resident of a long-term care facility is unable to engage in social interactions and religious and recreational activities with other facility residents or with family members, friends, loved ones, caregivers and external support systems.

 

5)         "Virtual visitation" means the use of face-to-face, verbal-based, or auditory-based contact through electronic means.  (Section 3-102.3(a) of the Act)

 

b)         Each facility shall adopt and implement written policies that provide for the availability of assistive and supportive technology and devices to facility residents.  Facilities shall ensure that appropriate staff are in place to help prevent the social isolation of facility residents.  (Section 3-102.3(b)(1) of the Act)

 

c)         The virtual visitation policies shall not be interpreted as a substitute for in-person visitation, but shall be wholly in addition to existing in-person visitation policies.  (Section 3-102.3(b)(2) of the Act)

 

d)         The social isolation prevention policies adopted by each long-term care facility pursuant to this Section shall be consistent with rights and privileges guaranteed to residents and constraints provided under Sections 2-108, 2-109, and 2-110 of the Act and this Subpart Q, and shall include the following:

 

1)         Authorization and inclusion of specific protocols and procedures to encourage and enable residents of the facility to engage in in-person contact, communication, religious activity, and recreational activity with other facility residents and with family members, friends, loved ones, caregivers, and other external support systems, except when prohibited, restricted, or limited by federal or State statute, rule, regulation, executive order, or guidance;

 

2)         Authorization and inclusion of specific protocols and procedures to encourage and enable residents to engage in face-to-face, verbal-based, or auditory-based contact, communication, religious activity, and recreational activity with other facility residents and with family members, friends, loved ones, caregivers, and other external support systems through the use of electronic or virtual means and methods, including, but not limited to,  computer technology, the Internet, social media, videoconferencing, videophone, and other innovative technological means or methods, whenever the resident is subject to restrictions that limit his or her ability to engage in in-person contact, communication, religious activity, or recreational activity as authorized by subsection (d)(1) and when the technology requested is not being used by other residents in the event of a limited number of items of technology in a facility;

 

3)         A mechanism for residents of the facility or the residents' representatives to request access to assistive and supportive technology and devices as may be necessary to facilitate the residents' engagement in face-to-face, verbal-based, or auditory-based contact, communication, religious activity, and recreational activity with other residents, family members, friends, and other external support systems, through electronic means, as provided by subsection (d)(2);

 

4)         Specific administrative policies, procedures, and protocols governing: 

 

A)        The acquisition, maintenance, and replacement of assistive and supportive technology and devices;

 

B)        The use of environmental barriers and other controls when the assistive and supportive technology and devices acquired pursuant to subsection (4)(A) are in use, especially in cases where the assistive and supportive technology and devices are likely to become contaminated with bodily substances, are touched frequently, or are difficult to clean; and

 

C)        The regular cleaning of the assistive and supportive technology and devices acquired pursuant to subsection (4)(A) and any environmental barriers or other physical controls used in association therewith; 

 

5)         A requirement that upon admission and at the request of a resident or the resident's representative, appropriate staff shall develop and update an individualized virtual visitation schedule while taking into account the individual's requests and preferences with respect to the residents' participation in social interactions and religious and recreational activities;

 

6)         A requirement that appropriate staff, upon the request of a resident or the resident's family members, guardian, or representative, shall develop an individualized virtual visitation schedule for the resident, which shall:

 

A)        Address the need for a virtual visitation schedule and establish a virtual visitation schedule if deemed to be appropriate;

 

B)        Identify the assessed needs and preferences of the resident and any preferences specified by the resident's representative, unless a preference specified by the resident conflicts with a preference specified by the resident's representative, in which case the resident's preference shall take priority;

 

C)        Document the facility's defined virtual hours of visitation and inform the resident and the resident's representative that virtual visitation pursuant to subsection (d)(2) will adhere to the defined visitation hours;

 

D)        Describe the location within the facility and assistive and supportive technology and devices to be used in virtual visitation; and

 

E)        Describe the respective responsibilities of staff, visitors, and the resident when engaging in virtual visitation pursuant to the individualized visitation plan;

 

7)         A requirement that, upon admission and at the request of the resident or the resident's representative, the facility provides notification to the resident and the resident's representative that they have the right to request of facility staff the creation and review of a resident's individualized virtual visitation schedule;

 

8)         A requirement that, upon admission and at the request of the resident or resident's representative, the facility provide, in writing to the resident or resident's representative, virtual visitation hours, how to schedule a virtual visitation, and how to request assistive and supportive technology and devices;

 

9)         Specific policies, protocols, and procedures governing a resident's requisition, use, and return of assistive and supportive technology and devices maintained pursuant to subsection (4)(A) and require appropriate staff to communicate those policies, protocols, and procedures to residents; and

 

10)        The designation of at least one member of the therapeutic recreation or activities department, or, if the facility does not have this department, the designation of at least one senior staff member, as determined by facility management, to train other appropriate facility employees, including, but not limited to, activities professionals and volunteers, social workers, occupational therapists, and therapy assistants, to provide direct assistance to residents upon request and on an as-needed basis, as necessary to ensure that each resident is able to successfully access and use, for the purposes specified in subsections (d)(2) and (3), the assistive and supportive technology and devices acquired pursuant to subsection (4)(A).  (Section 3-102.3(c) of the Act)

 

e)         A facility may apply to the Department for competitive civil monetary penalty fund grants for assistive and supportive technology and devices and may request other available federal and State funds.  (Section 3-102.3(d) of the Act)

 

f)         In addition to any other applicable penalties provided by law, a facility that fails to comply with the provisions of this Section or properly implement the written policies, protocols, and procedures adopted pursuant to subsection (b) shall be liable to pay an administrative penalty as a Type "C" violation, the amount of which shall be determined in accordance with subsections (f) and (g) of Section 330.282.  (Section 3-102.3(e) of the Act)

 

g)         Implementation of an administrative penalty as a Type "C" violation under this subsection will not be imposed prior to January 1, 2023.  (Section 3-102.3(e) of the Act)

 

h)         This Section does not impact, limit, or constrict a resident's right to or usage of his or her personal property or electronic monitoring under Section 2-115 of the Act.  (Section 3-102.3(g) of the Act)

 

i)          Specific protocols and procedures shall be developed to ensure that the quantity of assistive and supportive technology and devices maintained on-site at the facility remains sufficient, at all times, to meet the assessed social and activity needs and preferences of each facility resident. Residents' family members or caregivers shall be considered, as appropriate, in the assessment and reassessment.  (Section 3-102.3(h) of the Act)

 

j)          No administrative penalty shall be imposed against a facility for internet bandwidth limitations or internet access barriers beyond the control of the facility, such as a natural disaster.

 

k)         Nothing in this Section shall be interpreted to mean that addressing the issues of social isolation shall take precedence over providing for the health and safety of the residents.  (Section 3-102.3(k) of the Act)

 

(Source:  Added at 46 Ill. Reg. 14268, effective July 27, 2022)

 

Section 330.4510  Day Care in Long-Term Care Facilities

 

a)         For a licensed long-term care facility to be approved for a day care program, it is necessary that the facility meet all licensing requirements for its level of care.

 

b)         In addition, the following criteria must also be met.

 

1)         Staff:

Sufficient and satisfactory personnel shall be on duty to provide services that meet the total needs of the day care residents, without detracting from the services given to the residents in the facility in accordance with the various staffing requirements of this Part.

 

2)         Space:

 

A)        Dining – Adequate space and equipment available to accommodate the additional residents in accordance with Subparts I and K and Section 330.2870 and 330.3030 of this Part.

 

B)        Activity Area – Large enough area to accommodate capacity of facility, plus additional "Day Care" residents.

 

C)        Rest Area – A definite area should be designated as an area available for the Day Care resident to nap or rest.  This area should be equipped with beds (roll-aways can be used) or cots and portable screens.  There should also be adequate space available for personal items storage for the number of Day Care residents being cared for.  Suggested areas which can be utilized for the Day Care resident could include:

 

i)          Facilities having more than one communal area (such as a lounge or sunporch) could designate one of these for rest areas;

 

ii)         Non-occupied rooms (no one assigned to these rooms);

 

iii)        Toilets - Adequate number to accommodate extra number of residents in accordance with Sections 330.2860 or 330.3070 of this Part.

 

3)         Records:

 

A)        A statement by a physician who has evaluated the resident within the last 30 days stating the resident is free of communicable and infectious disease, and indicating any medication or treatments and diet needed by the resident during the period of time in the facility.  Permission should also be granted in this statement for the resident to participate in activities with any contraindications or limitations.

 

B)        Medication and Treatment record – Required for any medications or treatments given during resident stay in the facility.  (Medications must be in original containers and properly labeled.)

 

C)        "Face" sheet or admission sheet – Containing all pertinent information necessary for the "safe keeping" of the resident such as complete name; address, telephone number, social security number, medicare number, and age of resident; name, business, and home address, and telephone number of person to notify in an emergency; name of family physician; name of physician to call in an emergency.

 

D)        Incident Report – in case of medication error or accident of any kind.

 

4)         There must be written policies covering "Day Care" Service in the facility which explain implementation of this section.

 

5)         Permission for a Day Care Program requires identifying the services of the facility that will be used in the program.  Examples:  Activity area, dining area, administering of medications by nursing staff, physical therapy, speech, and social services

 

6)         The maximum number of "Day Care" residents served shall be reported with the application under Section 330.160 of this Part.

 

7)         The facility should consider the following in developing and providing "Day Care Programs":

 

A)        Use of house or advisory physician for emergencies;

 

B)        Insurance coverage;

 

C)        Signed agreement with family or responsible individual;

 

D)        Permission to be involved in activities outside of the facility (in the community);

 

E)        Attendance record; and

 

F)         Facility should be aware of method and time of pick-up and delivery of the Day Care residents.

 

(Source:  Amended at 16 Ill. Reg. 14370, effective September 3, 1992)

 

Section 330.APPENDIX A  Interpretation, Components, and Illustrative Services for Sheltered Care Facilities (Repealed)

 

(Source:  Repealed at 23 Ill. Reg. 8064, effective July 15, 1999)

 

Section 330.APPENDIX B  Classification of Distinct Part of a Facility For Different Levels of Service (Repealed)

 

(Source:  Repealed at 16 Ill. Reg. 14370, effective September 3, 1992)

Section 330.APPENDIX C   Forms for Day Care in Long-Term Care Facilities

 

 

SAMPLE

APPLICATION FOR DAY CARE

FORM A

NAME

AGE

BIRTH DATE

ADDRESS

PHONE

SOCIAL SECURITY NUMBER

MEDICARE NUMBER

WITH WHOM DO YOU LIVE?

RELATIONSHIP?

PERSON TO CONTACT IN AN EMERGENCY

ADDRESS

PHONE

BUSINESS PHONE

PHYSICAL LIMITATIONS (please list)

1.

2.

3.

4.

SPECIAL PHYSICAL NEEDS  (medications during day, special rest periods, etc. please list)

1.

4.

2.

5.

3.

6.

MEDICAL PROBLEMS (circle)

1.

diabetic

8.

hearing

2.

subject to seizures

9.

eyesight

3.

heart disease

10.

assistance with meals

4.

dizziness

11.

any paralysis

5.

urinary control problem

12.

difficulty in walking

6.

bowel control problem

13.

periodic confusion

7.

special diet

14.

allergies (list)

15.

others

ARE YOU PRESENTLY UNDER A DOCTOR'S CARE?

NAME AND ADDRESS OF PHYSICIANS

SPECIAL INTEREST OR HOBBIES

DAYS ENTERED IN PROGRAMMING

A.M.

P.M

Monday

Tuesday

Wednesday

Thursday

Friday

DOYOU HAVE TRANSPORTATION?

 

(Source added at 9 Ill. Reg. 11049, effective July 1, 1985)

 

 

FORM B

SAMPLE

PHYSICIAN PERMISSION FORM

has applied for admittance to the day care program at

.  Please supply the following information and also give written

permission for

to participate in the activity program.

Physical Limitations

Degree of activity

Can day care resident be involved in activities outside of the facility

(in the community)?

Has

been evaluated within the last 30 days

and found to be free of communicable and infectious disease?

Medications and/or treatments and diet needed by day care resident during

the period of time spent in the facility.

Can day care resident take own medication?

Allergies

Date:

Signature of Physician:

 

(Source:  Added at 9 Ill. Reg. 10974, effective July 1, 1985)

 

Section 330.APPENDIX D  Criteria for Activity Directors Who Need Only Minimal Consultation (Repealed)

 

(Source:  Repealed at 24 Ill. Reg. 17304, effective November 1, 2000)

Section 330.APPENDIX E   Guidelines for the Use of Various Drugs

 

A.        Long-Acting Benzodiazepine Drugs

Long-acting benzodiazepine drugs should not be used in residents unless an attempt with a shorter-acting drug (i.e., those listed under B. Benzodiazepine or Other Anxiolytic/Sedative Drugs, and under C. Drugs Used for Sleep Induction) has failed.

 

After an attempt with a shorter-acting benzodiazepine drug has failed, a long-acting benzodiazepine drug should be used only if:

 

1.         Evidence exists that other possible reasons for the resident's distress have been considered and ruled out;

 

2.         Its use results in maintenance or improvement in the resident's functional status;

 

3.         Daily use is less than four continuous months unless an attempt at a gradual dose reduction is unsuccessful; and

 

4.         Its use is less than, or equal to, the following listed total daily doses unless higher doses (as evidenced by the resident's response and/or the resident's clinical record) are necessary for the maintenance or improvement in the resident's functional status.

 

EXAMPLES OF LONG-ACTING BENZODIAZEPINES (not maximum doses)

 

Generic	Brand	Daily Oral Dosage
Flurazepam	(Dalmane)	15mg
Chlordiazepoxide	(Librium)	20mg
Clorazepate	(Tranxene)	15mg
Diazepam	(Valium)	5mg
Clonazepam	(Klonopin)	1.5mg
Quazepam	(Doral)	7.5mg
Halazepam	(Paxipam)	40mg

 

NOTES:

When diazepam is used for neuromuscular syndromes (e.g., cerebral palsy, tardive dyskinesia or seizure disorders), this Guideline does not apply.

 

When long-acting benzodiazepine drugs are being used to withdraw residents from short-acting benzodiazepine drugs, this Guideline does not apply.

 

When clonazepam is used in bi-polar disorders, management of tardive dyskinesia, nocturnal myoclonus or seizure disorders, this Guideline does not apply.

 

The daily doses listed under Long-Acting Benzodiazepines are doses (usually administered in divided doses) for "geriatric" or "elderly" residents.  The facility is encouraged to initiate therapy with lower doses and when necessary only gradually increase doses.  The facility may exceed these doses if it provides evidence to show why it was necessary for the maintenance or improvement in the resident's functional status.

 

For drugs in this category, a gradual dose reduction should be attempted at least twice within one year before one can conclude that the gradual dose reduction is "clinically contraindicated."

 

B.        Benzodiazepine or other Anxiolytic/Sedative Drugs

Use of the listed Anxiolytic/Sedative drugs for purposes other than sleep induction should only occur if:

 

1.         Evidence exists that other possible reasons for the resident's distress have been considered and ruled out;

 

2.         Use results in a maintenance or improvement in the resident's functional status;

 

3.         Daily use (at any dose) is less than four continuous months unless an attempt at a gradual dose reduction is unsuccessful;

 

4.         Use is for one of the following indications as defined by the Diagnostic and Statistical Manual of Mental Disorders; Fourth Edition (DSM-IV):

 

Generalized anxiety disorder;

 

Organic mental syndromes (now called dementia, delirium and amnestic and other "cognitive disorders" by DSM-IV) with associated agitated states which are quantitatively and objectively documented, which are persistent and not due to preventable reasons and which constitute sources of distress or dysfunction to the resident or represent a danger to the resident or others;

 

Panic disorder;

 

Symptomatic anxiety that occurs in residents with another diagnosed psychiatric disorder (e.g., depression, adjustment disorder); and

 

5.         Use is equal to or less than the following listed total daily doses, unless higher doses (as evidenced by the resident's response and/or the resident's clinical record) are necessary for the improvement or maintenance in the resident's functional status.

 

EXAMPLES OF SHORT-ACTING BENZODIAZEPINES (not maximum doses)

 

Generic	Brand	Daily Oral Dosage
Lorazepam	(Ativan)	2mg
Oxazepam	(Serax)	30mg
Alprazolam	(Xanax)	0.75mg

 

EXAMPLES OF OTHER ANXIOLYTIC AND SEDATIVE DRUGS

 

Generic	Brand	Daily Oral Dosage
Diphenhydramine	(Benadryl)	50mg
Hydroxyzine	(Atarax, Vistaril)	50mg
Chloral Hydrate	(Many Brands)	750mg

 

NOTES:

This documentation is often referred to as "behavioral monitoring charts" and is necessary to assist in:  (a) assessing whether the resident's behavioral symptom is in need of some form of intervention, (b) determining whether the behavioral symptom is transitory or permanent, (c) relating the behavioral symptom to other events in the resident's life in order to learn about potential causes (e.g., death in the family, not adhering to the resident's customary daily routine), (d) ruling out environmental causes such as excessive heat, noise, overcrowding, etc., (e) ruling out medical causes such as pain, constipation, fever, infection.

 

The daily doses listed under Short-Acting Benzodiazepines are doses (usually administered in divided doses) for "geriatric" or "elderly" residents.  The facility is encouraged to initiate therapy with lower doses and when necessary only gradually increase doses.  The facility may exceed these doses if it provides evidence to show why it was necessary for the maintenance or improvement in the resident's functional status.

 

For drugs in this category, a gradual dose reduction should be attempted at least twice within one year before one can conclude that a gradual dose reduction is "clinically contraindicated."

 

Diphenhydramine, hydroxyzine and chloral hydrate are not necessarily drugs of choice for treatment of anxiety disorders.  They are only listed here in the event of their potential use.

 

C.        Drugs Used for Sleep Induction

 

Drugs used for sleep induction should only be used if:

 

1.         Evidence exists that other possible reasons for insomnia (e.g., depression, pain, noise, light, caffeine) have been ruled out;

 

2.         The use of a drug to induce sleep results in the maintenance or improvement of the resident's functional status;

 

3.         Daily use of the drug is less than ten continuous days unless an attempt at a gradual dose reduction is unsuccessful;

 

4.         The dose of the drug is equal to or less than the following listed doses unless higher doses (as evidenced by the resident's response and/or the resident's clinical record) are necessary for maintenance or improvement in the resident's functional status.

 

EXAMPLES OF HYPNOTIC DRUGS (not maximum doses)

 

Generic	Brand	Oral Dosage
Temazepam	(Restoril)	7.5mg
Triazolam	(Halcion)	0.125mg
Lorazepam	(Ativan)	1mg
Oxazepam	(Serax)	15mg
Alprazolam	(Xanax)	0.25mg
Estazolam	(ProSom)	0.5mg
Diphenhydramine	(Benadryl)	25mg
Hydroxyzine	(Atarax, Vistaril)	50mg
Chloral Hydrate	(Many Brands)	500mg
Zolipiden	(Ambien)	5mg

 

NOTES:

Diminished sleep in the elderly is not necessarily pathological.

 

The doses listed are doses for "geriatric" or "elderly" residents.  The facility is encouraged to initiate therapy with lower doses and when necessary only gradually increase doses.  The facility may exceed these doses if it provides evidence to show why it was necessary for the maintenance or improvement in the resident's functional status.

 

Diphenhydramine, hydroxyzine, and chloral hydrate are not necessarily drugs of choice for sleep disorders.  They are listed here only in the event of their potential use.

 

For drugs in this category, a gradual dose reduction should be attempted at least three times within six months before one can conclude that a gradual dose reduction is "clinically contraindicated."

 

D.        Miscellaneous Hypnotic/Sedative/Anxiolytic Drugs

The initiation of the following hypnotic/sedative/anxiolytic drugs should not occur in any dose for any resident.  (See Notes for exceptions.)  Residents currently using these drugs or residents admitted to the facility while using these drugs should receive gradual dose reductions as part of a plan to eliminate or modify the symptoms for which they are prescribed.  A gradual dose reduction should be attempted at least twice within one year before one can conclude that the gradual dose reduction is clinically contraindicated.  Newly admitted residents using these drugs may have a period of adjustment before a gradual dose reduction is attempted.

 

(Caution:  The rapid withdrawal of these drugs might result in severe physiological withdrawal symptoms.)

 

EXAMPLES OF BARBITURATES
Generic	Brand
Amobarbital	(Amytal)
Amobarbital-Secobarbital	(Tuinal)
Butabarbital	(Butisol, others)
Pentobarbital	(Nembutal)
Secobarbital	(Seconal)
Phenobarbital	(Many Brands)
Barbiturates with	(e.g., Fiorinal)
other drugs

 

EXAMPLES OF MISCELLANEOUS HYPNOTIC/SEDATIVE/ANXIOLYTICS
Generic	Brand
Ethchlorvynol	(Placidyl)
Glutethimide	(Doriden)
Meprobamate	(Equinal, Miltown)
Methprylon	(Noludar)
Paraldehyde	(Many Brands)

 

NOTES:

Any sedative drug is excepted from this Guideline when used as a single dose sedative for dental or medical procedures.

 

Phenobarbital is excepted from this Guideline when used in the treatment of seizure disorders.

 

When Miscellaneous Hypnotic/Sedative/Anxiolytic Drugs are used outside these Guidelines, they may be unnecessary drugs as a result of inadequate indications for use.

 

E.         Antipsychotic Drugs

The following examples of antipsychotic drugs should not be used in excess of the listed doses for residents with organic mental syndromes (now called dementia, delirium, and amnestic and other "cognitive disorders" by DSM-IV) unless higher doses (as evidenced by the resident's response or the resident's clinical record) are necessary to maintain or improve the resident's functional status.

 

EXAMPLES OF ANTIPSYCHOTIC DRUGS FOR RESIDENTS WITH ORGANIC MENTAL SYNDROMES (not maximum dose)
Generic	Brand	Daily Oral Dosage
Chlorpromazine	(Thorazine)	75mg
Promazine	(Sparine)	150mg
Triflupromazine	(Vesprin)	20mg
Thioridazine	(Mellaril)	75mg
Mesoridazine	(Serentil)	25mg
Acetophenazine	(Tindal)	20mg
Perphenazine	(Trilafon)	8mg
Fluphenazine	(Prolixin, Permitil)	4mg
Trifluoperazine	(Stelazine)	8mg
Chlorprothixene	(Taractan)	75mg
Thiothixene	(Navane)	7mg
Haloperidol	(Haldol)	4mg
Molindone	(Moban)	10mg
Loxapine	(Loxitane)	10mg
Clozapine	(Clozaril)	50mg
Prochlorperazine	(Compazine)	10mg
Risperidone	(Resperdal)	4mg

 

NOTES:

The doses listed are daily doses (usually administered in divided doses) for residents with organic mental syndromes (now called dementia, delirium, and amnestic and other "cognitive disorders" by DSM-IV).  The facility is encouraged to initiate therapy with lower doses and when necessary only gradually increase doses.  The facility may exceed these doses if it provides evidence to show why it is necessary for the maintenance or improvement in the resident's functional status.

 

The "specific conditions" for use of antipsychotic drugs are listed under this Guideline G.

 

The dose of prochlorperazine may be exceeded for short term (seven day) treatment of nausea and vomiting.  Residents with nausea and vomiting secondary to cancer or cancer chemotherapy can also be treated with higher doses for longer periods of time.

 

When antipsychotic drugs are used outside these Guidelines, they may be deemed unnecessary drugs as a result of excessive doses.

 

F.         Monitoring for Antipsychotic Drug Side Effects

The facility assures that residents who are undergoing antipsychotic drug therapy receive adequate monitoring for significant side effects of such therapy with emphasis on the following:

 

1.         Tardive dyskinesia;

 

2.         Postural (orthostatic) hypotension;

 

3.         Cognitive/behavior impairment;

 

4.         Akathisia; and

 

5.         Parkinsonism.

 

When antipsychotic drugs are used without monitoring for these side effects, they may be unnecessary drugs because of inadequate monitoring.

 

G.        Use of Antipsychotic Drugs

Antipsychotic drugs should not be used unless the clinical record documents that the resident has one or more of the following "specific conditions":

 

1.         Schizophrenia;

 

2.         Schizo-affective disorder;

 

3.         Delusional disorder;

 

4.         Psychotic mood disorders (including mania and depression with psychotic features);

 

5.         Acute psychotic episodes;

 

6.         Brief reactive psychosis;

 

7.         Schizophreniform disorder;

 

8.         Atypical psychosis;

 

9.         Tourette's disorder;

 

10.         Huntington's disease;

 

11.         Organic mental syndromes (now called dementia, delirium, and amnestic and other "cognitive disorders" by DSM-IV) with associated psychotic and/or agitated behaviors:

 

Which have been quantitatively (number of episodes) and objectively (e.g., biting, kicking, scratching) documented.  This documentation is necessary to assist in: (a) assessing whether the resident's behavioral symptom is in need of some form of intervention, (b) determining whether the behavioral symptom is transitory or permanent, (c) relating the behavioral symptom to other events in the resident's life in order to learn about potential causes (e.g., death in the family, not adhering to the resident's customary daily routine), (d) ruling out environmental causes such as excessive heat, noise, overcrowding, (e) ruling out medical causes such as pain, constipation, fever, infection;

 

Which are persistent;

 

Which are not caused by preventable reasons; and

 

Which are causing the resident to:

 

Present a danger to her/himself or to others,

 

Continuously cry, scream, yell, or pace if these specific behaviors cause an impairment in functional capacity, or

 

Experience psychotic symptoms (hallucinations, paranoia, delusions) not exhibited as dangerous behaviors or as crying, screaming, yelling, or pacing but which cause the resident distress or impairment in functional capacity; or

 

12.          Short term (seven days) symptomatic treatment of hiccups, nausea, vomiting or pruritus.  Residents with nausea and vomiting secondary to cancer or cancer chemotherapy can be treated for longer periods of time.

 

Antipsychotics should not be used if one or more of the following is/are the only indication:

 

1.         Wandering,

 

2.         Poor self care,

 

3.         Restlessness,

 

4.         Impaired memory,

 

5.         Anxiety,

 

6.         Depression (without psychotic features),

 

7.         Insomnia,

 

8.         Unsociability,

 

9.         Indifference to surroundings,

 

10.         Fidgeting,

 

11.         Nervousness,

 

12.         Uncooperativeness, or

 

13.         Agitated behaviors which do not represent danger to the resident or others.

 

H.        Antipsychotic Drug Gradual Dose Reduction

Residents must, unless clinically contraindicated, have gradual dose reductions of the antipsychotic drug.  The gradual dose reduction should be under close supervision.  If the gradual dose reduction is causing an adverse effect on the resident and the gradual dose reduction is discontinued, documentation of this decision and the reasons for it should be included in the clinical record. Gradual dose reductions consist of tapering the resident's daily dose to determine if the resident's symptoms can be controlled by a lower dose or to determine if the dose can be eliminated altogether.

 

"Behavioral interventions" means modification of the resident's behavior or the resident's environment, including staff approaches to care, to the largest degree possible to accommodate the resident's behavioral symptoms.

 

"Clinically contraindicated" means that a resident need not undergo a "gradual dose reduction" or "behavioral intervention" if the resident has a "specific condition" (as listed in these Guidelines under G, 1-11) and has a history of recurrence of psychotic symptoms (e.g., delusions, hallucinations) which have been stabilized with a maintenance dose of an antipsychotic drug without incurring significant side effects (e.g., tardive dyskinesia).  In residents with organic mental syndromes (now called dementia, delirium, and amnestic and other "cognitive disorders" by DSM-IV), "clinically contraindicated" means that a gradual dose reduction has been attempted twice in one year and that attempt resulted in the return of symptoms for which the drug was prescribed to a degree that a cessation in the gradual dose reduction, or a return to previous dose levels, was necessary.  The resident's physician provides a justification why the continued use of the drug and the dose of the drug is clinically appropriate. This justification should include:  (a) a diagnosis, but not simply a diagnostic label or code, but the description of symptoms, (b) a discussion of the differential psychiatric and medical diagnosis (e.g., why the resident's behavioral symptom is thought to be a result of a dementia with associated psychosis and/or agitated behaviors, and not the result of an unrecognized painful medical condition or a psychosocial or environmental stressor), (c) a description of the justification for the choice of a particular treatment, or treatments, and (d) a discussion of why the present dose is necessary to manage the symptoms of the resident.  This information need not necessarily be in the physician's progress notes, but must be a part of the resident's clinical record.

 

I.          Antidepressant Drugs

The facility is not required to use behavioral monitoring charts when antidepressant drugs are used.  "Behavioral monitoring charts" include such records as quantitative evidence (number of episodes) and objective evidence (e.g., withdrawn behavior such as the resident staying in his/her room, refusal to speak, etc.) of patient behavior necessitating the use of the antidepressant drug.  The following is a list of commonly used antidepressant drugs:

 

EXAMPLES OF ANTIDEPRESSANT DRUGS
Generic	Brand
Amitriptyline	(Elavil)
Amoxapine	(Asendin)
Desipramine	(Norpramin, Pertofrane)
Doxepin	(Sinequan)
Imipramine	(Tofranil)
Maprotiline	(Ludiomil)
Nortriptyline	(Aventyl, Panelor)
Protriptyline	(Vivactil)
Trimipramine	(Surmontil)
Fluoxetine	(Prozac)
Sertaline	(Zoloft)
Trazodone	(Desyrel)
Clomipramine	(Anafranil)
Paroxetine	(Paxil)
Bupropion	(Wellbutrin)
Isocarboxazid	(Marplan)
Phenelzine	(Nardil)
Tranylcypromine	(Parnate)
Venlafaxine	(Effexor)
Nefazadone	(Serzone)
Fluvoxamine	(Luvox)

 

J.          Exceptions to These Guidelines

The facility shall have the opportunity to provide a rationale for the use of drugs prescribed outside these Guidelines.  The facility may not justify the use of a drug prescribed outside these Guidelines solely on the basis of "the doctor ordered it."  The rationale must be based on sound risk-benefit analysis of the resident's symptoms and potential adverse effects of the drug.

 

The unnecessary drug criterion of "adequate indications for use" does not simply mean that the physician's order must include a reason for using the drug (although such order writing is encouraged).  It means that the resident lacks a valid clinical reason for use of the drug as evidenced by the evaluation of some, but not necessarily all, of the following:  resident assessment, plan of care, reports of significant change, progress notes, laboratory reports, professional consults, drug orders, observation and interview of the resident, and other information.

 

In determining whether an antipsychotic drug is without a "specific condition" or that "gradual dose reduction and behavioral interventions" have not been performed, the facility shall justify why using the drug outside these Guidelines is in the best interest of the resident.

 

Examples of evidence that would support a justification of why a drug is being used outside these Guidelines but in the best interests of the resident may include, but are not limited to:

 

1.         A physician's note indicating, for example, that the dosage, duration, indication, and monitoring are clinically appropriate, and the reasons why they are clinically appropriate; this note should demonstrate that the physician has carefully considered the risk/benefit to the resident in using drugs outside these Guidelines;

 

2.         A medical or psychiatric consultation or evaluation (e.g., Geriatric Depression Scale) that confirms the physician's judgment that use of a drug outside these Guidelines is in the best interest of the resident;

 

3.         Physician, nursing, or other health professional documentation indicating that the resident is being monitored for adverse consequences or complications of the drug therapy;

 

4.         Documentation confirming that previous attempts at dosage reduction have been unsuccessful;

 

5.         Documentation (such as MDS documentation) showing resident's subjective or objective improvement, or maintenance of function while taking the medication;

 

6.         Documentation showing that a resident's decline or deterioration is evaluated by the interdisciplinary team to determine whether a particular drug, or a particular dose, or duration of therapy, may be the cause;

 

7.         Documentation showing why the resident's age, weight, or other factors would require a unique drug dose or drug duration, indication, monitoring; and

 

8.         Other evidence which may be appropriate.

 

(Source:  Added at 20 Ill. Reg. 12160, effective September 10, 1996)