Section 50.80  Written Responses


a)         For any case in which OIG substantiates abuse or neglect or makes one or more recommendations, the community agency or facility shall submit a written response on a prescribed form to the respective DHS program division office.


1)         The written response shall address the actions that it will take or has taken to protect individuals from abuse or neglect, prevent recurrence and eliminate problems.  Each substantiated finding or recommendation shall be addressed separately.


2)         All written responses shall include the following information:


A)        Investigative findings and/or recommendations by OIG;


B)        Specific actions for each finding or recommendation, identifying the persons the actions address, if any;


C)        Persons responsible for implementing each action;


D)        For each action, the actual or anticipated completion date;


E)        Signature of the Authorized Representative or, if the Authorized Representative is named in the investigation, the President of the Board of Directors.


3)         The written response shall be submitted to the respective Department Program Division within 30 calendar days after receiving the investigative report. 


4)         If a reconsideration request is received by OIG, the written response is due within 15 calendar days after the following:


A)        The date the community agency or facility is notified that the reconsideration is denied;


B)        The date the community agency or facility receives a revised cover letter based on a granted reconsideration indicating the finding remains substantiated, or there are recommendations.


5)         If a reconsideration request is granted and the revised cover letter indicates the finding is unsubstantiated or unfounded and there are no recommendations, a written response is no longer required.


b)         Division Responsibilities


1)         The respective DHS program division shall promptly review the submitted written response and may require the community agency or facility to plan or take additional administrative actions in response to the findings and/or recommendations.


2)         When the division agrees with the written response, the division's director, or designee, shall approve the written response by signing and dating the form.  The actions listed on the written response do not need to be completed for the division to approve it.


3)         To ensure timely implementation of identified actions, the division shall promptly do the following:


A)        Notify the community agency, facility and OIG of the approval; and


B)        Send to OIG the approved written response and any documentation received that confirms implementation of the designated actions.


c)          Implementation Status Reports


1)         Community Agency or Facility


A)        If the actions listed in the written response have not been completed by the time the division notifies the community agency or facility that the written response is approved, the Authorized Representative shall send OIG an implementation status report within 30 days of the date the written response was approved.


B)        The implementation status report shall detail the status of each administrative action taken or planned, including the actual or anticipated completion date.


C)        An updated implementation status report must be sent to OIG every 60 days thereafter until all administrative actions have been completed.


D)        Upon completion of actions for which at least one implementation status report was submitted, the community agency or facility shall promptly do the following:


i)          Notify OIG in writing of the completion date and the names of any persons who were the subject of the action; and


ii)         Submit to OIG documentation confirming implementation of each of those actions.


2)         OIG may review approved written responses and notify any community agency or facility when an implementation status report is overdue. Failure of the community agency or facility to comply with implementation status reports is a violation of the statute.


d)        Compliance Reviews


1)         OIG shall conduct a review of the following:


A)        Any written response in which an action takes more than 120 days after approval to complete; and


B)        A random sample of written responses approved by the division. The sample shall be chosen at least quarterly, shall be at least 10% of all written responses approved during that time period, and shall be proportionate by community agency and facility cases among the approved written responses.


2)         OIG shall determine compliance with the completed action as approved, which may include, but not be limited to, written and verbal requests for documentation, phone contacts or site visits.


3)         Community agencies and facilities shall fully cooperate with OIG during these compliance reviews, including providing access as defined in Section 50.10.  Cooperation with compliance reviews additionally includes the following:


A)        Arranging for interviews as requested and providing copies of any personnel action taken as a result of the findings or recommendations; and


B)        Responding promptly to OIG requests for documentation and related information.


(Source:  Amended at 41 Ill. Reg. 6516, effective May 26, 2017)