Current through Register Vol. 48, No. 12, March 22, 2024
To provide the highest possible quality of humane and
rehabilitative care and treatment for all recipients in the care of the
Department and to promote public health and safety, all recipients in
Department facilities shall receive comprehensive physical and dental
examinations.
a) Physical examination
1) Each person admitted to the Department in
accordance with the Code [405 ILCS 5 ] shall have a thorough physical
examination on admission and annually thereafter (see Section 1-119(2) of the
Code). Persons with mental illness shall be examined within 24 hours in
accordance with the Mental Health Standards (Joint Commission on Accreditation
of Healthcare Organizations (JCAHO), One Renaissance Boulevard, Oakbrook
Terrace, Illinois 60681, 1995) or the Accreditation Manual for Hospitals (Joint
Commission on Accreditation of Healthcare Organizations (JCAHO), One
Renaissance Boulevard, Oakbrook Terrace, Illinois 60681, 1996). In accordance
with 77 Ill. Adm. Code 350 (Intermediate Care for the Developmentally Disabled
Facilities Code) (ICFDD), persons with developmental disabilities shall be
examined within 72 hours. This requirement may be waived in the judgment of the
admitting physician only if such an examination was done within three days
prior to admission and the results are received by the facility and are entered
into the recipient's clinical record.
A) The
examination shall include an evaluation of the recipient's condition, including
height, weight, blood pressure and vital signs, diagnoses, plan of medical
treatment, recommendations for care, including personal care needs, treatment
orders, permission for participation in activity programs, as appropriate, and
any other examinations that are required by the accrediting agencies cited in
subsection (a)(1) of this Section, as well as the Standards for Services for
People with Developmental Disabilities (Accreditation Council for Services for
People with Developmental Disabilities (Council) 8100 Professional Place, Suite
204, Landover, Maryland 20785, 1990). The examination shall also include a
visual check of the oral cavity, including lips, teeth, gums and tongue.
Referral to a dental hygienist or dentist shall be completed if clinically
indicated. Plans of medical treatment, recommendations for care and treatment
orders shall be recorded in the recipient's individualized services plan as
defined in Sections 3-209 and 4-309 of the Code.
B) The presence or absence of communicable or
infectious diseases shall be noted by the examining physician with
recommendations given for curing or controlling the disease, as applicable.
Communicable or infectious diseases shall be reported in accordance with
Department of Public Health rules:
i) 77 Ill.
Adm. Code 690 (Control of Communicable Diseases Code);
ii) 77 Ill. Adm. Code 693 (Control of
Sexually Transmissible Diseases Code); and
iii) 77 Ill. Adm. Code 697 (AIDS
Confidentiality and Testing Code).
2) An electrocardiogram (EKG) shall be
provided within three days after admission, excluding Saturdays, Sundays, and
holidays, for any recipient age 40 or over, except that an admission EKG need
not be repeated on readmission if one was provided within the previous 12
months during a prior admission, unless otherwise clinically indicated by the
examining physician.
3) A
Papanicolaou (Pap) smear uterine cytologic examination for cancer shall be
offered to all female recipients admitted or readmitted to a Department
facility who are 20 years of age and over, or under 20 years of age if sexually
active, unless the examining physician considers the examination
contraindicated, the examination has been performed within the previous year
and the results were normal, or the examination is refused by the recipient on
the counsel of the examining physician or on her own judgment. Results of tests
performed outside the facility shall be obtained and entered into the
recipient's clinical record. A Pap smear uterine cytologic examination shall be
offered and recommended annually. The examining physician shall document in the
recipient's clinical record the results of the Pap smear, whether or not the
test was contraindicated, or that the recipient refused the
examination.
4) In the event that
the recipient's psychiatric, behavioral, or medical condition is such that the
physical examination as described in subsection (a)(1)(A) of this Section
cannot be completed within the times stated in subsection (a)(1) of this
Section, the examining physician may extend the time frame until the
recipient's condition has improved to allow the completion of the examination.
Every 72 hours the examining physician shall record in the recipient's clinical
record the condition preventing a complete physical examination and the
continuation of the recipient's condition until the physical examination has
been completed. If the recipient's physical examination is delayed in excess of
30 days, such delay shall require notice from the examining physician to the
facility director, and a special conference of the treatment team to identify a
course of action designed to protect the recipient from inappropriate treatment
based on inadequate information.
b) Dental examination
1) Persons with developmental disabilities
shall have a comprehensive diagnostic dental examination, including extra- and
intra-oral examinations within 30 calendar days after admission, unless the
admitting physician waives this requirement. The admitting physician shall
record the reason for the waiver in the recipient's clinical record.
A) The examination report shall include an
evaluation of the recipient's dental condition, diagnoses, plan of treatment,
recommendations for oral health care and dental hygiene, and treatment
orders.
B) The physician may extend
the time for conduct of the dental examination; however, the physician must
record the reason for the extension in the recipient's clinical record. If the
recipient's dental examination is delayed in excess of 30 days, such delay
shall require notice from the examining physician to the facility director, and
a special conference of the treatment team to identify a course of action
designed to protect the recipient from inappropriate treatment based on
inadequate information.
2) Persons with mental illness shall have a
comprehensive diagnostic dental examination, including extra- and intra-oral
examinations, within six months after admission. If the recipient's condition
is such that a dental examination is necessary less than six months after
admission, a referral to a dentist or dental hygienist shall be made.
c) Schedule for examinations and
treatment plan
1) Physical examinations shall
be repeated annually. In accordance with Section 7 of the Mental Health and
Developmental Disabilities Administrative Act [20 ILCS
1705/7 ], dental examinations shall be repeated every
18 months for recipients with mental illness while residing in Department
facilities. In accordance with the Standards for Services for People with
Developmental Disabilities (Accreditation Council for Services for People with
Developmental Disabilities, 8100 Professional Place, Suite 204, Landover,
Maryland 20785, 1990,) dental examinations shall be repeated annually for
recipients with developmental disabilities while residing in Department
facilities. These examinations shall be performed by a licensed dentist or a
registered hygienist and shall be independent of periodic reviews such as the
use of medications, blood levels of drugs and gingivitis checks.
2) If a recipient has been in the facility or
is transferred from another facility, the receiving facility shall perform
comprehensive diagnostic examinations if the individualized services plan does
not provide a treatment plan for medical and dental services for the
recipient.
3) On completion of the
comprehensive diagnostic examinations, a treatment plan for any medical and
dental services shall be established as part of the recipient's individualized
services plan.
A) Such a plan will include
procedures to address the special dental care needs of recipients who receive
medication known to promote tooth decay or gum disease.
B) Such a plan will include a procedure to
address the prevention and treatment of tardive dyskenesia.
d) Informed consent
Informed consent is defined as permission for a procedure
freely granted by a person or persons authorized by law to give consent to
services and treatment plans, i.e., the recipient, guardian (if the recipient
is under guardianship) or parent (if the recipient is under age 18). Informed
consent is based on the full disclosure to the authorized person of the
information required to make the decision intelligently, including a
description of the procedure, the possible benefits and the risks and the
alternative(s) to the procedure.
1)
For the purposes of this Section, the person(s) authorized to give consent
shall be informed of the treatment plan for medical and dental services, and
shall be provided with the information necessary to give informed consent. The
documented agreement to the individualized services plan will obviate the need
for specific agreement to the treatment plan for medical and dental
services.
2) The person(s)
authorized to give consent shall be informed of the method whereby he or she
can exercise the right to refuse medical and dental services.
3) For services listed below, the person(s)
authorized to give consent shall be informed that if an objection is not
received prior to performance of services, consent shall be implied for the
treatment plan:
A) Dental - preventive
procedures (such as prophylaxis, topical fluoride, periodontal scaling, and
gingival curettage,) and restorative procedures (such as, fillings and local
anesthesia).
B) Medical -
non-psychotropic medication, endoscopy not involving anesthesia, exercise
regimens and sutures.
4)
A written consent, signed by the person authorized to give consent, shall be
required for all other procedures, including general anesthesia, surgery (both
medical and dental) and radiation therapy. The written consent shall be
specific to the procedure or course of therapy to be used and shall only apply
to a particular procedure performed at a particular time or to a course of
therapy of which the procedure is a part. An additional consent shall be
obtained for each subsequent procedure. A consent authorizing a specific
Department staff person to perform a procedure is specific to that staff
person.
5) If consent is denied by
the person authorized to consent, medical or dental procedures shall not be
provided except pursuant to subsection (d)(6) of this Section. Such refusal
shall be documented in the recipient's clinical record.
6) In accordance with Section 2-111 of the
Code, when a medical or dental emergency exists, if the physician or licensed
dentist who examines the recipient determines that the recipient is not capable
of giving informed consent, essential medical or dental procedures may be
provided without consent. No physician nor licensed dentist shall be liable for
a non-negligent good faith determination that a medical or dental emergency
exists. The nature of the emergency shall be documented in the recipient's
clinical record and notice shall be given to the recipient, the legal guardian
or parent(s).
e)
Communicating examination findings
Significant or negative examination findings obtained from the
recipient's physical examination results of laboratory tests as they become
known shall be communicated to the recipient or, if the recipient is under
guardianship, to the recipient's guardian, or, if the recipient is a minor to
the recipient's parent or guardian. The fact that such findings were
communicated to the recipient, parent or guardian shall be documented in the
recipient's clinical record.