Illinois Administrative Code
Title 59 - MENTAL HEALTH
Part 115 - STANDARDS AND LICENSURE REQUIREMENTS FOR COMMUNITY-INTEGRATED LIVING ARRANGEMENTS
Subpart C - GENERAL AGENCY REQUIREMENTS
Section 115.320 - Administrative Requirements

Universal Citation: 59 IL Admin Code § 115.320

Current through Register Vol. 48, No. 52, December 27, 2024

a) Governing body

1) Each CILA provider which is owned or operated by any corporation, association, or unit of local government shall have a governing body in which is vested authority and responsibility for the organization, management, control, and operation of the CILA agency and all programs, services, facilities, and residences it administers.

2) Each CILA provider shall have provisions for obtaining input from individuals served, guardians and/or individual's representatives to the governing body.

b) Staffing

1) Mental health and developmental disabilities employees shall be licensed or certified as required by Illinois laws.

2) When paraprofessional, non-professional contractual workers or volunteers are used in direct services, they shall be supervised in the provision of services by professional employees.

3) A CILA provider shall not employ an individual (including contractual workers, volunteers, or practitioners who have the responsibility of caring for individuals) in any capacity, until the CILA provider has conducted the following registry checks concerning the potential employee, contractor/subcontractor, volunteer, or practitioner:
A) Department of Public Health (DPH) Health Care Worker Registry

B) Department of Children and Family Services (DCFS) State Central Register/Child Abuse and Neglect Tracking System (CANTS)

C) Illinois Sex Offender Registry

D) Illinois Department of Healthcare and Family Services (HFS) Sanctions List (maintained at the HFS Office of Inspector General website, https://www.illinois.gov/hfs/oig/Pages/SanctionsList.aspx)

4) A CILA provider shall not employ an individual (including contractual workers, volunteers, or practitioners who have the responsibility of caring for individuals) in any capacity until the CILA provider has inquired of and received the results from the applicable registry or list concerning the potential employee, contractor/subcontractor, volunteer, or practitioner. Inquiries shall not occur more than 30 calendar days prior to the first day of employment.

5) If the DPH, DCFS, or Illinois Sex Offender registries contain information concerning the potential employee, contractor/subcontractor, volunteer, or practitioner that indicates a finding of physical or sexual abuse or egregious neglect, a substantiated case of child abuse or neglect, a sex offense, or a disqualifying criminal conviction from which there is no waiver, the CILA provider shall not employ that person in any capacity. If the HFS Sanctions List indicates that the potential employee, contractor/subcontractor, volunteer, or practitioner has been terminated, suspended, barred, or otherwise excluded from the Illinois Medical Assistance Program, the CILA provider shall confirm that person or entity's status with the HFS OIG.

6) CILA providers shall make annual inquiries to the DPH, DCFS, and Illinois Sex Offender registries and the HFS Sanctions List concerning each current employee, volunteer, contractual worker, subcontractor, or licensed practitioner. If the annual check discloses that the individual or entity's name has been placed on the registry or list, that individual or entity must be terminated. The CILA provider must establish a schedule that results in completion of checks every full year (365 calendar days), which can be accomplished by:
A) Repeating the check on the anniversary of the employee's, contractor's/subcontractor's, volunteer's, or practitioner's hiring;

B) Repeating the check when the employee's, contractor's/subcontractor's, volunteer's, or practitioner's annual performance evaluation is due; or

C) Creating a specific schedule of checks to ensure timely completion.

7) The CILA provider must comply with the Health Care Worker Background Check Act [225 ILCS 46 ]. A CILA provider shall not knowingly hire or retain any person outside of the provisions of the Health Care Worker Background Check Act.

8) A person listed on the Health Care Worker Registry may request a waiver of the prohibition against employment by completing an application on a form prescribed by DPH in accordance with the Health Care Worker Background Check Act.

9) A waiver of an indication on the CANTS Register may be requested by completing an application per the guidelines issued and published by the Department.

c) General program requirements

CILA agencies funded by the Department shall meet the following general program requirements for all funded services:

1) Recordkeeping

Cumulative case records including a Personal Plan and Implementation Strategy shall be maintained for each individual.

2) Behavior management and human rights review
A) Each CILA agency is required to have a Human Rights Committee that will establish or ensure a process for the periodic review of human rights issues involved in the individual's services and supports. A program which uses behavioral interventions as specified in Section 115.214 for managing maladaptive behavior shall also establish a Behavior Management Committee. Each Committee must have at least five members. Members shall not be shared between committees with the exception of a physician, advanced practice registered nurse, registered professional nurse, or nurse practitioner/physician assistant.

B) The Human Rights Committee shall:
i) Review at least annually the CILA provider policies, procedures and practices which have the potential to restrict the rights of individuals;

ii) Review at least every six months practices which restrict a specific individual's rights;

iii) Inform the CILA agency of any complaints involving an individual's rights, deficiencies, and any corrective actions;

iv) Ensure that individuals, guardians, and natural supports as desired by the individual are included in the meetings in which their services and supports are discussed. The Committee shall also ensure that individuals are assisted to have meaningful interactions and are accommodated as necessary during the meetings; and

v) Maintain minutes, including attendance, and a record of decisions made per individual including justification of decisions and intended outcomes. When the committee approves restrictive interventions, the minutes must include the next review date.

C) The Human Rights Committee shall include:
i) At least 5 members.

ii) At least one person receiving services from the agency and/or the individual's family member or guardian.

iii) At least one-third of the members cannot be former employees of the CILA provider, individuals receiving services or guardians of individuals formerly served by the CILA provider, a vendor providing products or services to the CILA provider, or employees from other CILA providers or DD programs.

D) A Behavior Management Committee shall:
i) Approve behavior interventions prior to their implementation and review those interventions at least every six months;

ii) Review all behavior strategies at least annually and determine if a rights restriction exists. Plans that are found to have a rights restriction must also be reviewed by the CILA agency's Human Rights Committee;

iii) Maintain minutes, including attendance and a record of decisions made; and

iv) Seek input from individuals, guardians, and natural supports as desired by the individual whose services and supports are discussed. The Committee shall also ensure that individuals are assisted to have meaningful input and are accommodated as necessary.

E) A Behavior Management Committee shall be comprised in the following manner:
i) Members shall include persons qualified to evaluate the appropriateness of the proposed behavior management interventions.

ii) When drugs to manage behavior are used, a licensed professional qualified to evaluate their use shall be a member of the committee.

iii) At least one member shall be from outside the CILA agency.

3) Abuse, neglect, and exploitation
A) Each CILA agency shall have and use a process for reporting and handling instances of abuse, neglect, and exploitation in accordance with applicable standards, regulations and laws that shall include notification of the individual allegedly abused, neglected, or exploited and their guardian or parent of the allegation within 24 hours after receiving the allegation.

B) In addition to abuse, neglect, and exploitation, each CILA agency shall have and use a process for reporting and handling complaints regarding individual rights. The CILA agency shall share a copy of the Rights of Individuals form [IL 462-1201] with the individual and/or guardian when an individual enters the CILA program (see Section 115.250(a)).

4) Admission requirements
A) CILA agencies shall not discriminate in the admission to and provision of needed services to individuals on the basis of race, color, sex, religion (creed), gender identity, gender expression, age, national origin (ancestry), ethnicity, disability, marital status, sexual orientation or military status in any of their activities or operations.

B) Admission policies and procedures shall be set forth in writing and be available for review.

5) Compliance with life safety standards and requirements

All program facilities shall be in compliance with applicable State licensure requirements and local ordinances with regard to fire, building, zoning, sanitation, health, and safety requirements.

6) Visits to programs

The CILA agency shall ensure that Department-authorized individual protection and advocacy interest groups shall be permitted, with the consent of the individual or guardian, to visit provider-owned or controlled living arrangements.

7) Remote Monitoring and Supports

CILA agencies may provide remote monitoring and support services in community-integrated living arrangements pursuant to 305 ILCS 5/12-21.21, as determined by DDD. Remote monitoring and supports (i.e., video, web-cameras, or other interactive technology) may be provided to increase independence and daily living skills of an individual and address an individual's needs and outcomes identified in their personal plan. Remote supports and services must be based on an assessment which shall, at a minimum, identify risks important in considering whether remote monitoring and supports are appropriate for the individual.

d) Training

1) Direct service professionals and any other persons (paraprofessional, contractual workers, or volunteers) with responsibility for direct care of individuals served shall demonstrate competence in training areas listed in subsections (d)(1)(A) through (M) as a part of an orientation program. Anyone specified in this subsection (d)(1) without previous experience in direct service to individuals shall receive training and demonstrate competence prior to unsupervised responsibility for direct service unless trained employees are on site and available for on-the-job training. Direct service professionals and other persons as specified above who have completed training in the below mentioned areas, and demonstrated competence as documented in their personnel records, shall not be required to repeat that training as part of their orientation. Anyone specified in this subsection (d)(1) who has not demonstrated competence shall receive training until the person can demonstrate competence in the following areas, as recorded in their records. All direct service employees and any other compensated persons, regardless of staffing model, shall receive training and demonstrate competence as documented in employee records in the following training areas:
A) Cardiopulmonary resuscitation (CPR), back blows/abdominal thrusts, and first aid;

B) Concepts of habilitation and rehabilitation including behavior intervention and management, age appropriateness and psycho-social rehabilitation depending on the needs of the individuals served or to be served;

C) Safety and disaster procedures; public health emergencies; and fire procedures and the use of fire equipment such as a fire extinguisher;

D) Abuse, neglect, exploitation, coercion and critical incident prevention, handling and reporting to the DHS OIG (pursuant to 59 Ill. Adm. Code 50);

E) Individual rights in accordance with Section 115.250 and maintaining confidentiality in accordance with the Mental Health and Developmental Disabilities Confidentiality Act [740 ILCS 100 ];

F) The purpose and content of the Personal Plan pursuant to 42 CFR 441.301(c)(2);

G) Development and implementation of an Implementation Strategy;

H) The type, dosage, characteristics, effects, and side effects of medications prescribed for individuals. The CILA agency shall ensure that there is sufficient training in this area to provide coverage during expected and unexpected absences of caregivers by others who have been determined competent;

I) Observation, using the AIMS (Abnormal Involuntary Movement Skills), of involuntary muscular movement, which may be indicative of tardive dyskinesia;

J) Documentation and recordkeeping requirements with reference to the Personal Plan and Implementation Strategy;

K) Other training which relates specifically to the type of disability or treatment and intervention techniques being used specific to individuals living in CILAs, geared toward assisting employees to execute outcomes stated in the Personal Plans and Implementation Strategies;

L) The techniques associated with monitoring and regulating hot water temperatures prior to and during an individual's use to ensure safe hand-washing, hair-washing, bathing, and showering procedures. Water temperatures should be between 100 and 110 degrees to ensure safety; and

M) In CILA programs for individuals with developmental disabilities, all unlicensed, direct care employees, prior to assuming responsibility for supervising the self-administration of medication training programs or for administration of medications for persons with developmental disabilities, shall meet criteria set forth in 59 Ill. Adm. Code 116.40(c) including, but not limited to, successful completion of a Department approved training program provided by a CILA agency Nurse-Trainer. Authorized direct care staff shall be re-evaluated by a Nurse-Trainer at least annually or more frequently at the discretion of the registered professional nurse. Any retraining shall be to the extent that is necessary to ensure competency of the authorized direct care staff to administer medication (see 59 Ill. Adm. Code 116.40).

2) After completion of training specified in subsection (d)(1), each direct service employee shall participate in ongoing employee development activities as outlined in the CILA agency's employee development plan.

3) All training shall be documented and shall be readily available for review by BALC and DDD.

4) The CILA agency shall implement a written training plan which lists training to be offered to meet the requirements of this Part, the methods used for completion of any required training, and the process used to determine competency.

e) Volunteer training

The CILA agency shall provide an orientation and training program for volunteers specific to volunteer duties and shall provide supervision as necessary. Volunteers with responsibility for care of individuals served must complete and demonstrate competency in the training areas specified in subsection (d).

f) Quality assurance

1) There shall be a written quality assurance plan and ongoing activities designed to review and evaluate services to individuals and operation of programs and to resolve identified problems.

2) The CILA agency's quality assurance program shall be the basis for determining under its license that individuals are receiving appropriate community-based services consistent with their Personal Plans and Implementation Strategies and, that all programs and services are supervised by the CILA agency and comply with this Part.
A) If a certified CILA does not continue to meet standards, the CILA agency shall correct deficiencies within 30 days.

B) If deficiencies in a certified CILA cannot be corrected within 30 days, the CILA agency shall withdraw certification of the CILA program in question and notify the Department. The CILA agency shall remain responsible for those individuals who live in or lived in the affected CILA until the individuals have transitioned to other settings.

g) Critical incidents

1) The CILA agency shall have written policies and procedures for handling, investigating, reporting, tracking, and analyzing critical incidents through the CILA agency's management structure, up to and including the authorized CILA agency representative. The CILA agency shall ensure that employees demonstrate their knowledge of, and follow, such policies and procedures.

2) Within 24 hours of occurrence the CILA agency shall report any incident which is subject to the Criminal Code of 2012 [720 ILCS 5 ] to the local law enforcement agencies.

3) The CILA agency shall ensure that suspected instances of abuse, neglect or exploitation against individuals in programs which are licensed by the Department are reported to the Office of Inspector General (Section 1.17 of the Department of Human Services Act [20 ILCS 1305/1-17(k)(1)] ) within four hours of discovery.

4) Incidents other than those required to be reported to the Office of Inspector General shall be electronically reported to the Department's Division of Developmental Disabilities through its Critical Incident Reporting and Analysis System (CIRAS) (http://www.dhs.state.il.us/page.aspx?item=97101). Incidents to be reported are specified in Section 115.120 under Critical Incidents.

h) Individuals' records

1) The CILA agency shall ensure the confidentiality of individuals' records in accordance with the Act and shall ensure safekeeping of all records against loss or destruction.

2) The CILA agency shall maintain a chronological record for each individual. Records shall be accessible at the program site at which individuals are being served.
A) Each entry shall be legible, dated and authenticated by the signature and title of the person making the entry.

B) Corrections shall be initialed and made in such a way as to leave the original incorrect entry legible.

C) When symbols or abbreviations are used, the CILA agency shall provide a legend to explain them which shall be standardized throughout the CILA agency.

3) On an individual's entry into the CILA agency, the following information shall be obtained, recorded, and updated as necessary in the individual's record:
A) Identifying information including name, date of birth, sex, race, a copy of state ID, Medicaid number, birth certificate, when available, current photograph (if the individual consents to having their picture taken), social security number (this may be stored separately from the record if necessary to protect against identity theft), and legal status;

B) If applicable, the court appointed guardianship order;

C) The name, address and telephone number of the legal guardian or the person to be notified in case of an emergency;

D) The language spoken or understood by the individual including, in the case of an individual who is deaf or hard of hearing, the individual's preferred mode of communication, e.g., American sign language, signed English, aural, oral, or tactile communications device;

E) Prescribed medications, reactions and side effects to medications, allergies to foods, other medications, and substances;

F) Physical and dental examinations, and medical history;

G) Consent to receive emergency medical services; and

H) Copies of the authorization for release of information.

4) The following shall be entered in the individual's record during the period of service:
A) Written informed consent by the individual or guardian to participate in a CILA;

B) Prior service history;

C) Personal Plan and Implementation Strategy as specified in Section 115.230;

D) Assessments and reassessments as specified in Section 115.225;

E) Documentation of approval to use special procedures and the results of their use; and

F) Monthly documentation of the individual's progress towards the outcomes recorded in the Personal Plan and reflected in the Implementation Strategy. The documentation must be signed and dated by the QIDP.

5) Electronic signature or computer-generated signature codes are acceptable as authentication of record content.
A) In order for a CILA agency to employ electronic signatures or computer-generated signature codes for authentication purposes, the CILA agency must adopt a policy that permits authentication by electronic or computer-generated signature.

B) At a minimum, the policy shall include adequate safeguards to ensure confidentiality of the codes, including, but not limited to, the following:
i) Each user must be assigned a unique identifier that is generated through a confidential access code.

ii) The CILA agency must certify in writing that each identifier is kept strictly confidential. This certification must include a commitment to terminate a user's use of a particular identifier if it is found that the identifier has been misused. "Misused" shall mean that the user has allowed another person or persons to use their personally assigned identifier, or that the identifier has otherwise been inappropriately used.

iii) The user must certify in writing that the user is the only person with user access to the identifier and the only person authorized to use the signature code.

iv) The CILA agency must monitor the use of identifiers periodically and take corrective action as needed. The process by which the CILA agency will conduct monitoring shall be described in the policy.

C) A system employing the use of electronic signatures or computer-generated signature codes for authentication shall include a verification process to ensure that the content of authenticated entries is accurate. The verification process shall include, at a minimum, the following provisions:
i) The system shall require completion of certain designated fields for each type of document before the document may be authenticated, with no blanks, gaps or obvious contradictory statements appearing within those designated fields. The system shall also require that correction or supplementation of previously authenticated entries shall be made by additional entries, separately authenticated, and made subsequent in time to the original entry.

ii) The system must make an opportunity available to the user to verify that the document is accurate and the signature has been properly recorded.

iii) The CILA agency must periodically sample records generated by the system to verify the accuracy and integrity of the system.

D) Each report generated by a user must be separately authenticated.

i) Financial and operational requirements

Agencies licensed to provide CILA services shall comply with Department rules regulating their contractual and financial relationship with the Department.

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