Current through Register Vol. 48, No. 12, March 22, 2024
a)
Governing body
1) Each program 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 program in compliance
with the General Not For Profit Corporation Act of 1986 [805 ILCS 105 ], and
with the Department's rules at 59 Ill. Adm. Code 103 (Grants).
2) The names and addresses of all owners or
controlling parties (whether they are sole proprietorship, association,
partnership, corporation, or subdivisions of other bodies, such as public
agencies or religious, fraternal or other charitable organizations) shall be
fully disclosed and provided to the Department annually. For corporations, the
names and addresses of all officers, directors, and principal stockholders,
either beneficial or of record, shall be disclosed.
3) The governing body shall include persons
who have no direct or indirect financial interest in the program and who reside
in the geographic area served by the program and include persons with
developmental disabilities and consumer representatives.
4) The provider shall notify the governing
body of the Department's annual survey and other State and local inspections
which indicate the outcome and disposition of any findings resulting from a
survey.
b) Advisory
board
1) A program which is owned or operated
by a sole proprietor or partnership shall appoint and maintain an advisory
board whose members shall be persons who have no direct or indirect financial
interest in the program, and who reside in the geographic area served by the
program, and who include persons with developmental disabilities and consumer
representatives.
2) The advisory
board shall ensure that each program owned or operated by a sole proprietor or
partnership shall have a charter, mission statement, goals and
objectives.
c)
Authorized agency representative
The provider shall appoint an authorized agency
representative whose qualifications and duties are defined in writing and
include authority for program administration and management. His or her
performance shall be reviewed and documented annually by the governing
body.
d) Provider policy
requirements
1) The program shall have written
policies which shall be reviewed annually, revised as necessary and approved by
the governing body or advisory board and shall describe:
A) Goals and objectives reflecting annual and
long-range plans;
B) The population
served, including age groups, disabilities and the geographic service
area;
C) The services provided in
response to individual and community needs including:
i) The hours and days of operation;
ii) The methods used to perform initial
screening and assessment of individuals;
iii) A description of processes used for
development of the services plan;
iv) The use and approval of special training
procedures such as time-out, restraint and aversive techniques;
v) Handling emergencies and disasters;
and
vi) Maintenance of buildings,
vehicles and equipment.
2) Program policy shall ensure the
availability of professional, administrative and support staff to assess and
address the needs of individuals. This includes personnel and consultants who
can communicate, either verbally or non-verbally, with individuals.
3) Program policy shall ensure that
Department-authorized consumer-interest groups shall be permitted, with the
consent of the individuals, to visit a program.
A) Consumer interest groups must request
authorization in writing to visit specific programs. The request shall be made
to the Department and shall specify the program to be visited and the reason
for the group's proposed visit. If the group agrees to the conditions set out
below, the request shall contain those agreements.
B) The Department shall authorize a group to
visit a program for a period of one year if:
i) The group has as one of its organizational
purposes to review public services for mentally disabled individuals;
ii) The group agrees that its visits will not
interfere with the program; and
iii) The group agrees to abide by the
provisions of the Act concerning records and communications of individuals in
programs.
C) The
Department shall revoke its authorization or not renew the authorization if it
has information that the group has not abided by the conditions set out
above.
D) Any group whose
authorization has been denied, revoked or not renewed may appeal the decision
in writing to the Secretary, who shall review the decision and accept or
reverse it within 30 days. The Secretary shall uphold the decision if he or she
finds that the group has not abided by this Part.
e) Personnel requirements
1) Programs shall not discriminate in the
hiring or employment of staff on the basis of race, color, age, national
origin, sex, religion, or handicap.
2) Personnel policies and procedures shall be
in writing and available for review.
3) The program shall have written job
descriptions or contractual agreements for every position, including consultant
and direct-service volunteer positions, which list the job title, duties and
responsibilities, minimum experience and educational requirements, immediate
supervisor and subordinates.
4)
Staff shall be licensed, registered or certified by the State, if
required.
5) When paraprofessional
or untrained staff are used in direct services, they shall be supervised by
professional staff.
6) A pay plan
for all position titles in use shall be available for review by the
Department.
7) An agency shall not
employ a person in any capacity until the agency has inquired of the Department
of Public Health as to information in the Nurse Aide Registry concerning the
person. If the Registry has information substantiating a finding of abuse or
neglect against the person, the agency shall not employ him or her in any
capacity.
f) Staff and
volunteer training
1) Training in principles
and practices in the following areas shall be provided to direct service and
professional staff:
A) Cardiopulmonary
resuscitation (CPR), Heimlich maneuver and first aid;
B) Behavior management;
C) Normalization;
D) Age and cultural
appropriateness;
E) Safety, fire,
and disaster procedures including:
i) Use of
fire-fighting equipment; and
ii)
Familiarity with the disaster preparedness plan.
F) Prevention, handling, and reporting of
abuse, neglect, exploitation, unusual incidents (see subsection (h) of this
Section):
G) Individual rights in
accordance with Chapter 2 of the Code and maintaining confidentiality in
accordance with the Act;
H) Team
planning;
I) Infection control and
sanitation; and
J) Food preparation
and handling for staff who prepare and serve food to individuals.
2) Training for volunteers working
directly with individuals shall be provided in the areas discussed in
subsections (f)(1)(A), (E), (F) and (G) of this Section. The agency shall
provide a training program for other volunteers.
g) Quality assurance
1) There shall be a written quality assurance
plan and ongoing activities designed to review and evaluate services to
individuals, operation of programs and to resolve identified
problems.
2) The scope of quality
assurance shall include reviewing semi-annually, or more frequently if problems
are identified, at least the following:
A)
Service planning;
B) The use of
special training procedures including behavior management procedures;
C) Unusual incidents relative to services to
individuals;
D) Service
utilization;
E) Individuals'
records ensuring that they meet the requirements of this Part;
F) Subcontracted services to ensure that the
needs of individuals are being met; and
G) The status of individuals receiving
service.
3) Records of
quality assurance reviews and activities shall be filed separately from the
records of individuals.
h) Unusual incidents
1) The provider shall have written policies
and procedures for handling, investigating, reporting, tracking and analyzing
unusual incidents through the provider's management structure, up to and
including the authorized agency representative. The provider shall ensure that
staff demonstrate their knowledge of, and follow such policies and procedures
that shall include but are not limited to:
A)
Rape or sexual assault;
B) Abuse or
neglect;
C) Death;
D) Physical injury;
E) Assault;
F) Missing individuals;
G) Theft; and
H) Criminal conduct.
2) Within 24 hours after becoming aware of an
incident, the provider shall report to the appropriate law enforcement agencies
any incident which is subject to the Criminal Code of 1961 [720 ILCS 5
].
3) The provider shall ensure
that suspected instances of abuse or neglect against individuals in programs
that are certified by the Department are reported to the Office of Inspector
General (Section 6.2 of the Abused and Neglected Long Term Care Facility
Residents Reporting Act [210 ILCS
30/6.2 ]).
i) Individual's record (record)
1) The program shall ensure the
confidentiality of an individual's record in accordance with the Act and shall
ensure safekeeping of all records against loss or destruction. Individuals or
their guardians shall have access to the individual's record upon
request.
2) The program shall
maintain a chronological record for each individual. Records shall be located
at a site, designated by the program, that is accessible and convenient to
staff contributing to the plan.
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 program shall provide a legend,
standardized throughout the program, to explain them.
3) The following information shall be
obtained and recorded when an individual enters a program, and shall be updated
as necessary:
A) Identifying information
including name, date of birth, sex, race, social security number and legal
status;
B) The name, address and
telephone number of the guardian or the person to be notified in case of an
emergency;
C) The language spoken
or understood by the individual including, in the case of a hearing impaired or
non-verbal individual, the individual's preferred mode of communication, e.g.,
American sign language, signed English, aural, oral or tactile communications
device;
D) Psychological
assessments and recommendations;
E)
Prescribed 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) Prior service history;
B) Initial assessments and plan and the most
recent assessments and plan;
C)
Documentation of approval and their results when special training procedures
are used such as time-out, restraint and aversive procedures; and
D) Chronological progress notes, at least
monthly, documenting the individual's involvement in and response to the
plan.
j)
Financial and operational requirements
Programs shall comply with 59 Ill. Adm. Code 103
(Grants).